HARRIS: Dr. Weil, you are
certified by the American
Board of Physical Medicine & Rehabilitation with a
subspecialty certificate in pain medicine. It is my
understanding that pain medicine became a formal
certification in 1998. Could you tell us more about
this specialty and the training and background
of pain and chronic pain is a
quickly emerging specialty. At this point there are
essentially two ways of becoming board certified in
pain. The first is by the American Board of Pain
Medicine (ABPM). The second is by obtaining
"special qualifications" in pain. Both require taking
difficult examinations and extensive experience in
pain medicine. The second exam is given by the
American Board of Anesthesiology and open to
physicians in the specialties of anesthesiology
(physical medicine and rehabiliation and neurology).
Both are open only to physicians already board
certified in another specialty. I personally have
certification by both of these boards. However, many
physicians who refer to themselves as "pain doctors"
have neither. As pain is an emerging specialty, there
is perhaps less regulation than there ought to be.
It is very hard for patients to know who is who, unless
they directly inquire.
Another difficult issue is that there are similarly
named organizations, such as the American Board
of Pain Management. To obtain "certification" by this
organization, one has to only complete a 100
question multiple choice test. There are no other
requirements. Although the goal is to spread
knowledge about pain, this can add to confusion for
patients actually trying to choose a doctor board
certified in pain. Again, the only two ways of actually
becoming board certified are either through the
American Board of Pain Medicine (ABPM) or the
special qualification exam.
for Pain Medicine
“The specialty of Pain Medicine is concerned with
the prevention, evaluation, diagnosis, treatment, and
rehabilitation of painful disorders. …The pain physician
serves as a consultant to other physicians but is often
the principal treating physician….” http://www.abpm.org/what/
American Board of Pain Medicine
American Board of Anesthesiology
The American Academy of
Pain Medicine (AAPM) http://www.painmed.org/
It seems that the pain specialists come
generally from three or four different disciplines –
psychiatry and neurology, anesthesiology, and
physical and rehabilitative medicine. How would
someone decide whether to choose a pain doctor
and within that specialty, whether to chose
someone who trained in one field or another?
WEIL: As I mentioned
above, pain has two board
certification routes. Both ABPM and the special
qualifications route require board certification in
another specialty. Pain is not truly its own specialty
yet. There are no residency programs that exist yet
exclusively for training in pain.
Thus, when choosing a physician for chronic pain,
even one certified in pain, a patient must examine
the primary specialty. If a patient has a lot of
psychological problems, a psychiatrist may be a
good choice. If one has back, neck or extremity pain,
a physical medicine and rehabilitation physician
(PM&R) with additional training in pain, may be a
good choice. That said, at this point there is a
significant amount of overlap and cross specialty
training in pain.
Many non-pain specialist doctors often give a pain
diagnosis where one does not actually exist. The
reverse is also true. One example is a patient with
adhesive capsulitis (“frozen shoulder”), combined
with carpal tunnel syndrome, that was sent to me
for “reflex sympathetic dystrophy.” I use this example,
as this was a patient I actually saw three days prior
to this writing. Another example is a patient with
"failed back surgery syndrome" that actually had a
new, large disc herniation at the level above the
fusion. The point of these examples is that a pain
doctor, in addition to understanding pain, must have
an excellent background in orthopedics/PM&R, as
well as psychiatry and neurology. There is a great
deal of overlap.
In your practice, you treat many kinds of
patients with severe chronic pain. Is there any
way to predict at the outset who will find relief from
pain and who will continue indefinitely with severe
pain? Are there any tests that predict outcome?
WEIL: No. There
are some, but none has been
shown to be very accurate. Some predictors of a
poor outcome include a great deal of physical
pathology. Another is psychological factors. An
example is a patient who has an external locus of
control (“events happen to me and are beyond my
When I evaluate a patient, I first look at the underlying
pathology. This is certainly a predictor of outcome.
Is there something that has been missed? Most
patients, by the time they get to me, have seen an
average of 5 to 7 other physicians. Despite that, there
is often physical pathology that has been overlooked,
even though the prior doctors may be competent.
Opiates prescribed by medical doctors
have gotten a really bad rap lately. Those who take
them are stigmatized and scrutinized by others.
Just how dangerous is the long-term use of
WEIL: It depends.
In the civil war, morphine was the
only medicine available. It worked for pain and, in
fact, was called "God's own medicine." Opiates such
as morphine have a "bad rap" mainly from misuse.
It is well known that opiates can have a euphoric
effect. A percentage of people who take opiates have
an addiction. Unfortunately, many people assume
that all people who take opiates are addicted.
Addiction means use despite harm. Harm can be
physical, social, financial, etc. Physical dependence,
on the other hand, means that lack of use will have a
negative consequence (i.e., withdrawal). A diabetic is
physically dependent on insulin, but not addicted.
When opioids are properly used, a patient's function
should increase and the danger is minimized..
Another complaint I frequently hear is
that pain is not “objective.” Are there any ways
show that pain really exists in a patient and is not
being faked or exaggerated?
WEIL: There is
no way to tell how much pain a
patient has. No test can objectively measure the
intensity of pain and no imaging device can
accurately show pain. The best tool we have at this
point is the patient's history and physical
examination. Of course, we have some tests to
try to discern whether pain is being exaggerated or
feigned. Sometimes exaggeration can be subconscious. However,
much of the time the
pain is real and requires treatment.
What is your philosophy of treatment?
WEIL: My philosophy
is that treatment of pain should
increase the patient's function. This can be function
such as return to work, increased physical activity,
increased social activity, or other measures.
Treatments including injections, surgery, physical
therapy, medications, psychological programs,
medical devices or other treatments performed at
our practice all have the common goal of increasing
the patient's functioning in the world.
How are you dealing with the restrictions
imposed by the statutory requirement in Labor
Code §4600(b) that your treatment be based on
the ACOEM guidelines?
WEIL: The thought
behind the ACOEM (American
College of Occupational and Environmental Medicine)
guidelines, is that treatment should be based on
"evidence based" medicine. Although this certainly
sounds appropriate, many treatments that are
generally accepted by the medical community are
difficult to prove, especially to prove to the satisfaction
of the patient's insurance company. In fact, for back
pain, for example, no treatment is proven beyond a
reasonable doubt. Thus, the ACOEM guidelines can
be used by insurance companies to justify denial of
How are you dealing with the flood of
utilization review documents?
WEIL: At this
point in time, when most doctors in
California request approval for treatment from a
workers' compensation carrier, the treatment is
typically denied. Often, this has become almost an
automatic response by insurance companies. This is
especially true for patients with cases greater than
3 months old, whom the insurance companies are
already tired of. When treatment is requested, after
the initial denial, an appeal letter has to be written.
Sometimes there is a second denial. The patient's
physician then must speak with an insurance
company physician -- "the peer review." If the
treatment is still denied, the patient's attorney must
take over and threaten an expedited hearing. Often
the treatment is approved just before the expedited
hearing. The flood of utilization review documents is
somewhat of a "paper war" to delay treatment for
patients. The real problem is that insurance
companies have painted all physicians with the
same brush. In reality, it is only a very small
percentage of physicians who try to abuse the
system (i.e., order unnecessary treatments).
information on utilization review, including a complaint
California has two pain laws, the “Pain
Patient’s Bill of Rights” for patients diagnosed
“severe chronic intractable pain,” in the Health
Safety Code, and the “Intractable Pain Law” for
doctors, in the Business & Professionals Code.
How do these laws interact with the workers’
the patient's bill of rights and
intractable pain law are only applied to physicians,
and not insurance companies. This means that
patients are often denied ongoing treatments.
It seems to me that the medications given
for severe chronic pain produce an illness in and
of itself, in that the side effects can be devastating,
particularly the loss of will and the inability to
concentrate or remember or get engaged mentally
in the world outside the body. All of which was
described so well by Thomas de Quincey in
of an Opium-Eater,” published in
1822. How do you deal with this?
WEIL: The answer
to this question goes back to
inappropriate versus appropriate use of
medications. In the "Confessions of an Opium-Eater"
the medications were being misused. Proper use of
opioid medications generally produces an increase
in function and decrease in pain. The physician and
patient must monitor functional progress. Again, if a
patient's overall functioning is decreased, then
opioids should be decreased or discontinued.
Do you have any advice for how to pick a
treating physician? For example, what questions
should a patient ask about the doctor’s training
WEIL: First, does
the doctor listen and address the
patient's complaints as thoroughly as possible? Are
they board certified? Are they board certified in pain
(requires additional training)? Do they treat a large
number of pain patients? Have they had any lawsuits
resulting in significant judgments against them?
Do they understand the importance of increasing a
patient's function? Do they look at the underlying
Lawrence Weil, M.D.
2485 High School Avenue, Suite 201
Concord, CA 94520