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Department of Anesthesiology
Duke University Medical Center
Box 3094
Durham, NC 27710

Office of Medical Education
Duke University Medical Center
Box 3005
Durham, NC 27710

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Pain Management

Clinical Program

The Pain Service at Duke treats patients on both an inpatient and outpatient basis. Both services continue to see strong growth in the number of patient encounters. This multidisciplinary clinic includes clinicians from anesthesiology, neurology, psychiatry, neurosurgery, psychology and physical therapy. The range of services provided includes comprehensive evaluation of pain problems and therapies including medical management, nerve blocks, infusion therapies, evaluation for invasive procedures such as intrathecal pumps and spinal cord stimulators, neuroablative procedures, acupuncture, biofeedback, guided imagery, relaxation techniques, and physical therapy. This truly unique pain program is one of the few successful multidisciplinary pain clinics in the country. The proximity of the clinicians from varying backgrounds with a common interest in pain management has encouraged collaboration in clinical care, research, and teaching.

Anesthesiologists in the pain clinic evaluate and treat all types of chronic pain syndromes including neuropathic pain, musculoskeletal pain, headaches, cancer pain, as well as sympathetic and visceral pain syndromes. The comprehensive evaluation in the clinic includes a detailed pain history, physical examination, and laboratory assessments as indicated. Patients seen in the multidisciplinary clinic complete a comprehensive Pain Perception Profile to evaluate the multiple factors involved in the generation of chronic pain syndromes. The emphasis on the multidimensional aspect of pain evaluation and treatment is in accordance with the original mission of the pain clinic.

During 2004, the anesthesiology pain practitioners continued to see a large volume of patients for both procedures and clinic visits (see Table 1). The range of procedures performed at the anesthesiology pain clinic was also expanded to include intrathecal pump refills, radiofrequency lesioning, and Botox® injections.

Since opening in October of 2000, patient volumes at the Morreene Road Pain Clinic facility for clinic visits and injections have remained strong. This volume has not been at the expense of the thorough patient evaluations on which the attending staff takes great pride. Despite the busy clinic schedule, the anesthesiology pain clinic continues to accommodate same day consultations for urgent issues such as cancer patients, post lumbar puncture headaches, evaluations for injection therapy from the Back and Spine Clinic. Drs. Anne Marie Fras, Billy Huh, and Dianne Scott provide new patient consultations in the pain clinic. Allison Taylor, PA-C, assists in patient evaluation, continuity of care and performs the refilling and reprogramming of the intrathecal pumps.

The inpatient Acute Pain Service (APS) continues to provide patient care on a 24-hours per day, 7 days per week basis. The coverage that Drs. Brian Ginsberg, Huh and Fras provide is extensive. The APS establishes continuous catheters and maintains those established in the operating room for post-operative pain control. In addition, consultations are provided for difficult postoperative patients without catheters and for inpatients with chronic pain syndromes.

In 2004, the relationship between the APS and the members of the regional anesthesiology group was strengthened as the two groups collaborated to offer patients in the Musculoskeletal Center a unique form of postoperative pain management with the continuous peripheral nerve catheters and patient-controlled regional anesthetic blocks following joint replacement and other types of orthopedic extremity surgeries. At the end of 2004, members of the regional anesthesiology group began to round on the APS and this cooperative coverage for postoperative pain management is expected to strengthening in 2005.

Approximately 2,400 patients were followed on the APS in 2004; 1,571 of these patients had continuous epidural/caudal catheters and seven had intrathecal catheters (see Table 2). The number of patients followed with peripheral catheters continued the upward trend in 2004. This was primarily due to an increase in lumbar plexus and sciatic catheters placed for hip and knee arthroplasties. In 2004, there were 315 patients followed by the APS with lower extremity catheters and 147 patients with upper extremity catheters (total number of peripheral catheters was 537 for 2004). The inpatient pain service collaborates with the pain management pharmacists, who have traditionally answered dosing and medication questions. Five specially trained nurses assist the attending physicians in providing patient care on the APS. In addition, the nurses also assist in delivering stress management services that are frequently used as a complimentary method to the pharmacologic management provided by the APS.

The Durham VA Medical Center has seen expansion in the pain clinic as well. In 2004, the clinic moved into a newly designed custom space which tripled the clinic square footage. In addition, the VA pain clinic has access to fluoroscopy from the new space. Dr. Joel Goldberg continues to provide the leadership for that clinic. Dr. Goldberg and Dr. David Lindsay staff the anesthesiology pain management program. In addition, the clinic staff includes one psychiatrist and one nurse practitioner. The clinical activity of the VAMC increased to 4,224 visits in 2004 from approximately 3,700 patient visits in 2003.The clinic meets 4 days/week with one additional day of invasive procedures and inpatient consultations are provided 5 days/week. Dr. Goldberg has expanded clinical teaching by offering a training course for Fayetteville, NC, VAMC physicians. The pain fellows split time between the VAMC, the Morreene Road Clinic, and the APS. In addition, elective rotations with physicians from other pain disciplines are encouraged. The resident and fellowship education with the APS focuses on the evaluation and treatment of chronic pain patients in the Duke Pain Clinic and the VA Pain clinic, in addition to the strategies for postoperative pain management acquired on the APS.

The leadership of the division continued under interim division chief, Dr. Fras. This year Dr. Huh assumed the leadership for resident and fellow education and research in the pain division. Under Dr. Huh’s direction, the strong tradition of formal teaching conferences with the weekly lecture series, weekly journal club, monthly case conferences, and multidisciplinary case conferences with the spine surgeons and the neuroradiologists at Duke continued. The weekly academic conference has expanded its scope and educational mission to include the participation of practitioners from all specialties that treat chronic pain patients. Attendees and lecturers this past year have included anesthesiologists, neurologists, physical therapists, psychiatrists, internists, emergency medicine physicians, and psychologists. All bring their unique perspective and experience for the benefit of the group and the patients treated in the clinic. We have hosted experts from a broad range of clinical backgrounds within the Duke community as speakers. In addition, many nationally recognized experts in pain management have presented at our weekly didactic academic conferences.

Training Program

This year’s fellows, Drs. Shahzad Choudry and Janice Victor, have acquired valuable experience with the medical, psychological, and procedural aspects of the treatment of the patient in pain. The fellows have learned not only pain management injection techniques and use of the fluoroscope, but also advanced, interventional techniques such spinal cord stimulation, radio-frequency lesioning, intrathecal pump insertion, diagnostic discography, and neuro-ablative techniques for cancer pain management. The fellows organized a cadaver course, which attracted attention from many pain practitioners in the region.

Research Program

Research has continued in the division. Dr. Huh is investigating yohimibine infusion as a diagnostic test for the presence of complex regional pain syndrome. In addition, he is looking into the effects of high concentration local anesthetics in facet joint injections. Prior to his departure from Duke, Dr. Randall Brewer began a multicenter trial investigating intralaminar versus transforaminal lumbar epidural steroid injections for the treatment of acute low back pain which continues. In addition, Dr. Huh has a study evaluating intralaminar versus transforaminal lumbar epidural steroid injections for the treatment of chronic low back pain. Drs. Fras and Scott continue to collaborate with the behavioral management practitioners investigating areas of anger and self-discrepancy in patients with low back pain. Dr. Fras is collaborating with other pain clinic faculty on pharmacologic therapies for fibromyalgia. The project designed by the fellows involves a comparison of an amitriptyline cream and lidocaine cream for the treatment of neuropathic pain syndromes such as post-herpetic neuralgia, post-thoracotomy pain syndrome (Dr. Victor and former fellow, Dr. Eric Miller).

Table 1. Pain Clinic Statistics, 2004

Table 2. Acute Pain Service Statistics, 2004

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Winston C.V. Parris, MBBS, DA, FACPM, DABPM
Chief, Division of Pain Management
Professor of Anesthesiology
Office: (919) 684-6736
E-mail: parri035@mc.duke.edu

Faculty
Anne Marie Fras, MD
Brain Ginsberg, MB, ChB (Acute Pain Service)
Joel S. Goldberg, MD (Director, Pain Management, Durham VAMC)
Billy K. Huh, MD
David Lindsey, MD (VAMC)
Lesco Rogers, MD
Dianne L. Scott, MD
Allison Taylor, PA-C

Fellows
Jason Ravanbakht, MD
Matthew Ranson, MD
Garlon Lee Campbell, MD

Support Staff
Linda Hockaday
Lynda Zirillo
Stacy Morris