Dmitry Mironov, MD	Tim Malhotra, MD
Memorial Sloan-Kettering Cancer Center, New York , NY

Introduction: The aim of this paper is to introduce the structure of pain management practice in the USA to medical professionals in Russia. The structure, organization, and educational requirements established for pain management specialists in the USA will be discussed. The curriculum of a pain fellowship will also be reviewed. Some important terminology as well as problems in modern pain practice will also be addressed.

Structure: The physician specializing in pain medicine often serves as an educator and consultant to other physicians on the intricacies of helping patients with pain. Primarily, pain medicine physicians provide direct care to patients by evaluating, diagnosing, and treating their various conditions. Treatment includes prescribing medication and rehabilitative services, performing pain-relieving procedures, and counseling patients and their families. Physicians specializing in pain medicine provide care in a variety of settings and are able to treat the entire range of painful disorders encountered in the delivery of quality health care.

Historically, the pain service in the USA is based within the Department of Anesthesiology or the Department of Neurology.

Anesthesiology based pain services can have two divisions: an Acute pain service (APS) and a Chronic pain service (CPS). Large pediatric hospitals, pediatric oncology centers and hospitals, performing big volumes of complicated pediatric surgery often also run a Pediatric pain service (PedsP). These pain services usually consists of members of the anesthesiology department taking care of acute postoperative pain and complicated chronic pain problems. The active role of anesthesiologists in the operation of the pain service is justified by their knowledge of the physiology, pharmacology, and the anatomic pathways involved in the modulation of pain. Management by an anesthesia pain service not only includes pharmacological approaches, psychological interventions, referral for physiotherapy, but also invasive interventional procedures. These include epidural steroid injections, peripheral blocks (sympathetic, stellate ganglion, superior hypogastric, ganglion of impar, paravertebral-intercostal), placement of the intrathecal delivery systems (implantable pumps) or chronic epidural catheters.

Neurology based pain services have multiple referral systems. Patients seen by a neurology based pain service are recruited from different medical services: neurology, medicine, oncology, and headache clinics. Services offered by neurology pain may include pharmacological approaches, psychological approaches, counseling, but not invasive interventions. In addition, they have grown to include under their auspices care of the dying cancer patient. This recent trend in the USA is the development of a Pain and Palliative Care service, which is predominantly composed of members of the neurology team. The creation of the palliative care system brought a new prospective and philosophy to medicine about the dying patient. Here relief of pain and suffering for the patient and their family are key issues in management. One of the central tenets of the palliative care movement, now almost a decade old, is that dying is a natural process, not something to be postponed by unnecessarily aggressive therapies or hastened by deadly potions. Palliative care neither lengthens life nor shortens it. Rather, it attempts to make whatever time the patient has left as comfortable and as dignified as possible. This kind of care also supports family members, so that they are strengthened by the whole end-of-life process rather than hurt by it.

As may be appreciated, functions of the anesthesia and neurology based programs are very similar with interventional pain management being the primary responsibility of the anesthesiologist. It is very beneficial to have a multidisciplinary team established, where members of the neurology, anesthesiology, psychiatry, rehabilitation and social service departments care in conjunction for patients. This model is believed to bring the most benefit to the patient and leading groups in the USA follow such a multidisciplinary approach.

Organization: Medical providers in the USA can be divided into three general categories: University Centers, Community Hospitals, and solo practitioners. Presently, all University Hospitals have established pain programs. Community hospitals around the country are operating pain clinics or in the process of the creating ones. The recent interest of the medical and civilian community in the question of undertreated pain has initiated many legal actions that have forced community hospitals to organize pain services . Solo practitioners involved in the operation of pain clinics are mostly anesthesiologists unless the clinic is following a multidisciplinary pathway. It is still an searching area for an optimal functioning model.

Educational requirements: At present, the subspecialty of Pain management in the USA includes professionals from three different fields: neurology, anesthesiology and rehabilitation medicine

Neurology:

• 1 year of internship,
• 3 years of neurology training,
• 1 year of clinical fellowship in pain management in a neurology based program,
• board examination in neurology,
• board examination in pain management (written)

Anesthesiology:

• 1year of internship,
• 3years of anesthesiology training,
• 1 year of clinical fellowship in pain management in an anesthesia based program,
• written examination in anesthesiology,
• oral examination in anesthesiology,
• examination in the pain management (written)

A good place to review information on anesthesia based pain fellowships is the web-site of the American Society of Regional Anesthesia http://www.asra.com

Rehabilitation:

• 1 year of internship,
• 3 years of rehabilitation medicine,
• 1 year of clinical fellowship in the pain management in a neurology based
• programboard examination in rehab. medicine,
• board exam in pain (written)

In 1998, the American Board of Anesthesiology (ABA) issued its first subspecialty pain certificates to qualified ABA diplomats. In 1998, ABA supported a joint proposal by the American Board of Physical Medicine and Rehabilitation (ABPMR) and the American Board of Psychiatry and Neurology (ABPN) that allowed these boards to offer subspecialty certification in pain. With the single examination process, a joint committee was formed with representatives from each specialty. However, the ABA determines the passing standards for the examination[1]. Since, the ABA first offered the pain management examination in 1993, 2243 diplomates have passed the examination.

There are currently 97 anesthesia based accredited pain management programs in the USA; each program offers between 1-8 training positions. The number of physicians seeking fellowship training in pain management has steadily grown over the past decade. There were 260 fellows training in accredited pain management programs during the 1998-99 academic year[2]. There are several anesthesiology programs that offer fellowships to neurologists. Recent changes in the field highlight the importance of establishing an integrative approach and good communication among different specialties involved in the field of pain management.

The international association for the study of pain publishes the core curriculum for professional education in pain and ABA is following this direction in conducting board examination[3].

Training in the subspecialty of pain management: In order to provide a trainee with an adequate exposure to different pain syndromes and equip him/her with the ability to manage a variety of clinical pain scenarios enrollment in a fellowship program is a must. A fellowship program exposes participants to both acute and chronic pain patients. The introduction to an acute pain service in the hospital can serve as an initiating step in the formation of the pain specialist[4]. Memorial Sloan Kettering Cancer Center in New York has an active surgical program which requires continuos attention form the pain service. We provide surgical patients with acute postoperative pain control for the duration of their postoperative period. If, after discharge from the hospital, a patient still requires more than an average amount of pain medication we continue management in our “chronic pain clinic”. The most common means of postoperative pain control in the USA is through a patient controlled analgesia (PCA) machine[see picture]. PCA is a method of delivery of opioids via the intravenous route using a computerized infusion system (pump). Our pumps are able to deliver medication continuously and provide additional boluses of the medication upon the patient pushing a button. We limit amount of medication patient is able to receive via computerised lock. We evaluate patients postoperatively, assess analgesic requirements and place an order for a PCA. Presently there are six opioids that we use for intravenous PCA. These are: Morphine, Hydromorphone, Fentanyl, Methadone, Oxymorphone and Levorphanol. The selection criteria for each opioid are generally formalized but are not limited by strict regulations, in part to fulfill the educational objectives of our program. Every day, the pain team has a formal report where we discuss all the patients, construct a plan and receive information from the person on call the previous night. After the report is completed, the pain team rounds on all patients adjusting medications according to the patient’s condition. We also manage all side effects that may arise from the drugs we prescribe.

Due to the high volume of complex surgeries performed at our center and the large number of thoracotomies performed, part of the acute pain service experience is an intense exposure to infusions via thoracic epidural catheters. We place approximately 4-15 epidural catheters each day. Usually we manage 10-15 epidural catheters per day. A choice of 3 opioids (morphine, hydromorphone or fentanyl) and 2 local anesthetic agents (bupivacaine or lidocaine) as well as clonidine are employed in our epidural infusions. Since epidural analgesia is delivered via the pump with patients partially controlling the device we call it EPI-PCA, which stands for epidural patient controlled analgesia. We deliver medication via a continuos infusion, and for additional analgesia, the patient is able to receive a rescue dose every 20-30 minutes, pushing a special initiating button. Also, all side effects from epidural infusions, such as nausea, sedation, numbness from local anesthetics, inadequate pain relief etc. are managed accordingly by our team.

Care for Cancer patients (which our center specializes in) is full of nuances due to the nature of the disease. Many patients are suffering from advanced neoplastic processes which require extraordinary measures to control pain. Multiple side effects from the therapy also contribute to the challenges of the patient’s day to day care . On many occasions growing tumors expand in space limited by body structures, such as the pelvic cavity. Due to limited surrounding space tumor rapidly invade tissues, elements of the peripheral nervous system, fracturing bones and penetrating to the vertebral bodies, epidural space and spinal canal. Compression of the nervous plexuses or vertebral compression fractures are among most dramatic pain experiences in our practice. Due to limitation of the efficacy of the opioids in the treatment of the “compression syndromes” we are forced to try invasive modalities in an attempt to control a patient’s pain. We always start with a trial of conservative pharmacological therapy. Nevertheless, there are situations when inadequate pain control or severe side effects force us to abandon conservative routes and proceed with invasive treatments. We place chronic epidural catheters with externalized pumps, intrathecal catheter with internalized pumps and recently we started to employ externalized intrathecal infusions for pain syndromes resistant to conventional therapy. We also perform epidural neurolysis with phenol for pain due to esophageal malignancies, paravertebral neurolytic blocks with alcohol for pain from rib’s metastasis , neurolytic celiac plexus blocks for pancreatic cancer and ganglion of Impar block for resistant pelvic pain.

Pain Clinic: Patients are referred to the pain clinic by surgical or medical services. In addition, patients may choose to refer themselves to a pain clinic. Patients of all ages can be referred to the pain treatment clinic: those suffering from acute or chronic pain, patients suffering from post-operative or post traumatic pain, or any type of chronic pain whether the source is malignant or non-malignant. Here, a thorough and formal evaluation of a patient occurs through a history , physical and detailed examination of laboratory and imaging. Although some syndromes are diagnosed by history and physical, most require the use of some form of imaging, such as CT Scans and Magnetic Resonance Imaging. While there, the pain is defined and appropriate therapies are planned. Patients call the clinic again in 3-7 days to update the physicians on the effectiveness of their treatments and any side effects. Patients are seen in the clinic approximately every month at which time medications are adjusted. Effective therapy requires the patient to be an active member of the treatment team as well as the patient’s referring physician.

Problems and future trends: As with any newly developing field, pain management has it is own internal and external problems. Some of these include:

By not being a primary care specialty, pain management is not a primary reason patient’s coming to a hospital. Rather, it is an adjunct to the treatment of their disease, even though it may dominate their life more than the disease itself.

The Pain management specialist can not fully implement his/her plans without the approval and support of the referring physician.

Often, we see patients late in the chain of health care professionals, at a time when our options are limited.

Our colleagues have a limited knowledge regarding our potential and our abilities to take care of complicated pain issues. This is especially true in the area of interventional pain management, where the referring specialties should be aware of the benefits of the procedures we perform.

Fear of drug addiction is a major limiting factor for many patients seeking treatment.

Professionals from a variety of the medical fields and paraclinical personal are trying to get involved in pain management , including attempts to get certification in interventional procedures.

There is a need for future developments of standards in the training and conduction of randomized controlled trials to assess the efficacy and the safety of the therapies we offer.

Conclusions: We described the general organization, functions and legal aspects of pain management in the USA. We hope , that issues we introduced will be of some benefit to our Russian colleges. If it generates any interest , please, do not hesitate to contact us at smironov@aol.com for D. Mironov and malhotrv@mskcc.org for T. Malhotra. We appreciate your attention.

Literature :

1. A. Still, Pain Medicine-untangling the Web of Certification, American Society of Anesthesiologist; Newsletter, November 2000,p8-9
2. J. Rathmell, Are we training too many pain specialists, American Society of Anesthesiologist; Newsletter, November 2000, p10-11.
3. International Association for the Study of Pain, Core Curriculum for Professional Education in Pain,1998
4. Acute Pain, Mechanisms and Management; R S. Sinatra, A. H.Hord, B. Ginsberg, L Preble, 2000
5. Bonica’s Management of Pain; Loeser, Butler, Chapman, Trunk., 2000.

РЕЗЮМЕ

СТРУКТУРА МЕНЕДЖМЕНТА ХРОНИЧЕСКОЙ БОЛИ В США

Дм. Миронов, Тим Малхотра
Мемориальный Раковый Центр Sloan-Kettering , Нью-Йорк

Противоболевая служба в США организована в рамках департамента анестезиологии или неврологии. Анестезиологические противоболевые службы подразделяются на Службу острой боли и Службу хронической боли. Детские крупные больницы, детские онкологические центры, связанные со сложными хирургическими вмешательствами, часто прибегают к услугам Педиатрической службы боли. Ведущую роль в указанных службах играют анестезиологи, как специалисты более других знакомые с фармакологией, патофизиологией и другими аспектами боли.

Болевые службы, относящиеся к неврологии, имеют различные направления и занимаются пациентами с неврологической, онкологической патологией, пациентами с висцеральными заболеваниями, пациентами клиник головной боли. Паллиативная медицинская помощь раковым больным также преимущественно оказывается членами неврологической команды специалистов.
Наиболее эффективным направлением в противоболевой помощи считается создание мультидисциплинарных групп, в состав которых входят невролог, анестезиолог, психиатр, отделение реабилитации и социальной помощи.

Медицинские услуги в США оказываются тремя основными категориями учреждений: университетскими центрами, общественными больницами и частнопрактикующими врачами. Все университетские клиники создают собственные противоболевые программы, многие общественные больницы работают как клиники боли, в деятельности которых принимают участие и частнопрактикующие врачи, преимущественно анестезиологи.

Менеджмент боли в США включает подготовку специалистов из трёх клинических специальностей: неврологии, анестезиологии и реабилитационной медицины.
С 1998 года сертификаты специалистам по боли выдаёт объединённый комитет, состоящий из представителей Американского Совета Анестезиологии, Американского Совета физической медицины и реабилитации, Американского Совета психиатрии и неврологии. Ведущее место в определении стандартов подготовки и сертификации специалистов по боли занимает Совет Анестезиологии. В последнее время в подготовке специалистов преобладает интегративный подход, объединяющий различные специальности и основанный на разработанном Международной Ассоциацией по изучению боли Core Curriculum для профессионалов в области боли.

Авторы статьи работают в раковом центре Нью-Йорка, где обеспечивают контроль острой боли хирургическим больным в течение продолжительного послеоперационного периода. Наиболее распространённый способ послеоперационного контроля боли состоит в использовании метода "пациент -контролируемой анальгезии". Применяются шесть опиоидных препаратов: морфин, гидроморфин, фентанил, метадон, Oxymorphone и Levorphanol. В связи с большим объёмом сложных хирургических вмешательств ежедневно устанавливается 4 - 15 эпидуральных катетеров и ведётся контроль за 10 - 15 уже установленными эпидуральными катетерами, посредством которых ведётся частично управляемая пациентом эпидуральная анальгезия.

Каждый день "болевая команда" специалистов получает отчёт о состоянии всех пациентов, обсуждает полученную информацию и корригирует медикаментозную терапию.
В раковом центре кроме интратекального введения лекарственных веществ применяется эпидуральный невролизис фенолом при злокачественных опухолях пищевода, нейролитические паравертебральные блокады алкоголем при метастазах в рёбра, нейролитические блокады целиакального сплетения при раке поджелудочной железы и др.

Если у пациента сохраняется боль при выписке из Центра, лечение продолжается в "клинике хронической боли" Центра.
Клиники боли. В клиники боли направляются пациенты с различными видами болей из хирургических или других медицинских учреждений. Обычно в клиниках существуют возможности для интраскопических видов исследования (КТ или МРТ). Пациенты проводят в клинике 3-7 дней, затем наблюдаются ежемесячно до установления необходимой медикаментозной терапии. В течение этого времени пациент активно участвует в лечении.

В заключении статьи указываются основные проблемы развития менеджмента боли. Авторы надеются на то, что их заметка окажется полезной для коллег в России, и в случае интереса к данной проблеме предлагают обращаться к Дм. Миронову smironov@aol.com или T.Malholtra malhotrv@mskcc.org

С.С. Павленко