DRAFT POLICY * DRAFT POLICY * DRAFT POLICY *

The Board will discuss the policy statement and receive public comment about it on May 20. Written comments for the Board are due by April 24 and should be mailed to Board Executive Director Mark Bowden, 400 S.W. Eighth Street, Suite C, Des Moines, IA 50309 or emailed to mark.bowden@iowa.gov.

Iowa Board of Medicine Draft Policy on Chronic Interventional Pain Management

Approved ___________

This policy statement is not a legally binding opinion of the Board, but is only intended to provide guidance to the public. The Board may make formal policy only through administrative rules, declaratory orders or contested case decisions.

Definition

Chronic interventional pain management, as defined by the National Uniform Claims Committee, is the diagnosis and treatment of pain-related disorders primarily with the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain.1 Interventional pain techniques include percutaneous (through the skin) needle placement. Drugs are then placed in targeted areas, nerves are ablated (excised or amputated), or certain surgical procedures are performed. By way of example, procedures often involve injection of steroids, analgesics, and anesthetics and include: lumbar, thoracic, and cervical spine injections, intra-articular injection, intrathecal injections, epidural injections (both regular and transforaminal), facet injections, discography, vertebroplasty, kyphoplasty, nerve destruction, occipital nerve blocks, and lumbar sympathetic blocks. Interventional pain management may also include the use of fluoroscopy.

Diagnosis and Treatment

Chronic interventional pain management involves interactive procedures in which the physician is called upon to make continuing adjustments, noting that it is not the procedures themselves, but it’s the “the purpose and manner in which such procedures are utilized” that demand the ongoing application of direct and immediate medical judgment that constitutes the practice of medicine. These procedures are used to assess the cause of a patient’s chronic pain, as a therapeutic modality of treatment, and as a basis on which to recommend additional treatment, including the need for surgical intervention and repeated or additional treatments. Often times the pain physician will perform a different chronic interventional pain management procedure than prescribed by the referring physician based on the pathophysiology of the patient and the determination that a patient would be unable to withstand the prescribed procedure. In order to practice competent chronic interventional pain management the pain physician must understand

1 Manchikanti, L. Medicare in interventional pain management: A critical analysis. Pain Physician. 2006;9: 171-197.

the particular history of the patient, which includes a complete neurological, musculoskeletal and psychological assessment, as well as review of the available diagnostic studies (both pre-procedure images and those obtained during the actual performance of the procedure). Only then can the pain physician develop a proper treatment plan which may or may not differ from the referring physician’s order.2 Chronic interventional pain management requires constant medical diagnosis and judgment.

Risks

Interventional pain medicine carries serious risks: infections, brain damage, paralysis, or, even death.3 The assessment of risks of invasive procedures must always be taken into account. The performance of a “simple” epidural steroid injection, for example, for a herniated disk may be associated with a multitude of side effects and complications including weight gain, immune system suppression, spinal headache, nerve damage or even paralysis.4 Issues of concomitant administration of anticoagulants and the appropriate management of these when performing spinal or perispinal injections remains a paramount concern as well. Complications associated with performing these procedures without proper training arise not only from the procedures themselves, but from mismanagement of the patient as well.5 Allied health care practitioners, including certified registered nurse anesthetists, and others, do not possess the medical training or, therefore, the requisite knowledge or equivalent skills to perform the above in a safe and competent manner.

Chronic interventional pain management constitutes the practice of medicine.

The practice of chronic interventional pain medicine has been established as a separate and distinguished subspecialty of medicine in medical schools and in medical residencies and fellowships throughout the United States for decades. Established academic medical centers have pain medicine training programs within numerous medical specialties, and these training programs are recognized for eligibility for board certification and are recognized by the American Medical Association. Chronic interventional pain medicine training involves intensive medical training and education in academic and other medical centers by physicians who are themselves certified as physician pain medicine specialists.6 The duration of pain management training exceeds by at least one year the intensive medical residency period, adding one to two years to the duration of supervised medical interventions and treatments involving full-time patient care and responsibility as well as participation in research.

2 Spine Diagnostics Center of baton Rouge, Inc. v. Louisiana State Board of Nursing, 2008 WL 5351729, p. 14 (La.App. 1 Cir.)

3 Timothy Wayne McDuell v. Health Care Indemnity, Inc., 2001-0057, Medical Review Panel Proceeding, State of Louisiana.

4 Id.

5 Id.

6 ACGME Program Requirements for Fellowship Education in Pain Medicine. July 1, 2007.

 

Upon completion of a pain management residency, pain physicians are certified by the American Board of Interventional Pain Physicians (ABIPP). This board is recognized by the American Board of Medical Specialties (ABMS). The ABIPP certification exam exclusively tests the physician’s knowledge regarding pain assessment (5%), diagnostic testing (5%), pain syndromes (15%), interventional techniques (15%), and other issues related to the practice of pain management.7

CRNAs do not possess the requisite education or training to practice medicine and, particularly, to perform chronic interventional pain management.

Lack of training. Nurse anesthetists are required to have a bachelor’s degree which earns them an RN designation. They then undergo CRNA training which consists of 18-24 months of didactic and clinical training in administration of anesthetics. By way of example, CRNAs only receive a total of six to seven years of total education compared to a physician practicing chronic interventional pain management who is required to have a minimum education of twelve years, and several have up to sixteen years of documented education.CRNAs cannot document any formal education in performing chronic interventional pain management.8 In fact, the College of Accreditation’s (COA) current standards, last revised in January 2006, do not require nurse anesthetist programs to provide any clinical case experience in pain management (acute or chronic).9 Additionally, the COA does not list pain management in the description of “full scope of practice” for a CRNA.10 This acknowledgment by the national accreditation body that the medical specialty of chronic interventional pain management is beyond the skills of a CRNA further supports the separation between nursing and medicine.

Since CRNAs cannot show any formal didactic or clinical training, many justify their competency to practice medicine by attending a weekend seminar. In a 2008 American Academy of Pain Management newsletter, it was reported that the American Association of Nurse Anesthetists was pursuing continuing education shortcuts to expertise in interventional pain-management techniques.

Through the Institute for Post Graduate Education, AANA is offering a 3-day Interventional Pain Management Cadaver Model Lab course for CRNAs. The course’s learning objectives include epidural steroid injections, discography, facet injections, coding, and cervical, thoracic, and lumbar radiofrequency lesioning. Although a 3-day comprehensive course in interventional pain management may not seem adequate for providing comprehensive knowledge in the discipline, it is the amount of training that most CRNAs receive in the practice of pain management. The prevailing argument is that doing epidural and selective nerve

7 Web. ABIPP Information Bulletin for Certification as Fellow for Interventional Pain Practice. http://www.abipp.org/forms/diplomate/default.aspx. Retrieved December 3, 2008.

8 Web. University of Iowa College of Nursing Anesthesia Nursing Course Sequence, (www.uiowa.edu). Retrieved November 24, 2008.

9 COA, Standards for Accreditation of Nurse Anesthesia Education Programs, 2004 edition, revised January 2006. p. 6-7.

10 Id. Glossary, p. 25. Note that this definition is attributed to “Scope and practice for nurse anesthesia practice,”available from the AANA.

 

blocks for acute pain in the operation room will naturally extend to performing interventional procedures for chronic pain.11

Lack of certification. Unlike physicians, the only certification a CRNA can receive in this area is from the American Academy of Pain Management (AAPM). In order to sit for the 100 question AAPM certification exam, one must only possess a bachelor’s degree in a health care related field.12 In addition, the exam rarely contains a single question regarding interventional pain management. This certification process may better inform a CRNA regarding patient pain but obviously is not designed to elevate a CRNA to the position of a physician pain specialist.

Rural Access

The Board reviewed state maps demonstrating the location and availability of pain management specialists throughout Iowa and along its bordering states. The maps show that at any given location within Iowa a patient’s access to chronic interventional pain management treatment is never more than 120 miles away. Chronic pain by its own terms (nature) does not require emergency treatment; rather, it has time to be treated. The availability of such treatment at the hands of trained specialists is more than sufficient to meet our rural citizen’s needs, while at the same time removes the risk of patients receiving such treatment form unqualified practitioners.

Conclusion

The Board concludes that the practice of chronic interventional pain management, including the use of fluoroscopy, is the practice of medicine and is not within the scope of practice of other health care professionals, including CRNAs. Physicians and osteopathic physicians are trained to diagnose and treat pain using a myriad of diagnostic techniques and a wide variety of treatment modalities. Advanced specialty training in chronic interventional pain management allows for sufficient education in pain, pain management and related areas, e.g., radiology, that supports the proper performance of chronic interventional pain management. Other health care professions, including CRNAs, lack the breadth or depth of education and expertise that physicians and osteopathic physicians possess in chronic interventional pain management. For this reason the Board finds that specialty trained physicians and osteopathic physicians credentialed, and actively engaged in, chronic interventional pain management are the most prepared to offer safe chronic interventional pain management.

The Board recognizes that other health care professionals, including CRNAs, have a great deal to offer in the treatment of pain and the Board encourages physicians to work cooperatively with these other health care professionals. However, due to the inherent risks involved in chronic interventional pain management and the limited education and training possessed by other health professionals, including CRNAs, the Board finds that other professionals performing chronic interventional pain management procedures should do so only under the supervision of a physician or osteopathic physician who is actively engaged in the practice. Physicians and

11 Web. Francis, Michael. LSBN to Allow CRNAs to Practice Pain Management Procedures. Pain Medicine Network. Winter, 2008. 4. www.painmed.org/pdf/2008winter_newsletter.pdf.

12 Web. American Academy of Pain Management Credentialing Brochure, revised 01/31/08. www.aapm.com.

 

osteopathic physicians considering such supervision should have an appropriate understanding of the other health care professional’s training and experience in the proposed procedures.

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