Note: These guidelines are for
historical reference only. IASP adopted the Recommendations for Pain Treatment
Services in May 2009.
Desirable Characteristics for Pain Treatment Facilities
Task Force on Guidelines for Desirable Characteristics for
Pain Treatment Facilities
IASP believes that patients throughout the world would benefit from
the establishment of a set of desirable characteristics for pain
treatment facilities. The principles set forth in this document can
serve as a guideline for both health practitioners and those
governmental or professional organizations involved in the establishment
of standards for this type of health care delivery.
This Task Force has not addressed the issues of pain management in the
postoperative or post-trauma setting. Such treatment programs may occur
within a pain treatment facility, but they are not required for the
assessment and treatment of patients with chronic pain.
Definition of Terms
The following terms will be briefly defined in this section; a more
complete description of the characteristics of each type of facility
appears in subsequent portions of this report.
1. Pain treatment
A generic term used to describe all forms of pain treatment
facilities without regard to personnel involved or types of patients
served. Pain unit is a synonym for pain treatment facility.
2. Multidisciplinary pain
An organization of health care professionals and basic
scientists which includes research, teaching and patient care related to
acute and chronic pain. This is the largest and most complex of the pain
treatment facilities and ideally would exist as a component of a medical
school or teaching hospital. Clinical programs must be supervised by an
appropriately trained and licensed clinical director; a wide array of
health care specialists is required, such as physicians, psychologists,
nurses, physical therapists, occupational therapists, vocational
counselors, social workers and other specialized health care
The disciplines of health care providers required is a function of
the varieties of patients seen and the health care resources of the
community. The members of the treatment team must communicate with each
other on a regular basis, both about specific patients and about overall
development. Health care services in a multidisciplinary pain clinic
must be integrated and based upon multidisciplinary assessment and
management of the patient. Inpatient and outpatient programs are offered
in such a facility.
3. Multidisciplinary pain
A health care delivery facility staffed by physicians of
different specialties and other non-physician health care providers who
specialize in the diagnosis and management of patients with chronic
pain. This type of facility differs from a
Multidisciplinary Pain Center only because it does not include research
and teaching activities in its regular programs. A Multidisciplinary
pain clinic may have diagnostic and treatment facilities which are
outpatient, inpatient or both.
A health care delivery facility focusing upon the diagnosis and
management of patients with chronic pain. A pain clinic may specialize
in specific diagnoses or in pains related to a specific region of the
body. A pain clinic may be large or small but it should never be a label
for an isolated solo practitioner. A single physician functioning within
a complex health care institution which offers appropriate consultative
and therapeutic services could qualify as a pain clinic, if chronic pain
patients were suitably assessed and managed. The absence of
interdisciplinary assessment and management distinguishes this type of
facility from a multidisciplinary pain center or clinic. Pain clinics
can, and should be encouraged to, carry out research, but it is not a
required characteristic of this type of facility.
This is a health care facility which offers a specific type of
treatment and does not provide comprehensive assessment or management.
Examples include nerve block clinic, transcutaneous nerve stimulation
clinic, acupuncture clinic, biofeedback clinic, etc. Such a facility may
have one or more health care providers with different professional
training; because of its limited treatment options and the lack of an
integrated, comprehensive approach, it does not qualify for the term,
Desirable Characteristics of Multidisciplinary Pain
- A multidisciplinary pain center (MPC) should have on its staff a
variety of health care providers capable of assessing and treating
physical, psychosocial, medical, vocational and social aspects of
chronic pain. These can include physicians, nurses, psychologists,
physical therapists, occupational therapists, vocational counselors,
social workers and any other type of health care professional who can
make a contribution to patient diagnosis or treatment.
- At least three medical specialties should be represented on the
staff of a multidisciplinary pain center. If one of the physicians is
not a psychiatrist, physicians from two specialties and a clinical
psychologist are the minimum required. A multidisciplinary pain center
must be able to assess and treat both the physical and the psychosocial
aspects of a patient's complaints. The need for other types of health
care providers should be determined on the basis of the population
served by the MPC.
- The health care professionals should communicate with each other on
a regular basis both about individual patients and the programs which
are offered in the pain treatment facility.
- There should be a Director or Coordinator of the MPC. He or she
needs not be a physician, but if not, there should be a Director of
Medical Services who will be responsible for monitoring of the medical
- The MPC should offer diagnostic and therapeutic services which
include medication management, referral for appropriate medical
consultation, review of prior medical records and diagnostic tests,
physical examination, psychological assessment and treatment, physical
therapy, vocational assessment and counseling and other facilities as
- The MPC should have a designated space for its activities. The MPC
should include facilities for inpatient services and outpatient
- The MPC should maintain records on its patients so as to be able to
assess individual treatment outcomes and to evaluate overall program
- The MPC should have adequate support staff to carry out its
- Health care providers active in a MPC should have appropriate
knowledge of both the basic sciences and clinical practices relevant to
chronic pain patients.
- The MPC should have a medically trained professional available to
deal with patient referrals and emergencies.
- All health care providers in an MPC should be appropriately licensed
in the country or state in which they practice.
- The MPC should be able to deal with a wide variety of chronic pain
patients, including those with pain due to cancer and pain due to other
- An MPC should establish protocols for patient management and assess
their efficacy periodically.
- An MPC should see an adequate number and variety of patients for its
professional staff to maintain their skills in diagnosis and
- Members of a MPC should be carrying out research on chronic pain.
This does not mean that everyone should be doing both research and
patient care. Some will only function in one arena, but the institution
should have ongoing research activities.
- The MPC should be active in educational programs for a wide variety
of health care providers, including under-graduate, graduate and
- The MPC should be part of or closely affiliated with a major health
sciences educational or research institution.
Desirable Characteristics for a Multidisciplinary Pain
The distinction between a Multidisciplinary Pain Center and a
Multidisciplinary Pain Clinic is that the former has research and
teaching components that need not be present in the latter. Hence, items
#15, 16 and 17 above are not required for a Multidisciplinary Pain
Clinic. All of the other items should be present.
Desirable Characteristics for a Pain Clinic
- A Pain Clinic should have access to and regular interaction with at
least three types of medical specialties or health care providers. If
one of the physicians is not a psychiatrist, a clinical psychologist is
- The health care providers should communicate with each other on a
regular basis both about individual patients and programs offered in the
pain treatment facility.
- There should be a Director or Coordinator of the Pain Clinic. If he
or she is not a physician, there should be a Director of Medical
Services who is responsible for the monitoring of medical services which
are provided to the patients.
- The Pain Clinic should offer both diagnostic and therapeutic
- The Pain Clinic should have designated space for its
- The Pain Clinic should maintain records on its patients so as to be
able to assess individual treatment outcomes and to evaluate overall
- The Pain Clinic should have adequate support staff to carry out its
- Health care providers working in a Pain Clinic should have
appropriate knowledge of both the basic sciences and clinical practices
relevant to pain patients.
- The Pain Clinic should have a trained health care professional
available to deal with patient referrals and emergencies.
- All health care providers in a Pain Clinic should be appropriately
licensed in the country and state in which they practice.
The Task Force is strongly committed to the idea that a
multidisciplinary approach to diagnosis and treatment is the preferred
method of delivering health care to patients with chronic pain of any
etiology. Not every patient referred to a pain treatment facility is in
need of multidisciplinary diagnosis or treatment, but the facility
should have those resources available when they are appropriate.
Although the Task Force recognizes that health care resources are not
uniformly distributed throughout any country or the world and that
compromises will be necessary, all health care providers should strive
to attain the standards set forth in this document for the care of
patients with chronic pain. Health care providers in pain treatment
facilities should be encouraged and expected to be members of IASP and
its national chapters in order to facilitate exchange of information and
The primary goal for a pain treatment facility is to provide
effective, humane care for those who suffer from chronic pain. The
complexities of the chronic pain patient must be recognized to
accomplish these goals. In the modern era, however, the issue of cost
effectiveness must also be considered and we cannot erect standards for
chronic pain treatment which are above and beyond the standards for
patients with other types of complaints. Moreover, health care delivery
systems are rapidly changing and standards that prevent innovation and
progress should not be proposed.
All patients with chronic pain should be appropriately evaluated
before treatment is implemented. Facilities that offer only one type of
treatment or have limited access to professionals in various disciplines
must demonstrate appropriate patient selection prior to the initiation
of therapy. Patients who attend such a health care facility should have
been fully evaluated elsewhere before such a referral is made. For
example, if a "pain clinic" specializes in headache patients and offers
only biofeedback therapy, the patients referred to such a facility must
have an appropriate medical evaluation prior to embarking on this
treatment program. Pain treatment facilities must go beyond this
stereotypic approach and determine what services the patient needs prior
to embarking upon one or another type of treatment. If what the patient
needs is not available, the patient should be referred elsewhere.
Resources and patient demands vary throughout the world, and there is
no single guideline that can be made which will apply to every location.
In developing nations, pain treatment facilities may appropriately
consist of a small number of health care professionals with limited
resources. Such groups may mainly see chronic pain due to cancer or to
nervous system injuries; the problems of chronic pain as seen in the
industrialized nations may have not yet arrived. Treatments may be
limited to nerve blocks and drugs if economic conditions preclude more
expensive treatment strategies. It is unlikely that research activities
will be carried out in such an environment, but the mission of teaching
other health care providers should never be overlooked.
In the developed nations of the world, there would seem to be no
reason to allow an isolated practitioner to call himself a pain clinic.
The diagnosis and management of patients with chronic pain has become so
complex that multiple skills and knowledge are required. There are many
possible combinations, but such a facility must have at least one
physician who assumes responsibility for obtaining a complete history
and performing a screening physical examination. Old records must also
be reviewed. The specialty of the physician performing this review is
not particularly relevant, but clearly someone with expertise in the
type of disease process responsible for the patient's chronic pain
should be either the referring physician or part of the pain treatment
facility's assessment team. At least two other medical specialties as
well as other types of health care providers should be represented to
justify the term, multidisciplinary pain clinic. There is some question
as to whether any pain management facilities which are not
multidisciplinary should exist in a developed nation.
Other types of health care professionals are of great value in a pain
treatment facility. These include psychologists, nurses, physical
therapists, occupational therapists, social workers, vocational
counselors and others. The variety and number will be determined by the
types of patients seen and the number of visits per year to the
facility. We should remember that the etiologies of chronic pain are not
well understood; medical treatments have already failed many of these
patients and effective evaluation and treatment may be administered by
other health care professionals.
In summary, the developed nations should require that any facility
calling itself a pain clinic or pain center offer a multidisciplinary
array of diagnostic and treatment facilities. Single modality therapy
programs should be identified by the modality they utilize; e.g.
"Biofeedback Clinic" rather than the term, "Pain Clinic." Neurosurgeons
who perform pain-relieving procedures do not call themselves a "Pain
Clinic", nor should any other solitary specialist. Health care
facilities which specialize in one region of the body should be
identified by that region in their title; e.g. "Headache Clinic", rather
than "Pain Clinic". A Multidisciplinary Pain Clinic or Center should
provide comprehensive, integrated approaches to both assessment and
In developing nations, it may not be immediately possible to amass
the professional and physical resources to establish a multidisciplinary
pain clinic. A single health care provider may initiate a health care
facility with the goals of adding other personnel as the institution
evolves. This should be encouraged by IASP even though the health care
facility at its inception may not meet the desired standards.
Pain Clinics and Pain
Centers require not only
physical resources but also specially trained health care providers.
There is no specific training program in pain management at this time,
so all health care providers have entered this area from existing
specialties. Fellowships in pain management are beginning to develop,
and those individuals who wish to specialize in pain management should
be encouraged to obtain such a period of training. Others become
reasonably skilled through their work with pain patients, but the field
should move toward the establishment of specific training programs in
pain management and the development of a method of evaluation and
certification of individual health care providers by responsible
All pain clinics should work toward the use of a single method of
coding diagnoses and treatments. Although the ICD-9 system is utilized
in many countries, it is not particularly good for illnesses in which
pain is the major complaint. The IASP Taxonomy system is a step in the
right direction, but it will need further refinement before it becomes
clinically acceptable. Nonetheless, excellence in pain management will
require a standardized reporting system which can be used by all types
of treatment facilities throughout the world.
Finally, excellence is dependent upon education of young health care
providers who may wish to enter this field. Pain Centers need to
establish educational programs on all levels to accomplish this goal.
These programs should attempt tointegrate with degree
granting institutions in all the health sciences as well as
post-graduate educational programs.
This document has been prepared by a Task Force appointed by the
President of IASP, Dr. Michael J. Cousins, and chaired by the Secretary
of IASP, Dr. John D. Loeser.
Members of the Task Force were:
John D. Loeser, MD,
Francois Boureau, MD, PhD,
Peter Brooks, MBBS, MD, FRACP, FRACM, Australia
Teresa Ferrer-Brechner, MD, USA
Howard L. Fields, MD, PhD,
Corey D. Fox, PhD,
Hans U. Gerbershagen,
Douglas M. Justins, MBBS, United Kingdom
Terrence F. Little, MBBS, FFARCS,
George Mendelson, MBBS,
Isaac Pinter, PhD,
Russell K. Portenoy, MD,
Robyn J. Quinn, RMN,
Howard L. Rosner, MD,
John C. Rowlingson, MD,
Bengt H. Sjolund, MD, PhD,
Peter J. Vicente, PhD,
C. Peter N. Watson, MD,
Michael Wood, PhD,