“The aim of the wise is not to secure pleasure, but to avoid pain.”
Symptoms of pain and discomfort have no doubt been one of the biggest problems facing mankind over the course of history. References to physical pain have been made in many forms of ancient writings. Pain is defined by the International Association for the Study of Pain as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Describing the actual sensations of pain and precisely what makes these symptoms so unpleasant is difficult. Indeed, these symptoms are widely varied across individuals and even in animals.
It has been postulated that humans have more intense sensations of pain and are much more connected to the emotional, behavioral, and psychological responses to pain than are other animals. Indeed, it is widely known that pain does not always match the degree of tissue damage or injury. In fact, sometimes a very small wound such as a shallow cut or abrasion can lead to sensations of excruciating pain. The symptoms of pain are subjective. In early childhood, children learn to communicate their symptoms of pain with others. In fact, symptoms of pain and discomfort are most often the reasons why an individual will seek out treatment.
Pain is a critical aspect of the human experience. It serves sometimes as the primary indicator that something is wrong and motivates the individual to seek out treatment. Nonetheless, there are times when the pain message is faulty, such that the pain alarms continue to go off even when there is no serious underlying condition for which to treat. Moreover, this pain can be quite severe and debilitating, such that it has the potential for reducing the individual’s quality of life. Should you be suffering from symptoms of refractory or debilitating pain, it may be time for you to contact a pain specialist.
A pain specialist has received specialized training in assessing and treating conditions that result in severe symptoms of pain and discomfort. Pain specialists have received in-depth training in the variety of treatment options available for reducing or even completely eliminating symptoms of pain at their source. This article will review in more detail the role of a pain specialist, define what interventional pain specialists do, and provide an overview of the training that a pain specialist must undergo and the types of care they are trained to provide. This article will also include a short description of the various pain management techniques, including oral pain medications, analgesic injections, and nerve blocks.
What Is A Pain Doctor?
One field of medicine that is rapidly growing is the field of allopathic medicine. In fact, this area is almost as vast and complex as the human body itself. Given this, training to become a physician can be a quite lengthy and rigorous process. To complicate this, advances in medical technology are being made every day, which has made it quite challenging for most physicians to remain up-to-date on all topics within the field of medicine. To offset this, many physicians will choose to specialize in one or more areas of medicine, following completion of their formalized medical training.
The role of the primary care physician is a challenging one, as they must stay up-to-date on nearly all general areas of medicine, in order to continually monitor the overall health of their patients. When a primary care physician encounters a condition for which they are unsure how to manage, they will generally refer that patient to a specialist in that area. Indeed, for many physicians, specializing can have many advantages. One of the biggest advantages is that they have the ability to remain current and, therefore, provide the most well-informed patient care in that specialty area.
Pain management, also sometimes referred to as pain medicine, is one of the medical specialties that a doctor may choose while in training. Pain itself has been a big concern as part of the human condition since the beginning of written language. Nonetheless, pain management, defined as a medical specialty, is still fairly new. In fact, pain management dates back to only the late 1980s and early 1990s. Prior to the emergence of this field as its own entity, the practice of pain medicine was typically done by anesthesiologists as a side activity. Moreover, these anesthesiologists generally only managed the symptoms of pain, rather than treated the source of the pain.
Currently, pain specialists are ones who specialize in managing symptoms of pain. They specialize in both identifying and treating the sources of pain. Given that a pain specialist can only focus on the management of the patient’s pain, it should be noted that a pain specialist cannot replace a patient’s primary care physician for monitoring overall physical health. Conversely, the pain specialist will generally rely upon the primary care physician to provide information in terms of the patient’s current pain symptoms and course of the condition. The pain specialist then is equipped with the most up-to-date tools and information that allows them to gather the most accurate information for diagnosing and treating most acute (intermittent or short-term) and chronic (intractable and long-term) instances of pain and discomfort. Indeed, the pain specialist may work cooperatively with your primary care physician in order to accurately identify and treat the source of the chronic pain.
Pain specialists must have a thorough understanding of pain in order to properly diagnose, treat, and manage the symptoms. The pain specialist must understand each of the different varieties of pain conditions, including neuropathic, nociceptive, psychogenic, and incident pain, as well as some less common types of pain that are associated with specific health conditions.
There are specific types of nerve fibers within the body that transmit information specifically pertaining to noxious, injurious, or thermal pain, which is known as nociceptive pain. Other nerve fibers within the body transmit non-pain information, such as body pressure and position. Abnormal stimulation of these nerve fibers is known to result in neuropathic pain. Pain that is associated with moving a sore and achy joint or by pressing on a wound or a bruise is known as incident pain. Psychogenic pain is pain that is exacerbated by psychological factors, such as mental, emotional, or behavior factors. These have also been referred to as “mind over matter” incidents of pain, which may include things such as stomachaches or nausea that is caused by anxiety, or headaches and other body aches that are linked to symptoms of depression.
Less common types of pain include cancer pain and phantom limb pain, which is reported by amputee patients. A pain specialist must have expertise in diagnosing and treating all types of pain, including both acute and chronic conditions. Given the complexity of these conditions, the pain specialist must develop skill in assessing the various chemical, physical, behavioral, emotional, and biological states of a patient, in order to develop a comprehensive treatment plan.
What Is An Interventional Pain Doctor?
The term interventional pain doctor refers to a specialist that practices a subspecialty of pain medicine that utilizes more substantial and sometimes invasive procedures for treating and managing various pain conditions. Among the oldest techniques in interventional pain management is the technique of cutting or re-sectioning a pain fiber tract, which runs longitudinally along the spinal cord. All nerve fibers that transmit pain information enter the spinal cord along the spinal column (also known as the vertebral column). These nerve fibers that carry pain signals to the spinal cord and brain tend to run together, thus making it easy for pain specialists to identify the source of the pain. Treating symptoms of pain and discomfort is essentially done by interrupting the transmission of these signals to the spinal cord and brain. This procedure then leads to significant reductions in pain sensations throughout the body, or even complete relief of pain symptoms.
Think of the system as a series of homes along a straight road that comes to a dead end. Along this road, the houses are connected to the phone service with one main phone cable that runs down along the street, with each individual house receiving service from a cable branching off from this main line. Should this cable be cut somewhere along the road, then all of the houses from where the cable is spliced to the end of the road then will lose phone service. This same principal is true for a slice in the pain fibers of the spinal cord. More specifically, information coming from connections below the cut are unable to reach the spinal cord and brain. Provided that the pain specialist has only cut the neural fibers that transmit pain information, while allowing the motor nerves to remain intact, then the individual is still capable of motor reflex responses, though the individual may not be able to feel any sort of pain sensation from these areas. Indeed, this procedure is generally regarded as a last resort, following several trials of other methods of treating the pain.
In general, the field of interventional pain management has at its disposal a wide variety of advanced and sophisticated procedures, which vary in their level of invasiveness and permanence. Deciding on the appropriate treatment option generally depends on the individual’s particular underlying condition. As one example, cancer-related pain that arises as the result of bone metastases or even tumor-related neural fiber compression can be managed with radiation therapy. Essentially, low doses of radiation are delivered to a targeted area and produce pain-relieving benefits. The precise mechanisms for why this method is so effective is not completely understood, as more research is necessary in this area.
Other techniques, such as deep brain electrical stimulation and spinal cord stimulation, can be used for the management of non-cancer related pain. Pain specialists may also recommend that the patient take oral medications as a temporary treatment for pain and discomfort. These medications can range from over-the-counter analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), to prescription pain relievers, such as opioid drugs. Anesthetic medications can also be delivered directly to the area of the pain using either epidural or intrathecal injections. These techniques deliver the medication directly to the area surrounding the affected nerve. With these tools at their disposal, a pain specialist is armed to treat a wide variety of pain conditions. This treatment, however, must begin with an accurate diagnosis of the pain. Then the specialist will develop a detailed treatment plan, which includes long-term and short-term goals for managing symptoms.
What Is A Pain Fellowship?
Receiving medical training in the United States and Canada requires multiple years. Typically, applicants to medical school must complete a four-year bachelor degree at an accredited college or university before applying to medical school. Medical school applicants are also required to complete roughly three years of required coursework and also must have scored very well on the generalized medical school entrance exam. Applying to medical school and the selection process is quite rigorous. Indeed, only the top most talented applicants are chosen. Programs for medical training typically span between four and five years of continuous training, which includes coursework in core subjects for the first half, followed by clinical rotations for a second. During clinical rotations, medical students receive close supervision from an attending physician. A portion of students in medical school may wish to receive additional, more specialized training, given that most medical school programs provide only broad range medical training over the many topics of human health.
Once a medical student successfully completes the coursework for medical school, they will then begin a specialized internship that may last for one or more years. During this point in training, medical students have had their degrees conferred but have not been fully licensed to practice medicine without supervision. It is at this stage in training when most trainees decide to begin to specialize in one particular area of medicine. Once the trainee successfully completes internship and passes the final licensing exam, they may begin to practice medicine independently as a general practitioner. Many physicians, however, wish to seek additional supervised experience in their area of specialty during what is called their medical residency. Within the U.S., nearly all trainees in medical school complete a residency. Generally the year-long internship ends up becoming the trainees’ residency in subsequent years. Specialized residency training generally lasts between two to seven years.
Once a medical trainee is able to complete residency, they may wish to seek out even more specialized training by completing a fellowship with an accredited program within their specialized field. Typically, fellowship programs span one or more years and, during this time, the medical trainee is able to act as an attending or consulting physician in the general field, while receiving supervision in their specialized area. Once the medical trainee completes a specialized fellowship program, the physician is then able to practice independently within that specialty. It is not uncommon for board certification to be required at this stage of completing the fellowship program. Board certification can include both written and oral exams.
A pain fellowship is a fellowship program in which the medical trainee is able to specialize in pain management or pain medicine. As noted above, this is typically the physician’s final stage in training within their chosen specialty. For a pain doctor, completing a pain fellowship is the capstone experience prior to being certified and practicing as an independent physician specializing in pain management. There are many academic medical institutions within the United States who offer pain management fellowship programs. Many of these institutions are housed within anesthesia departments.
A full list of domestic pain fellowship programs is maintained on the American Pain Society’s website. These pain specialty programs generally consider applicants who have had previous training in specialty areas such as physical medicine and rehabilitation, psychiatry, neurology, and anesthesia. In general, each pain fellowship program typically accepts a very small number of medical fellows each year. Classes of medical fellows tend to be as few as one to three students. As such, it is not surprising that admission into these fellowship programs is highly competitive. A small number of fellowship programs may even offer a second year of training to those fellows who were successful in the program during year one.
As noted above, pain fellowship programs are generally housed within academic research and training institutions, and receive their accreditation from the Accreditation Council for Graduate Medical Examination. There are over 100 of these ACGME-accredited programs and the vast majority of them are in anesthesia. Around 10-20% of these programs may also be in other areas, such as rehabilitation and physical medicine. Most fellows in the specialty program will complete 12 months of both in- and outpatient care, with a focus on the assessment and treatment of a variety of conditions causing pain, including acute, chronic, and cancer pain.
Given that there are a number of conditions that may lead to symptoms of pain and discomfort, the pain fellow will generally train in a multidisciplinary environment. These fellows will work closely with other specialists, including neurologists and surgeons. Trainees in pain fellowship programs will learn to access all of the available treatment modalities for managing pain. These modalities can include surgical, non-surgical, pharmacological, non-pharmacological, and implant-based methods for managing pain. The most important goal of a trainee within a pain fellowship program is to be given a breadth of experience in both the basic and advanced techniques for managing pain. These techniques may include neurolytic techniques, sympathetic blocks, head and neck blocks, ultrasound guided injections and blocks, neuraxial injections and blocks, and headache specific management procedures. Trainees in pain fellowship programs may also participate in a number of didactics, including seminars, lectures, and conferences. This year of training in the pain fellowship program is rigorous and busy for most trainees.
Fellows within the pain fellowship program also have the opportunity to learn the business and management side of practicing pain management as well as the opportunity to participate in many research projects. Pain fellowships attempt to prepare physicians, who would like to specialize in pain management, for success within a demanding career while also allowing them to earn the necessary board certification to practice pain medicine independently. It should be noted that one distinction for successful pain fellows is to be certified by the American Board of Anesthesiology, by receiving the Certificate of Added Qualification in Pain Management. Patients who are interested in pain management for their chronic pain condition are encouraged to review the credentials of their potential pain specialists.
What Is Comprehensive Care?
The term comprehensive care in medicine is used to summarize the evaluation and treatment paradigm that is focused around a specific health concern for which a patient is seeking care. Comprehensive care also focuses on providing the patient with health care that takes into consideration the patient’s broader overall health and wellbeing. As such, comprehensive care has generally placed more emphasis on the impact of comorbidities, which are other conditions that may occur concurrent to the presenting condition.
Comprehensive care does not utilize a reductionist approach, which generally isolates and treats conditions on an individual basis. The theory behind this is that by isolating and treating individual health conditions, the physician may have limited success given that the patient has other health complications. Even if these other health complications appear to fall outside of the causal pathway of the current condition, they likely have an impact. As an example, many chronic conditions, such as kidney disease, diabetes mellitus, or cardiovascular disease, are taken into consideration when evaluating and treating specific pain conditions, such as sore and aching joints. Indeed, these more chronic medical conditions do not generally cause sore and achy joints, however, they may lead to or exacerbate other conditions that contribute to the individual’s symptoms of sore and achy joints.
In some cases, by not using a comprehensive care approach the physician may only be able to achieve temporary pain relief, as the full problem has not been considered. By using the comprehensive care approach, the patient’s treatment plan may include a short-term treatment plan for providing relief from the pain and discomfort from the condition, as well as long-term treatment plans for improving the patient’s overall health and, ideally, preventing the symptoms of pain from returning. The pain specialist may wish to monitor the patient’s progress toward the final goal of overall health using a variety of assessments and quantitative measures. Probably of most importance, a patient who presents with one or more chronic medical conditions will be referred to other medical specialists in order to provide the patient with the most effective overall comprehensive care.
Given the goal of the comprehensive care approach in providing the patient with care for all of their needs, including those that are partially related to their current condition, the comprehensive care approach may also include assessment and management of non-medical concerns. Thus, the comprehensive care team is multidisciplinary and the specialists involved in an individual’s comprehensive pain management team are capable of providing in-depth evaluations of the psychosocial, physical, and biological factors involved in various pain conditions. Interestingly, the comprehensive care team approach is beginning to develop among anesthesiology departments, as well as other areas such as rehabilitation and physical medicine. Some medical fields, including cancer and hemophilia, have provided ample evidence as to the success of the comprehensive care approach. Given that symptoms of chronic pain are generally associated with an underlying complex condition, it is not surprising that these conditions need to be addressed from multiple perspectives. Pain management is an ideal field for utilizing the comprehensive care approach.
A particular area in which the comprehensive care approach to pain management has been successful is in finding the delicate balance between the pharmacological management of pain, such as by balancing the use of opioid medications and drug addiction. Opioid medications are highly addictive and, when they are prescribed, they need to be very closely monitored by the physician and other specialists on the comprehensive care management team. In fact, before an opioid medication is prescribed, it is best to clearly define a goal for the pain management, as well as a plan for when to discontinue the use of the medication. Many patients, such as those with challenging comorbidities, like depression, may require increased supervision. Moreover, the comprehensive care team will need to be ready to be assertive in terms of managing the possible development of an opioid addiction.
How Does A Pain Doctor Diagnose Your Pain?
It is normal for individuals to experience new types of aches and pains as they get older. Many adults complain of pain that arises within the joints and tendons after physical activity, and they may experience an increase in muscle pain. This pain and discomfort that arises in response to engaging in an activity is not typically much to be concerned about; however, other pain that occurs not in response to increased activity can be an indication that something is wrong. In particular, if you have symptoms of pain or discomfort that wakes you up from sleep or interrupts your normal day-to-day activities, such as household tasks, exercise, work, or other things that you enjoy, for more than a week or two, then it is recommended that you talk to your primary care physician about options for managing your symptoms. In some instances, these symptoms may be the result of a condition that cannot be managed. If this is the case, your doctor may refer you to see a pain specialist for managing your symptoms.
The primary goals of a pain specialist are: 1) identifying the source of the pain, 2) developing a short-term treatment plan for managing the symptoms of pain and discomfort, and 3) developing a treatment plan targeting the underlying cause for the pain, so as to reduce or eliminate the symptoms of pain all together.
The first goal, when seeing a pain specialist, is to make a proper diagnosis. In many cases, the pain specialist will work with your primary care physician to gather information regarding the patient’s medical history, overall health, and history of current condition. The pain specialist will also collect information directly from the patient on their health history. This information will assist the pain specialist in arriving at an appropriate diagnosis for the underlying cause of the pain. Generally, a pain specialist will perform an in-depth physical examination on the patient, and the patient will be asked detailed questions regarding the location of the pain, duration, intensity, and any variables that may seem to aggravate or alleviate the pain.
There are a wide variety of pain conditions that may be either acute or chronic in nature. The specific descriptions for the pain will vary; however, chronic pain is generally defined as pain lasting three months or more or pain that persists well beyond what would be expected in terms of recovery for the underlying condition. Both acute and chronic pain can be quite challenging to diagnose, as the varying types of underlying causes can produce similar types of symptoms. Further, the symptoms of pain and discomfort may be quite diffuse, making locating the precise cause for the pain almost impossible. Your pain specialist may request that you undergo imaging, laboratory tests, or other diagnostic procedures in order assist properly identifying the underlying condition. This information will be used in their assessment of the symptoms, along with discussions with your primary care physician, in order to arrive at the most accurate diagnosis possible.
Your pain specialist may wish to order tests like blood draws or even X-rays. Other imaging techniques may be employed for diagnosing pain conditions. These include magnetic resonance imaging (MRI), computed tomography (CT) scan, or computed axial tomography (CAT) scan. Some of these imaging techniques may employ the use of radiation (i.e., the CT or the CAT scans) or they may use electromagnetism (MRI) in order to develop a high-resolution image of the internal structures of the body. The pain specialist will inspect these images for any abnormalities or injuries to the underling tissue. Ultrasound devices may also be employed for imaging the internal structures of the body.
All of these aforementioned imaging techniques are non-invasive. There are other types of imaging that involve the use of a contrast dye. These techniques include myelogram and discography. A myelogram or discography are techniques that can provide more in-depth information from a simple X-ray by injecting a contrast dye into the intervertebral disc or area of the spinal cord and spinal nerves near the region of reported pain. Disorders that affect the bone can be linked with severe symptoms of pain, however, they are difficult to diagnose. The pain specialist may wish to order a bone scan, which is an imaging technique that utilizes a radioactive substance to provide a detailed image of the internal bone tissue. Images from bone scans can help the pain specialist identify infections, bone fractures, or other conditions that affect bone tissue. These imaging techniques can serve as a powerful toolkit for pain specialists in terms of diagnosing the various underlying conditions that lead to symptoms of pain and discomfort. Indeed, an accurate diagnosis is essential in order for the pain specialist to develop an appropriate and effective treatment plan.
In some instances, diagnosing the underlying pain condition is an iterative process. In other words, the pain specialist may formulate an initial diagnosis of the pain and begin a pain management plan accordingly. During the implementation of this treatment plan, the pain specialist will monitor the pain’s symptoms. The change (or even lack of change) in symptoms following the implementation of a treatment plan can, in fact, provide the pain specialist with critical diagnostic information. Thus, dependent on the effectiveness of the treatment plan, the pain specialist may choose to change the initial diagnosis, and as such change the course of the treatment. Occasionally, the pain specialist will wish to order evaluations by other specialists in the area, in order to provide a more comprehensive coordination of care. These evaluations can include specialists, such as a neurologist or a psychiatrist. These physicians will then share information in an effort to refine the patient’s diagnosis. In most instances, it is possible to identify the underlying source of the pain and discomfort. Moreover, more instances of pain can be effectively treated. A proper diagnosis, however, is the important initial step in this process.
How Does A Pain Doctor Manage Your Pain?
Your pain specialist will utilize a comprehensive care treatment approach for managing your symptoms of pain and discomfort. The pain specialist will coordinate the effort of the various members of the treatment team and will use information gathered from each member in order to more fully develop an individualized treatment plan. The role of the pain specialist is a complex one. In fact, their job does not end once they have arrived at what is believed to be an accurate diagnosis. Following an initial diagnosis, the pain specialist will monitor the effectiveness of the intervention, as this will provide a wealth of useful information in terms of the precise underlying condition. Depending on the effectiveness of the intervention chosen, the pain specialist may wish to change the initial diagnosis and try another treatment technique.
There are many treatment options available for individuals suffering from refractory or unremitting symptoms of chronic pain and discomfort. Some of the more conservative approaches can include physical therapy, heat therapy, ice therapy, or even just resting the affected area. The pain specialist may recommend that the individual use an over-the-counter oral medication for pain relief, such as a non-steroidal anti-inflammatory drug like ibuprofen or naproxen.
Should the patient attempt these more conservative approaches with little to no effects, then the pain specialist may recommend a more interventional approach. For instance, the pain specialist may prescribe the patient with a stronger oral analgesic, such as opioids for the short-term management of the individual’s pain. Other approaches to treating pain may include injecting an analgesic drug directly to the affected area. This approach usually involves the use of anxiolytics, anesthetics, or steroidal anti-inflammatory drugs. Individuals receiving treatment for chronic pain conditions may also be evaluated by a psychologist or psychiatrist and receive treatment in the form of other alternative approaches, such as homeopathic medications, acupuncture, or chiropractic care. These types of interventions are typically recommended as a complementary approach in conjunction with the primary treatment plan. Your pain specialist will discuss with you what options are available and best suited for treating your particular pain condition.
Indeed, the condition of pain is a very complex emotional and sensory experience that most every individual will experience at multiple points within their lifetime. In fact, most everyone is expected to have to deal with symptoms of somewhat chronic aches and pains of simple day-to-day life. However, patients with chronic and refractory pain that has persisted despite a number of efforts to treat the pain and that has begun to interfere with the individual’s daily functioning may wish to speak to their doctor about being evaluated by a specialist in pain management.
These specialists receive additional training in pain conditions and in the techniques for managing pain that is above and beyond the training required for traditional medical school. These individuals become highly skilled at assessing, treating, and managing the often debilitating symptoms of chronic pain. The pain specialist is also trained in recognizing the various behavioral, emotional, and mental factors that can influence the individual’s experience of pain and provide referrals for specialists, as appropriate, for additional consultation. Individuals who are interested in seeing a pain specialist for managing their symptoms of pain are encouraged to speak with their primary care provider about possible referrals for a pain specialist.
Professional Organizations And Resources
- Accreditation Council for Graduate Medical Education — www.acgme.org
- American Academy of Pain Medicine — www.painmed.org
- American Board of Anesthesiology — www.theaba.org
- American Board of Medical Specialties — www.abms.org
- American Board of Pain Medicine — www.abpm.org
- American Board of Physical Medicine and Rehabilitation — www.abpmr.org
- American Board of Psychiatry and Neurology — www.abpn.com
- American Pain Society — www.americanpainsociety.org
- American Society of Regional Anesthesia and Pain Medicine — www.asra.com
- International Association for the Study of Pain (IASP) — www.iasp-pain.org
- World Institute of Pain — www.worldinstituteofpain.org
- Guidelines for fellowship training in Regional Anesthesiology and Acute Pain Medicine: Second Edition, 2010. Reg Anesth Pain Med. 2011;36(3):282-288.
- Balmer JT. The transformation of continuing medical education (CME) in the United States. Adv Med Educ Pract. 2013;4:171-182.
- Bhasin B, Estrella MM, Choi MJ. Online CKD education for medical students, residents, and fellows: training in a new era. Adv Chronic Kidney Dis. 2013;20(4):347-356.
- Bhatia A, Brull R. Review article: is ultrasound guidance advantageous for interventional pain management? A systematic review of chronic pain outcomes. Anesth Analg. 2013;117(1):236-251.
- Blanchard CG, Ruckdeschel JC. Psychosocial aspects of cancer in adults: implications for teaching medical students. J Cancer Educ. 1986;1(4):237-248.
- Blondell RD, Azadfard M, Wisniewski AM. Pharmacologic therapy for acute pain. Am Fam Physician. 2013;87(11):766-772.
- Boezaart AP, Munro AP, Tighe PJ. Acute pain medicine in anesthesiology. F1000Prime Rep. 2013;5:54.
- Bokarius AV, Bokarius V. Evidence-based review of manual therapy efficacy in treatment of chronic musculoskeletal pain. Pain Pract. 2010;10(5):451-458.
- Bosnjak S, Maurer MA, Ryan KM, Leon MX, Madiye G. Improving the availability and accessibility of opioids for the treatment of pain: the International Pain Policy Fellowship. Support Care Cancer. 2011;19(8):1239-1247.
- Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. Br J Anaesth. 2008;101(1):17-24.
- Brescia FJ. Pain management issues as part of the comprehensive care of the cancer patient. Semin Oncol. 1993;20(2 Suppl 1):48-52.
- Breuer B, Pappagallo M, Tai JY, Portenoy RK. U.S. board-certified pain physician practices: uniformity and census data of their locations. J Pain. 2007;8(3):244-250.
- Buser BR. A single, unified graduate medical education accreditation system. J Am Osteopath Assoc. 2012;112(12):772-773.
- Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502-511.
- Carinci AJ, Mao J. Pain and opioid addiction: what is the connection? Curr Pain Headache Rep. 2010;14(1):17-21.
- Chon TY, Lee MC. Acupuncture. Mayo Clin Proc. 2013;88(10):1141-1146.
- Christo PJ. Opioid effectiveness and side effects in chronic pain. Anesthesiol Clin North America. 2003;21(4):699-713.
- Coyle N. Facilitating cancer pain control in the home: opioid-related issues. Curr Pain Headache Rep. 2001;5(3):217-226.
- de Bruin SR, Versnel N, Lemmens LC, et al. Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health Policy. 2012;107(2-3):108-145.
- Debono DJ, Hoeksema LJ, Hobbs RD. Caring for patients with chronic pain: pearls and pitfalls. J Am Osteopath Assoc. 2013;113(8):620-627.
- Desjardins G, Cahalan MK. Subspecialty accreditation: is being special good? Curr Opin Anaesthesiol. 2007;20(6):572-575.
- Fanciullo GJ, Rose RJ, Lunt PG, Whalen PK, Ross E. The state of implantable pain therapies in the United States: a nationwide survey of academic teaching programs. Anesth Analg. 1999;88(6):1311-1316.
- Gold PM. The 2007 GOLD Guidelines: a comprehensive care framework. Respir Care. 2009;54(8):1040-1049.
- Gourlay DL, Heit HA. Pain and addiction: managing risk through comprehensive care. J Addict Dis. 2008;27(3):23-30.
- Huntoon E. Education and training of pain medicine specialists in the United States. Eur J Phys Rehabil Med. 2013;49(1):103-106.
- Johnson SH. Providing relief to those in pain: a retrospective on the scholarship and impact of the Mayday Project. J Law Med Ethics. 2003;31(1):15-20.
- Labianca R, Sarzi-Puttini P, Zuccaro SM, Cherubino P, Vellucci R, Fornasari D. Adverse effects associated with non-opioid and opioid treatment in patients with chronic pain. Clin Drug Investig. 2012;32 Suppl 1:53-63.
- Lalani I. Emerging subspecialties in neurology: Pain medicine. Neurology. 2006;67(8):1522-1523.
- Lee MC, Tracey I. Imaging pain: a potent means for investigating pain mechanisms in patients. Br J Anaesth. 2013;111(1):64-72.
- Livengood JM, Johnson BW. Are we training future pain specialists? Pain Pract. 2003;3(4):277-281.
- Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173(17):1639-1643.
- Manchikanti L, Boswell MV, Raj PP, Racz GB. Evolution of interventional pain management. Pain Physician. 2003;6(4):485-494.
- Merskey H, Bogduk N, International Association for the Study of Pain. Task Force on Taxonomy. Classification of chronic pain : descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press; 1994.
- Narouze SN, Provenzano D, Peng P, et al. The American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, and the Asian Australasian Federation of Pain Societies Joint Committee recommendations for education and training in ultrasound-guided interventional pain procedures. Reg Anesth Pain Med. 2012;37(6):657-664.
- Nicholson S. Barriers to Entering Medical Specialties. NBER Working Paper Series. 2003;Working Paper 9649:1-37.
- Novy D, Hamid B, Driver L, et al. Preliminary evaluation of an educational model for promoting positive team attitudes and functioning among pain medicine fellows. Pain Med. 2010;11(6):841-846.
- Pioli G, Davoli ML, Pellicciotti F, Pignedoli P, Ferrari A. Comprehensive care. Eur J Phys Rehabil Med. 2011;47(2):265-279.
- Rathmell JP. American Society of Regional Anesthesia and Pain Medicine 2011 John J. Bonica Award Lecture: the evolution of the field of pain medicine. Reg Anesth Pain Med. 2012;37(6):652-656.
- Schnitzer TJ. Update on guidelines for the treatment of chronic musculoskeletal pain. Clin Rheumatol. 2006;25 Suppl 1:S22-29.
- Seppala M. Patients with pain and addiction: what’s a doctor to do? Minn Med. 2006;89(9):41-43.
- Shapiro LJ. Transforming the future of medicine. Mo Med. 2013;110(5):389-392.
- Trescot A, Hansen H, Helm S, Varrassi G, Iskander M. Pain management techniques and practice: new approaches, modifications of techniques, and future directions. Anesthesiol Res Pract. 2012;2012:239636.
- Turk DC, Dworkin RH. What should be the core outcomes in chronic pain clinical trials? Arthritis Res Ther. 2004;6(4):151-154.
- van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology and its clinical relevance. Br J Anaesth. 2013;111(1):13-18.
- Venkat A, Fromm C, Isaacs E, Ibarra J. An ethical framework for the management of pain in the emergency department. Acad Emerg Med. 2013;20(7):716-723.
- Weingarten TN, Martin DP, Bacon DR. The origins of the modern pain clinic at the Mayo Clinic. Bull Anesth Hist. 2011;29(3):33, 36-39.