Cite as: Tolba R., Salti A. How I do it: establishing a pain management practice in the Middle East: challenges we face and how to solve them. ASRA News. 2021;46. https://doi.org/10.52211/asra050121.032.

For decades in North America, chronic pain management has been a well-established service, and its practice has gradually and continuously evolved over the years. The Accreditation Council for Graduate Medical Education currently offers accredited fellowships in pain medicine that provide trainees with formal, well-structured, evidence-based training. In addition, there is a growing familiarity about the practice of pain management and which interventions can be offered to patients. There are several established pain practice models, which vary in size depending on whether they are academic-, health-system, or privately-owned practices.

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Despite the challenges, there is a tremendous opportunity to develop proper pain practices in the Middle East.

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The situation is different in other parts of the world, such as the Middle East, where pain management practices are far from being fully developed. To this day, there is a lack of knowledge on interventional pain programs among the public who require the service and the physicians who practice it. Most pain management programs are integrated into individual or small group practices, where the practitioner is an anesthesiologist who works part-time at the pain clinic. While recruiting Western-trained physicians can partially solve the problem, establishing a multidisciplinary practice with interventional pain physicians, psychologists, physical therapists, rehabilitation therapists, and addiction specialists is difficult and expensive and may not be cost-effective. Moreover, we have observed that some patients jump between programs or clinics to seek care. The lack of communication between these services and institutions, as well as a lack of patient trust, contributes to this behavior.

We also face a problem regarding the education and training of our anesthesiology residents. While anesthesiology training programs are available, they do not provide their trainees with adequate exposure to chronic pain services. There is also a scarcity of formally-trained pain physicians who can mentor these residents. However, as the field of chronic pain management grows in the region, we expect to provide more formalized training for our juniors as well.

There is also a lack of awareness on the part of public, as well as referring physicians, regarding the services being offered by pain management clinics. Educational lectures, webinars, grand rounds, and community outreach programs may play a role in raising awareness about these services. Integrating pain management with primary care services and creating referral protocols for patients who require pain management are also essential.

Some patients also inaccurately believe that pain physicians are solely responsible for providing immediate pain relief. During the first visit, realistic expectations and treatment goals should be clearly communicated to patients. This includes expectations for long-term goals, such as weight loss, exercise, and other lifestyle changes. A referral to a psychiatrist or psychologist must also be considered when anxiety, depression, and other psychiatric disorders are seen to play a role in the patient’s pain experience.

Despite the strict rules and regulations enforced by the government on the prescription of controlled medications, we still observe an increase in the abuse of controlled substances, such as tramadol, pregabalin, and gabapentin, in the Gulf region. To curb this increase, drug monitoring, urine drug screening, and opioid screening programs should be enforced. Fortunately, monitoring programs to track the prescription of controlled substances have been implemented in some countries. Urine drug screening programs remain a challenge, because certain laws can potentially criminalize patients based on their urine drug screen results. To limit the overprescription of pain medication, health authorities have also set restrictions on the type and quantity of pain medications that can be prescribed by primary care physicians. However, this also means that patients who need special pain medication require referrals to pain physicians, which can take a few weeks. These patients consequently suffer while waiting to be seen by a pain physician.

Drug dependence, addiction, and abuse is a large problem in every part of the world. However, some cultures, such as that of the Middle East, are more resistant to drug rehabilitation programs. In these cultures, patients and families are more likely to deny the substance abuse problem, because being diagnosed or labelled as an addict is a cultural and religious taboo. This makes affected individuals even more reluctant to seek care in specialized addiction centers, where appropriate and timely treatment are key to long-term cure. This issue is compounded by a fear of criminal prosecution for abusing illicit drugs. As such, it is essential to have a continuous line of communication between pain management institutions and addiction centers, so appropriate referrals can be made for patients in need. It is also important to have an honest conversation with the patient and his or her family about the nature of the problem and the necessity of seeking help.

On an institutional level, we need to work with insurance companies so that they cover outpatient clinic visits, clinic-based procedures, and more complex surgical procedures, such as spinal cord stimulation and intrathecal pumps. While the latter is initially expensive for an insurance company to cover, these also potentially lower costs in the long-term. These procedures are particularly important for patients with cancer experiencing pain and who stand to benefit from intrathecal drug delivery. To lower the high costs associated with these types of procedures and account for the relatively small volume of cases, insurance companies can negotiate with hospitals and manufacturers regarding pricing and reimbursement. Certain institutions also use outdated International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes, which make requesting insurance coverage more complicated. Updating and standardizing ICD and CPT codes, as well as providing payment models for these, will provide insurance companies, physicians, and patients with a more streamlined experience. There should also be continuous dialogue among pain physicians, coding, revenue cycle teams within the hospital, and insurance companies to ensure that proper coding and fair reimbursement are achieved.

Communication barriers among patients, their families, and healthcare providers can also be a challenge. Many patients in the Middle East only speak Arabic and, despite the availability of interpreters, prefer an Arabic-speaking physician with whom they can relate. However, regardless of language barriers, emotional intelligence and cultural understanding are crucial characteristics for all healthcare providers.

Despite all of these challenges, there is a tremendous opportunity to develop proper pain practices in the Middle East. Because there is a limited number of pain clinics in the Gulf region, we established a multidisciplinary spine program that offers all of the services our patients may need under one roof. This has drastically reduced the need to travel abroad to seek medical care. We also decided to establish our pain practice within a large institution, because it allowed us to provide our patients with multidisciplinary care. We collaborated with other hospital departments to recruit a team of board-certified pain physicians who offer the latest interventions that range from basic injections to more advanced procedures, such as spinal cord stimulation, intrathecal drug delivery, and peripheral nerve stimulation. We also have a roster of clinical psychologists specializing in pain medicine, as well as a team of physical therapists and neurorehabilitation specialists. Electronic medical records are also becoming the standard of care in the Gulf region. We utilize these electronic records in our clinic, because our physicians can collaborate through them.

Establishing a large, multidisciplinary pain service takes years of dedication and hard work. It requires significant investments in infrastructure and equipment, as well as the proper recruitment and training of staff; the road can be long. Nevertheless, growing such a practice into a well-developed service is an extremely rewarding process. 

Reda Tolba, MD, is chairman of the pain management department at Cleveland Clinic Abu Dhabi in the United Arab Emirates.

Ammar Salti, MD, is a pain medicine consultant in anesthesia and pain medicine at Cleveland Clinic Abu Dhabi in the United Arab Emirates.