EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

When I was in medical school, one of the first things I learned was the value of making a precise diagnosis. The more precise the diagnosis, the more precise the treatment, the management, and the prognosis. Because chronic pain is subjective, with no objective measurement of its intensity, this model is extremely important when dealing with chronic pain. Many questions need to be precisely answered before further treatment is authorized for patients with chronic pain. When critical therapeutic decisions must be made for a given patient, the questions below may help refine the diagnosis and define the medical baseline for each patient.

General/Diagnostic

Is there a specific medical/surgical diagnosis (as opposed to chronic pain)?
Does the pain fit the biomedical model, or does it fit the psychosocialbiological model?
Is the pain neuropathic or nociceptive?    
What other medical conditions are present?
Has there been a psychosocial assessment?
Has there been an AME/QME report?

Medications

What are the specific medications currently being prescribed (both WC and non-WC)?
What is the Morphine Equivalent Dose (MOD) the patient is taking?
Is there a pain contract?
Is there a CURES report?
Has the patient had a UDS?        
Is the patient (possibly) diverting (some of) the medication?        
Does the dose of prescription medication indicate the possibility of non-medical use?
Do any medication Black Box warnings apply to this patient?
Are the medications causing any adverse side effects?

Function

What is the precise functional capacity of the patient?
Is the patient working?

Programs

Has a detoxification program been considered/attended?
Has a chronic pain program been considered/attended?    
Has a functional rehabilitation program been considered/attended?
Has a multidisciplinary pain clinic been considered/attended?
Has the patient attempted an active rehabilitation program?

Treatment

What surgical procedures/interventional have been performed?
Frequency of visits; last periodic review

Additionally, California treating physicians are bound by the Medical Board of California’s Pain Act, “Guidelines for Prescribing Controlled Substances for Pain,” 2007, as noted below:
http://www.medbd.ca.gov/pain_guidelines.html:

1. The physician must perform an appropriate prior medical exam documenting an assessment of the pain, physical and psychological functioning, substance abuse history, history of prior pain treatment, and an assessment of underlying or coexisting diseases or conditions
2. The physician must identify a medical indication
3. The physician must keep accurate and complete medical records, including treatment, medications, and periodic reviews (at least annually) of treatment plans
4. The physician must define the treatment plan and objectives including pain relief and functional improvement.

As we develop our exciting new Next Step Medical Advisory Program℠ to deal with the most complicated cases, we find it more and more important to establish the above information when dealing with chronic pain patients. Obtaining this amount of information may be exhaustive and very difficult to achieve, but it must be completed for each patient. Surgery, imaging, interventions, and tertiary consultations are not warranted in chronic pain patients until a precise diagnosis is made and certain baselines, as noted above, are established.

As stated in MTUS, chronic pain must be managed, not cured.  It is difficult, if not impossible, to prescribe an effective treatment and management plan without a precise diagnosis and understanding of the patient’s medical and functional baseline. Making a precise diagnosis and establishing baselines will provide greater insight into appropriate therapeutic and management strategies.