TARGETED RELIEF Ms. Rowles provides such pain treatment therapies as spinal injections with fluoroscopy, joint injections and peripheral nerve blocks.

Pain is very difficult to diagnose and treat because multiple pain generators cause the same symptoms. Work with your patients to overcome this challenge and do all you can to eliminate pain from their lives through multimodal therapy that combines medications, physical therapy, injections and psychological interventions. Read on for 10 keys to an efficient pain service.

Require new patients to bring in all medicines. Most chronic pain patients are on multiple medications, and they rarely remember what medicines they're taking, the dose or the frequency. This information is critical to delivering safe, appropriate care, so we instruct new patients to bring all of their medicines, including vitamins, herbs and supplements, to their first appointment. This is the only truly effective way to document exactly what medicines patients are taking.

Reconcile medication lists at every visit. A patient's medicines can change in between visits, so reconcile their medication list at every appointment. Print out the list of medications you entered into the patient's file during their previous visit, and require patients to review this list to let you know if there have been any changes. Medications interact with each other in many different ways. Be sure to take any changes into account when determining a treatment plan.

Use a consistent pain scale rating system. Because there's no universally accepted and adapted pain rating scale, scales differ from facility to facility. We can't control what happens in other facilities, but we can control what happens here, so we make sure to use the same pain rating scale every time for every patient visit.

Whenever patients come in, hand them a hard copy of your rating scale, review it and remind them how you use the scale to assess their pain. We've had patients come in and say their pain is a 10, but a 10 on our scale means emergency care is required, so they'll then adjust their rating to our system. Have patients use this scale to rate their pain, function limit due to pain, anxiety and depression. By having patients use the same rating scale each visit, we're able to identify whether patients are actually seeing improvement in these different areas and adjust our care accordingly.

Employ genetic testing. Genetic testing has been available for a few years now, and we find it very helpful in making treatment decisions. We swab a patient's cheek, send that DNA sample to a lab and within a few days learn how a patient metabolizes analgesic, ADHD and antipsychotic drugs, which ones should work normally and which we should use with caution.

For example, results came back for a recent patient that indicated she could have a reduced response to certain analgesics. If she didn't respond as normal to a normal dose, a higher dose and frequent monitoring may have been needed to achieve the expected result. This information is invaluable, especially if you don't know a patient very well. Medicare, Medicaid and Tricare will cover the test, but private insurers won't. When it's not covered, there's a sliding scale in which most patients pay a couple hundred dollars. That's a small price to pay for more effective and personalized care.

Count on C-arm fluoroscopy. Use of the C-arm has become standard of care for injections, and we primarily rely on fluoroscopy for needle visualization guidance. The use of fluoroscopy lets us precisely target the needle to treat specific pain generators. Visualization guidance increases the accuracy and therefore speed and success of the injection, which is better and safer for the patient. There are many injections you cannot perform blindly, so the ability to utilize imaging is essential.

Address radiation safety. You may employ a trained and certified radiation technician to run the fluoroscopy, but this doesn't diminish the importance of teaching radiation safety to your staff. Provide radiation training to new staff members, and make sure they understand what they need to do to decrease radiation exposure, including standing back from the C-arm during injections, always wearing lead aprons or standing behind a rolling lead shield, and making sure never to reach in to help a patient while the fluoroscopy is in use. We use the C-arm's low-dose setting whenever possible to limit exposure.

Prioritize top pain areas. Many of your patients may present with multiple complaints of pain. They may have back, hip and knee pain. Typically you can't address everything in one session, and in most cases, insurers won't cover multiple injections in one day, so it's imperative from a time and financial perspective to prioritize the areas of pain you'll treat. Have your patients identify the top few areas they'd like you to focus on and tackle those areas first. Sometimes treating pain in one area will help reduce pain in other areas because they are interrelated. For example, treating knee pain can help with back pain, and treating foot pain or an abnormal gait can improve knee, hip and back pain.

Schedule patients with the same provider. Whenever possible, make sure patients are seen by their primary provider at the practice. Patients tend to find comfort in seeing and speaking to the same people, which can only help with their satisfaction and outcomes. As providers, the more we get to know patients, the better we can learn and understand their specific character traits and needs, recognize emerging issues and be in a better position to determine the best course of treatment.

Hold team discussions. Pain management is a field where collaboration is valuable. We hold many team discussions to review our patients and their treatment progress (or lack thereof). These discussions provide an opportunity to bounce ideas off one another and see if anyone has a fresh perspective on what to do for a particular patient. Sometimes we'll also collaborate with a patient's physical therapist or pain psychologist and ask how the patient is doing during therapy, whether the patient is keeping appointments and seems motivated to improve. We'll also ask their primary care provider or family members for observations. They'll tell you a lot about how a patient is really doing.

Spare no details. A detailed chart gives you talking points and direction for treatment. Take comprehensive notes to help you remember patients' physiological and physical states during their last visit. Jot down how patients answer your questions, their mood, how they look at someone in the room who is with them. Are they quick to anger? Do they admit irritation? How groomed are they? How are they standing? Do they look to be in more or less pain since their last visit? What's their level of focus? Document anything that could provide insight into their well-being and the effectiveness of your treatment plan.