Interventional Options for the Management of Chronic Pain

An Interview with Bert L. Fichman, MD

Bert L. Fichman, MD, is Board Certified in Anesthesiology and Hospice and Palliative Medicine. After working for many years as a pain management specialist in suburban New York City, Dr. Fichman transferred to his current practice in the Pain Management Center at Dartmouth-Hitchcock Medical Center in Lebanon, NH.

Evelyn Corsini, MSW:

Where does interventional pain management typically intersect with other treatments for patients with chronic pain?

Bert L. Fichman, MD: I see interventional pain management as one tool in a multi-modal approach to pain treatment. Choosing an interventional treatment depends on the etiology of the pain. The majority of the patients I typically see for interventional pain treatment have back pain or neck pain due to problem with their spine. Typically, the cause of their pain is either age-related, herniated discs, or failed back surgery.

EC: How are patients typically referred to you and how do they transition back to the referring health care provider?

BF: As pain specialists, we’re probably often the last person to see the patient for treatment of chronic pain. Patients are referred to us after their primary care provider or surgeon (orthopedists, neurosurgeons) feel that they have done all that they can do. The consultation will generally be with regard to seeking assistance in improving their level of pain management. Sometimes we provide medication management, and sometimes interventional management. I now practice in an academic setting where patients are often referred from a great distance, and I may likely only see the patient for the initial evaluation and recommendations, occasionally with them returning if they have not had a positive initial response to the treatment plan I formulated. Some patients will stay on for medical management; some will come until they are stabilized on a regimen, or come back for periodic procedures. Previously, when I was in a community practice and the patients lived near my office, many of their referring physicians were more interested in turning over total care of the patient’s pain management to me.

EC: How to do you communicate with referring providers?

BF: A surgeon may refer a patient to me with a request for a specific intervention, or I may get a request from a primary care provider who wants help developing a plan. My first meeting with the patient is to develop the plan, and that plan is communicated to the referring provider by mail or electronically. Once the plan is carried out, I send procedure notes to the referring physician, and they will typically resume the medical management.

EC: Are interventional treatments short or long term solutions for chronic pain? Do you see patients too early or too late in their pain course?

BF: I would say that interventional treatment is a time limited treatment, as procedures such as epidural injections for spinal stenosis, for example, or radiofrequency ablation are not curative. I don’t consider a treatment successful if it only lasts a week or two. If it works for six months, that’s great, and then the patient can probably benefit from repeating the treatment as needed. Sometimes I will plan a series of injections, but there is really no “magic number” for a series of interventional procedures. For example, I usually do not do more than three epidural steroid injections in a year, out of my concern for the risks, including the dose of steroids. The least amount of interventions the better.

Regarding the timing of the referral, for spine problems these patients usually come late, after all other options have been tried. There are other patients though, with sub-acute problems, who I think would probably have benefitted from an earlier referral, to keep their pain from becoming chronic.

EC: From an interventional perspective, which pain conditions are the most challenging, and what works well?

BF: Conditions like abdominal pain and pelvic pain are often the most difficult to treat. The efficacy of neurolytic blocks can be transient, and it is difficult to use spinal cord stimulators for these areas. I have found that the use of intrathecal pumps for non-malignant pain is diminishing in popularity, as there have been increasing numbers of complications, for instance, catheter tip granulomas. It is also not uncommon, when a patient is receiving the intrathecal opioids, that some will still require PO opioids for supplemental breakthrough pain.

I have found neuromodulation with stimulation to be more effective, especially for peripheral and radicular problems. At Dartmouth-Hitchcock Medical Center we have successfully used peripheral nerve stimulation for occipital neuralgia, and supra and infra orbital neuralgias.

EC: What new treatments do you see on the horizon?

BF: The controversy between stimulation and implantable pumps will likely continue. Devices are becoming smaller and smaller, technology is improving, batteries are getting smaller, and the devices are much more user-friendly. Unfortunately, we don’t have a lot of good data about what works and what doesn’t work, so we need to see the results of more research. I think there will be more pressure by insurers and patients for pain physicians to practice evidence based medicine. It is a very reasonable goal to provide cost effective treatment that has been shown to work.

When I see a patient with chronic pain, I will consider all treatment modalities, including medical management. I don’t want to use a treatment that is not long lasting and therefore, not worth the risk and the cost.