The American Society of Interventional Pain Physicians estimates the United States has fewer than 7,000 practicing interventional pain physicians. Meanwhile, approximately 60 million Americans live with chronic pain, including roughly 21 million with high-impact chronic pain, pain that substantially limits a person’s ability to work, care for themselves, or participate in social activities. These numbers translate to roughly 3,000 patients with high-impact chronic pain per interventional physician. This is an impossible patient load. The math alone demonstrates that interventional pain falls far short of meeting the need. Other forms of treatment are necessary.
Interventional pain faces other limitations. Common interventional procedures are best suited for selected neuropathic, radicular, or regional musculoskeletal pain. They have limited or no role for many other causes of chronic pain, including widespread joint pain from rheumatoid arthritis or connective tissue disorders, structural deformities caused by congenital abnormalities or trauma, and pain arising from internal organs such as pancreatitis. They are also poorly suited for pain caused by inadequate blood flow, infected ulcers, ill-fitting prosthetic limbs, and many central pain syndromes, including some forms of post-stroke and phantom limb pain. Episodic pain syndromes such as sickle cell disease present another challenge. Pain patients need additional options beyond interventional pain.
Even when interventional procedures target appropriate types of pain, their benefits are generally regional. An epidural steroid injection might make sense for someone with unilateral sciatica. However, many patients have pain in multiple body regions from backs to feet, knees, and other body parts. No regional intervention, regardless of effectiveness, can simultaneously treat widespread pain. These patients require systemic, whole-person approaches, including appropriate medications.
Many patients are poor candidates for various interventional procedures. Clotting disorders, uncontrolled medical conditions, anatomical abnormalities, inability to provide informed consent, and other circumstances can render certain procedures inappropriate. Access to other treatment options is essential.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Interventional pain also faces limitations of perspective. The interventional model tends to conceptualize pain primarily as errant neural signals. “Interventional pain” is so named because the goal is to “intervene” in the transmission of pain signals. The focus is on the symptom rather than the whole patient.
My three decades as a family physician have given me a different perspective. I’ve seen chronic pain destroy patients’ ability to maintain gainful employment, fulfill family obligations, and function as contributing members of society. I’ve watched patients go from being the primary breadwinner to becoming a major drain on family resources. I’ve witnessed social isolation set in as patients lose their ability to participate in family activities and friendships. I’ve watched standards of living collapse along with self-esteem, as independence is replaced by reliance on government programs. Hopelessness can turn into despair, depression, and suicidality.
Chronic pain is not merely an unpleasant sensation. It can destroy who the person is, taking away their sense of identity, self-worth, and dignity. It can impact their ability to earn a living, affecting their role in the family. It can rob them of their lifestyle, financial security, their social circles, and much more. Chronic pain is a destroyer of dreams. It can be transformative in the worst possible way.
Pain is best approached through a biopsychosocial model. Unfortunately, very few interventional pain clinics offer multidisciplinary approaches to coordinated care for their patients’ physical, psychological, and social needs.
To summarize, the ratio of interventional pain physicians to patients makes it mathematically impossible to service the chronic pain population’s needs. Many types of pain are not amenable to interventional procedures. Interventions cannot address the multifaceted impacts of chronic pain. Interventional pain isn’t enough, not by a long shot.
Who else can take care of chronic pain? The logical answer is primary care. No other specialty has the bandwidth to care for 21 million high-impact chronic pain patients. Primary care is also uniquely positioned to adopt a biopsychosocial approach to chronic pain management.
Aren’t opioids too risky? Won’t expanding opioid prescribing unleash another opioid epidemic? These are legitimate concerns. Opioids can cause dependence, addiction, and death. But opioid-related risks do not mean that opioids have no legitimate role in treating chronic pain. After all, we use medications with potential for serious harms throughout all of medicine.
Opioids are not intrinsically too addictive to prescribe. Opioids were widely prescribed for much of the 20th century without producing anything resembling the current epidemic. Blaming the opioid crisis on the addictive nature of opioids is too simplistic, ignoring key roles played by Purdue Pharma, pill mills, illicit opioids, and other factors.
In the aftermath of the opioid epidemic and the backlash against opioid prescribing, a multibillion-dollar ecosystem emerged around interventional pain. I call this ecosystem the “pain-industrial complex.” It includes physicians and surgeons, hospital systems, imaging centers, and companies producing equipment, supplies, devices, and surgical hardware.
I suggested in a previous KevinMD.com article that the terrible reputation opioids have today might have been promoted and/or augmented by the pain industry’s agenda to restrict opioid prescribing. I’m not implying the existence of any formal or clandestine conspiracy, but the pain-industrial complex shares a common non-opioid treatment philosophy. From a business perspective, opioids can be jointly perceived by this industry as their major competitor. With billions invested in interventional pain and surgery, the context of the opioid epidemic makes villainizing opioids an easy and effective strategy.
Opioids are not the enemy. Interventional pain clearly cannot meet the needs of the chronic pain population. Appropriate patients should not be denied access to opioids simply because these medications carry risks. Opioids must remain part of our pain management toolkit.
The goal is neither to maximize nor to eliminate opioids from chronic pain management. The goal should be to give physicians and patients access to every available tool to appropriately relieve suffering. Opioids must not be taken off the table.
Chronic pain respects no demographic privilege. No one is immune. Each of us, and everyone we love, could fall victim to a lifetime of pain. We must protect access to effective pain treatment, including appropriately prescribed opioids, for all our sakes.
Simon Feng is a family physician and addiction medicine specialist in Indiana, where he serves as medical director of two opioid treatment programs and runs an independent clinic managing chronic pain patients on opioids as well as outpatient addiction. He is affiliated with Valle Vista Health Systems.
He graduated from medical school in Vancouver, Canada, and practiced family medicine for three decades. His career took him from a rural mining town in the Canadian Rockies to urban Toronto and suburban Indiana, and his clinical experience ranges from delivering babies to nursing homes, urban ERs, and office-based practice.
When pharmaceutical companies began aggressively promoting opioids in the 1990s, he became concerned about the consequences and developed protocols to monitor opioid use and misuse. Colleagues began referring their opioid patients to him, which led to his expertise in managing opioids. He subsequently pursued training in addiction medicine and is certified by the International Society of Addiction Medicine.
He is the author of Abstinence Kills, available on Amazon, and shares his work with more than 70,000 followers on TikTok, spanning more than ten countries across four continents. He can also be found on LinkedIn.
