Keywords

Introduction

Chronic pain is a complex and multidimensional problem. Chronic pain is defined as “pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur” [1, 2]. Other definitions include pain that persists beyond the usual course of an acute disease or a reasonable time for an injury to heal that is associated with chronic pathologic processes that cause continuous pain or pain at intervals for months or years [1,2,3].

Interventional pain management started with the origins of neural blockade and regional analgesia in 1884 [4]. Since then, regional anesthesia and interventional techniques have evolved by leaps and bounds. Today there are claims of overuse, abuse, and fraud [5, 6].

Due to the explosive increase of interventional techniques, accountable interventional pain management , and value-based practice , the performance of evidence-based, cost-effective, and clinically effective techniques is coming into play.

History

The development of interventional techniques dates back to the 1884 invention of regional anesthesia by Koller (a colleague of Sigmund Freud) [4, 7]. Based on this foundation, regional analgesia developed into interventional pain management. Subsequently, in 1899 Tuffer [8] described therapeutic nerve blocks in pain management using spinal injections of cocaine to control pain from sarcoma of the leg. In 1903, Cushing described pain relief with nerve blocks [9] along with reports of trigeminal alcohol blockade [10]. During the same time, spinal interventional techniques also started developing, dating back to 1901, with descriptions of caudal epidural injections by three independent investigators in 1 year [11,12,13].

Around the same time, epidural injections with local anesthetic and various types of nerve blocks were developing. Epidural steroids were described by Robechhi and Capra [14] and transforaminal approach by Lievre [15] in 1952 and 1953. Steroids were reported by Cappio in 1957 [16]. The wide use of epidural steroid injections, since then by multiple approaches, has become very popular [2, 17].

Diagnostic blocks originated from the descriptions of von Gaza [18] in 1924 followed by White [19] conceptualizing the diagnostic utility of procaine block of sensory sympathetic nerves to determine the pathways of peripheral nerves. Subsequently, Steindler and Luck [20] in 1938 described applications for diagnostic interventional techniques. MacNab [21] in 1971 demonstrated the value of diagnostic, selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies and clinical findings of nerve root irritation. The concept of controlled diagnostic blocks was developed by many authors; however, it was popularized by Bogduk [22, 23].

John Bonica nurtured interest in pain medicine and published a seminal work, The Management of Pain, in 1953 and started a multidisciplinary clinic in 1960 [24]. Vandam and Eckenhoff [25], in 1954, described the integrative approach.

  • Vandam and Eckenhoff [25], a year after the publication of Bonica’s text on the management of pain [24], suggested that the focus should not only be on pain relief from nerve blocks but also on the basic nature of pain and an integrated approach to treatment.

Subsequently, the twenty-first century has been marked with numerous developments of interest to interventional pain physicians and pain sufferers. The unprecedented development and progress in managing chronic pain, specifically utilizing interventional techniques, heralded the evolution of interventional pain management [1, 2, 5, 6].

Definitions

  • The National Uniform Claim Committee (NUCC) [26] defined interventional pain management as “the discipline of medicine devoted to the diagnosis and treatment of pain related disorders principally with the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatments.”

  • The Medicare Payment Advisory Commission (MedPAC) [27] defined interventional techniques as “minimally invasive procedures including: percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques for the diagnosis and management of chronic, persistent or intractable pain such as laser or endoscopic diskectomy, intrathecal infusion pumps and spinal cord stimulators.”

Development

Organizations

  • The first organization devoted to interventional pain management was started in 1998.

    • The American Society of Interventional Pain Physicians (ASIPP) was conceived in 1998 and has evolved into a premier organization representing more than 50% of interventional pain physicians in the United States.

  • The first multidisciplinary organization, entitled the International Association for the Study of Pain (IASP), was started by Bonica in 1974. It eventually took shape as a biopsychosocial organization.

    • The American Pain Society, the American Chapter of IASP, was established in 1977.

    • This was followed by the American Academy of Pain Medicine, which was founded in 1983.

Specialty Designation

  • Due to the efforts of ASIPP, a specialty code for interventional pain management was conceived in 2001. However, it was converted into pain management (−72) and later on pain medicine [28].

    • A specific code for interventional pain management (−09) was provided by the Centers for Medicare and Medicaid Services (CMS), along with a definition of interventional pain management in 2003 [29].

    • CMS has recognized interventional pain management as an evolving, but crucial specialty, leading to representation on the Carrier Advisory Committees in each state in the United States [30].

Board Certification

  • The American Board of Anesthesiology provided its first subspecialty certification in pain medicine in 1993.

    • The American Board of Pain Medicine provided a board certification in 1993.

    • In 2005, the American Board of Interventional Pain Physicians was established.

    • On the international front, the World Institute of Pain established a fellow of interventional pain practice, testing the competency of physicians in performing interventional techniques.

    • A subspecialty in pain medicine is now provided by the American Board of Anesthesiology, the American Board of Physical Medicine and Rehabilitation, the American Board of Psychiatry and Neurology, and the emergency/sports medicine. They are ABMS-recognized boards; others are in consideration.

  • The American Board of Interventional Pain Physicians, specifically established for interventional pain physicians to promote didactic and practical competency, provides a comprehensive examination system. Part I establishes a candidate’s didactic knowledge, followed by competency testing via oral examination and a practical examination that assess competency of interventional techniques.

    • The American Board of Interventional Pain Physicians also provides multiple competency examinations in controlled substance management, practice management, and fluoroscopic safety.

Accountable Interventional Pain Management

The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, the numerous modalities of treatments applied in managing these patients continue to increase as well. In the period from 2000 to 2013 (Table 1.1 and Figs. 1.1 and 1.2), interventional techniques increased 236% [31, 33]. In addition, an analysis of utilization trends and expenditures for spinal interventional techniques alone from 2000 to 2008 illustrates an increase in Medicare fee-for-service expenditures of 240% in terms of dollars spent in the United States [34]. The Office of Inspector General (OIG) of the Department of Health and Human Services showed an increase in facet joint and transforaminal epidural injections ; a significant proportion of these services did not meet medical necessity criteria [35, 36].

Table 1.1 Utilization of interventional techniques in fee-for-service Medicare population from 2000 to 2013
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Fig. 1.1
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Illustration of distribution of procedural characteristics by type of procedures from 2000 to 2013

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Fig. 1.2
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Utilization of interventional pain management techniques by specialty from 2000 to 2013, in Medicare recipients

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Overall utilization of procedures has increased by 169.2%, with a rate of 105.6% per 100,000 Medicare beneficiaries for epidural injections (Table 1.2 and Fig. 1.3); 415%, with a rate of 293% for facet joint interventions (Table 1.3 and Fig. 1.4); and overall 438% with a rate of 311% for sacroiliac joint interventions (Table 1.4 and Fig. 1.5). Certain high-volume interventions, such as lumbar transforaminal epidural injections and lumbar facet joint neurolysis , have increased a startling 786.6% and 715%, respectively.

Table 1.2 Characteristics of Medicare beneficiaries and sacroiliac joint injections
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Fig. 1.3
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Frequency of utilization of sacroiliac joint injections by specialty groups from 2000 to 2013, in Medicare recipients

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Table 1.3 Utilization rates (per 100,000 Medicare recipients) of various facet joint interventions in the Medicare population from 2000 to 2013
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Fig. 1.4
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Frequency of utilization of facet joint injections by specialty groups from 2000 to 2013, in Medicare recipients

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Table 1.4 Utilization of epidural injections in the Medicare population from 2000 to 2013
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Fig. 1.5
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Frequency of utilization of epidural injections by specialty groups from 2000 to 2013, in Medicare recipients

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Coverage policies across ambulatory settings and by multiple payers are highly variable. Apart from variability in the development of coverage policies, payments also substantially vary by site of service. In general, among the various ambulatory settings, the highest payments are made to hospital outpatient departments (HOPDs) and the lowest to in-office procedures, with payment to ambulatory surgery centers (ASCs) falling somewhere in the middle [34,35,39].

Evolving Role

  • Interventional pain management is an emerging specialty . Consequently, the problems faced by this specialty may be disproportionate compared to established specialties.

    • Interventional pain management is also faced with increased utilization. Increased utilization will reduce the reimbursement for procedures, as the total amounts disbursable are limited, also known as budget neutrality.

  • Rapid advances in interventional pain management have enhanced the ability of physicians to diagnose and treat a variety of painful conditions:

    • This enhanced ability often leads to improved outcomes for patients. However, these improvements, combined with a rise in entrepreneurial activity by physicians, the practice of defensive medicine in order to avoid malpractice suits, and the power of patients who demand more tests and treatments, have led to sharp increases in the volume of interventional pain management services and the expenditures for them.

    • This is similar to imaging services. For imaging services, in recent years, growth in spending has outstripped that of most other services covered by Medicare and private insurers.

  • Many private insurers either have narrowed or may narrow their provider networks, may require all interventional pain management services be preauthorized, and may either have imposed or may impose other constraints to prove medical necessity and brand many procedures as experimental or investigational.

  • Much of the rapid growth in interventional techniques is attributable to the expanded coverage of procedures in multiple settings including facility and nonfacility, increased understanding of the pain and the ability of understanding by the patient community to be managed for their pain problems, the emergence of sophisticated and accurate diagnostic and therapeutic interventions, and the emergence of evidence-based medicine and clinical guidelines.

  • Based on growth patterns and various other issues, Medicare and other insurers have been developing coverage policies at various levels:

    • While coverage policies generally reduce utilization, they may also improve appropriate care by documenting medical necessity and reduce fraud and abuse investigations.

  • Interventional pain management is a predominantly procedural-based service in contrast to pain medicine, which is a cognitive-based service.

  • The recent proposed changes to the physician fee schedule methodology could be harmful for the specialty of interventional pain management.

    • At the same time, this may be an opportunity for interventional pain management to establish not only its distinctive nature differing from pain medicine and other specialties but also to establish practice values, within the framework of budget neutrality.

Key Points

  1. 1.

    The twenty-first century is marked with numerous developments of interest to interventional pain physicians and pain sufferers.

  2. 2.

    Interventional pain management is defined as the discipline of medicine devoted to the diagnosis and treatment of pain and related disorders by the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatments.

  3. 3.

    Interventional techniques are defined as minimally invasive procedures, such as percutaneous precision needle placement of drugs in targeted areas, ablation of targeted nerves, and some surgical techniques, such as discectomy and the implantation of intrathecal infusion pumps and spinal cord stimulators.

  4. 4.

    Chronic pain is considered an acute, recurrent problem that is characterized by periods of quiescence punctuated by flare-ups or, similar to chronic diseases, like diabetes or hypertension, requiring long-term treatment with ongoing care.

  5. 5.

    The first news of neural blockade followed reports from Koller of the numbing effect of cocaine on the tongue in 1884. A description of a therapeutic nerve block occurred in 1899 and a description of caudal epidural injections in 1901.

  6. 6.

    Diagnostic blockade in pain management was pioneered as early as 1924 when von Gaza used procaine for determining the pathways of obscure pain.

  7. 7.

    Board certifications are available by ABMS-recognized boards in anesthesiology, PM&R, and neurology and psychiatry.

  8. 8.

    Overall interventional techniques have increased by 236% with a rate of 156% per 100,000 Medicare beneficiaries; for epidural injections 169.2% with a rate of 105.6%; for facet joint interventions 415% with a rate of 293%, and for sacroiliac joint interventions 438% with a rate of 311%. High-volume interventions such as lumbar transforaminal epidural injections and lumbar facet joint neurolysis have increased by 786.6% and 715%, respectively.

  9. 9.

    Coverage policies across ambulatory settings and multiple payers have been extremely variable with a differential of 70% to 300% higher payments in hospital settings.

  10. 10.

    The primary role of physicians is to improve the health and well-being of patients, with the future of interventional pain management being promising.