As The National Pain Foundation's newest monthly columnist, Dr. John Oakley will focus on interventional pain management. Interventional pain medicine includes the diagnosis and treatment of pain by applying techniques that directly interact with the structures involved with a patient's pain. Dr. Oakley's "Interventional Pain Management" column will focus on the actions physicians can take to modify or manage the effects of pain, including introducing medications, electrical current, heat, cold or chemicals at the sites within the body involved in producing pain.

Dr. Oakley has been interested in pain management techniques since doing an anesthesia rotation in the early 1970s with Dr. John Bonica, a physician who was instrumental in establishing pain medicine as a medical specialty and who helped establish the first real pain clinic in the country at the University of Washington, Seattle. "Dr. Bonica would bend my ear about pain," says Dr. Oakley, "and Dr. John Loeser would talk about concepts of pain, what we know and don't know. These two physicians were instrumental in my interest in pain medicine." During his time in Seattle, Dr. Oakley saw his first spinal cord stimulator implanted and became very interested in nerves and electrical stimulation to modify the effects of epilepsy, stroke, and multiple sclerosis.

After working at the National Institutes of Health as a clinical associate in neurosurgery, Dr. Oakley eventually joined the University of Arizona as an assistant professor of neurosurgery. While in Arizona, Dr. Oakley's "interest in interventional and interthecal techniques was solidified" as he became involved in a multidisciplinary pain management program in Arizona from 1979 to 1982. "I then moved back to Seattle and entered private practice, clinically treating pain for 18 years," says Dr. Oakley.

About four years ago, Dr. Oakley had an opportunity to move to Billings, Mont., to participate in a regional pain center, where he continues to work on developing interventional devices and participates in multi-center studies, incorporating psychological, psychiatric, neurosurgical, and neurophysiological aspects of pain. He is the director of pain management of the Northern Rockies Pain Center, where he is involved in public education, improving access to pain management in rural settings, and educating physicians and patients about the interventions available to treat pain. "There's a great need for such centers in rural areas," says Dr. Oakley. "In my first 2.5 years here, we treated more than 2,000 patients. Now, we get 20 new patients a week from Montana, western North and South Dakota, northern Wyoming, and a few from Idaho."

"The majority of patients at the Northern Rockies Pain Center—more than 90%—have failed back surgery syndrome or failed neck surgery syndrome, but we also treat pain conditions such as atypical face pain and complex regional pain syndrome," says Dr. Oakley. "By the time they come to us, a typical patient has had, on average, 3.5 surgeries on the spine to correct disc fragmentation or to fuse the spine." Dr. Oakley says the center's multidisciplinary team "tries to figure out why the pain is still there. We look for an injury to the nerve, instability, retained fragments, untreated spine disease, or if a surgery was performed at the wrong level of the neck or spine." He says that they examine the complex set of issues surrounding pain and explains that "we don't hesitate to use interventional techniques, such as electrical stimulation or implanted pumps, but they're further down on the list." The multidisciplinary practice employs an internist, psychiatrist, physiologist, nurses, physical therapists, and rehabilitation specialists. The goal is to combine medical pain management and behavioral pain management with interventional techniques, says Dr. Oakley.

"With pain, it's difficult to define success. If a patient has a functional life by using medication or can return to work, that can be considered success. Some patients want modern medicine to cure pain, but that's not going to happen. We can relieve pain and help people become more functional," explains Dr. Oakley. "Patients can ensure success by taking responsibility for their own wellness. With people who want to be well and who demonstrate that they want to be better, we do our best to provide them with the means to do well," he says. "Patients who go through our program typically have an 85% improved function and satisfaction rate one year later. We don't discharge patients. We continue to work with their primary care physicians and provide follow up."

Patients may be involved in the center from three months to up to a year, but it's highly variable due to insurance carriers. "Some insurance carriers don't recognize complex regional pain syndrome or the fact that spinal cord stimulation does work. Pain is one of the biggest medical problems in the country," says Dr. Oakley, "with $50 billion a year in medical resource utilization and lost patient productivity. But it's difficult to make people sitting in an office somewhere, like insurance agencies or workers' compensation representatives, to understand what chronic pain is all about."