Chronic nonmalignant pain is one of the most difficult types of pain to treat. Treating chronic pain is problematic because there may be little known as to what causes the pain, and the pain often occurs in the absence of any ongoing illness or disease. The pain usually occurs following an acute injury, but for an unknown reason, continued pain signals are sent to the brain after the injured area has healed. While a pain-free patient is the ultimate goal for all physicians, each one may approach the treatment for chronic pain in different ways. Woody McDaniel works for Dr. Ron Moon at The Industrial Athlete in Birmingham, and he said their treatment options depend on the patient. “Pain management is what we do to get the patient to a point where he or she can function and live with the pain but not be overmedicated to the point that it can cause social problems,” he said. Their treatment protocols include functional pain management where they teach patients how to stretch, exercise and utilize “corrective techniques” and soft tissue manipulation to relieve enough pain that they can reduce medication. “We typically have four types of ‘chronic pain patients’: those who are pure pain patients; those who are pure addicts; those who are chronic pain patients who have become addicts; and those addicts who have chronic pain,” said McDaniel. The goal as a physician is to determine your patient type and develop an individualized treatment program for each patient. Heather Waters, program director for The Industrial Athlete, said they often are required to treat the patient who becomes addicted to an opiate drug such as Lortab or OxyContin. While physicians carefully monitor the use of these drugs and adhere to federal dosing requirements, some patients still develop a dependency on these medications. “I’ve seen orthopedic surgical patients who stay on these meds for four weeks and come off them with no problem, but we also see some patients who have been on opiates for 18 years,” Waters said. “For those patients, we have an opiate dependency program to help them get off their medications and on something less addictive that will control their pain.” Waters said most patients stay on the program for six months to a year. “The longevity is important,” she added. McDaniel pointed out that if a true pain patient is addicted to a pain medicine, they still have a pain issue to deal with after coming off the drug. “The objective of pain management is to get to a point where the patient can function and feels that life is worth living,” he said. Dr. Brad Goodman, a psychiatrist who treats pain and musculoskeletal disorders at Alabama Orthopedic Spine & Sports Medicine Associates PC at Medical Center East, does not provide medicine management for pain. Instead, he specializes in providing exercise therapy and precisely guided, targeted injections done under a live X-ray beam to identify the source and alleviate the pain. “My goal is to try to address the underlying problem through injections and exercise,” Goodman said. “Pain medicine management is vitally important and patients need it; it just isn’t my practice.” These diagnostic injections follow a strategy. First, determine what could be causing the pain. Next, inject the structure that is most likely the pain source with a medication that should reduce or eliminate the pain temporarily. If the pain is eliminated, then the structure injected is almost surely the cause of the pain, Goodman said. Goodman’s ideal patients are those who have been addicted to pain medicines previously and need help monitoring their pain without narcotics. “Another ideal patient is the one with a problem who wants to avoid surgery if possible,” he said. When surgery is necessary, Goodman works closely with the surgeon to help identify the problem and the prognosis. “With diagnostic injections, we can more precisely provide a diagnosis so the surgeon has a better idea whether he or she can get a good outcome surgically,” he said. August 2007