This page is written for pharmacists, referring physicians and dispensing partners — but it is deliberately public. We publish the same protocol to patients, in plain language, at our patient FAQ.
We do not describe our practice one way to clinicians and another way to the people we treat. If you are a patient reading this and something here concerns you, please raise it at your next visit or call (314) 481-5000.
Our process for establishing the medical necessity of interventional care is rigorous, physician-led and strictly data-driven. We view pain as a signal of underlying structural or metabolic imbalance rather than a condition to be managed solely through medication.
Roughly 95% of our patients are interventional pain patients; about 5% are co-managed for addiction alongside severe pain. The average new patient reaches us after more than two and a half years in pain and on more than 90 MME per day. Under active interventional treatment, 21% are completely off opioid pain medication within 90 days, and 34% are completely off all opioid pain medication within one year. Across the established population, approximately 60–65% receive any opioid analgesic at all, and of those who cannot be fully weaned the large majority are held under 30 MME. Our preference is to avoid opioids altogether, though that is not achievable in every complex case.
Long-term opioid therapy without interventional support is not consistent with evidence-based practice, so we do not offer it. Patients must be willing to undergo procedural treatment such as nerve blocks or spinal injections; refusal is grounds for discharge.
Nearly 100% of our patients receive interventional pain management. We do not accept patients for medication management alone, and we do not accept direct addiction referrals — only complex patients such as failed back surgery syndrome or oncologic pain with co-occurring addiction who cannot be managed in a standard addiction center.
This is the single most common point of friction we encounter, and we want to be direct about it. Pill-count metrics — driven largely by enforcement headlines quoting raw tablet numbers — create pressure to consolidate a patient onto fewer, longer-acting units. That improves the optics of a prescribing ratio while, in our clinical view, worsening the pharmacology.
Chronic opioid therapy, and long-acting formulations in particular, impose persistent receptor occupancy that precludes essential physiological receptor cycling. We would rather defend a higher unit count at a low total MME than accept a lower unit count achieved through continuous receptor saturation.
The mu-opioid receptor is a G-protein-coupled receptor regulated by phosphorylation of the C-terminal tail domain, which facilitates recruitment of beta-arrestin proteins and subsequent receptor internalization. When an agonist is constantly present, this regulatory feedback loop drives receptor desensitization and uncoupling, contributing to opioid-induced hyperalgesia — a paradoxical increase in pain sensitivity despite escalating dose.
Long-acting agents are especially problematic because they deny the nervous system the pharmacological rest periods required for receptor resensitization and homeostasis. Chronic exogenous stimulation also suppresses endogenous endorphin and enkephalin production, so patients lose the capacity for innate pain and mood modulation — a state of physiological insolvency. The clinical result is diminishing analgesic return alongside worsening central sensitization.
Patient-facing explanation: what we mean by opioid bankruptcy.
We integrate three independent data streams:
- Objective symptom mapping — documented chronic pain, typically of at least one to three months, that has failed to improve with conservative modalities including physical therapy, chiropractic care and non-narcotic pharmacological trials.
- Multimodal correlation — imaging (MRI, CT, X-ray) and electrodiagnostic testing (EMG/NCS) to correlate subjective pain reports with objective structural or neurological findings.
- Metabolic and inflammatory assessment — metabolic health screening, because chronic pain is frequently an extension of systemic metabolic inflammation.
We treat pain not only as a neurological event but as a biological one requiring internal terrain stabilization. Background: our clinical approach.
Interventional procedures are both diagnostic and therapeutic. Where a patient requests repeat intervention, we require documentation of at least 50% functional improvement. Without that functional data we discontinue the therapy rather than continue an assembly-line model of endless injections.
Medication management is formally reviewed every four months; if no functional improvement is observed, medication is tapered and care may be transferred back to the primary physician. A comprehensive six-month retrospective analysis is conducted for each patient.
Validated instruments, applied systematically rather than selectively:
- Substance use: Opioid Risk Tool (ORT), Drug Abuse Screening Test (DAST), NIDA single-question screen, ASSIST, and AUDIT for alcohol.
- Psychiatric: PHQ-9, GAD-7, Mood Disorder Questionnaire and the Altman Mania Scale.
- Developmental: Adverse Childhood Experiences (ACEs) scoring.
- Cognitive: neuropsychological screening to evaluate decision-making capacity.
Behavior expectations are revalidated at every visit — roughly every two weeks — including willingness to maintain opioid compliance and a review of addiction and diversion risk factors.
Urine drug testing is routine, performed approximately every six to twelve weeks, and sent to an independent high-complexity laboratory. We specifically use gas chromatography rather than moderate-complexity immunoassay, because our population includes co-occurring addiction and immunoassay will miss a range of relevant substances.
Interpretation is explicit: absence of the prescribed medication is treated as a clinical anomaly suggesting diversion or non-adherence and is flagged for immediate intervention. Presence of illicit substances or non-prescribed sedatives results in immediate termination of the treatment agreement.
Providers perform asynchronous PDMP reviews to identify pharmacy shopping or multi-provider sourcing.
One structural limitation worth flagging to dispensing partners: Missouri statute requires us to use the Missouri program and prohibits us from using another state’s program in our decision-making when the patient is seen in Missouri. Where a patient also receives care in a neighboring state, we request that the patient supply a release for those records, but the out-of-state database itself is not available to us for that encounter.
Physical bottle checks — patients bring all prescribed medication bottles to every visit for inspection.
Behavioral review — we monitor for malingering, meaning presentations inconsistent with objective findings, and for disproportionate focus on obtaining more medication. Clinical areas are camera-monitored.
External reports — we investigate credible reports from family, caregivers, pharmacists or other clinicians regarding unusual medication behavior.
On arrival: the average new patient comes to us on more than 90 MME per day, after more than two and a half years in pain. We frequently inherit patients from primary care at 400–500 MME.
Under active interventional treatment: 21% are completely off opioid pain medication within 90 days, and 34% are completely off all opioid pain medication within one year. Of those who cannot be fully weaned, the large majority are brought below 30 MME per day — well beneath the thresholds at which federal prescribing guidance places its sharpest cautions.
Maintained: the average established patient sits at approximately 27–32.5 MME, and typical dosing is under 30–40 MME. Inherited high-dose patients are tapered deliberately, generally reaching a routine dose within one to three months.
These are practice-reported figures from our own population rather than trial results, and individual results vary.
No. That figure describes patients arriving, not patients staying: the average new patient reaches us above 90 MME, and fewer than 1% of our established patients remain there.
Those few are specific clinical situations — active cancer pain under co-management, or postoperative failed back surgery syndrome and arachnoiditis — where the elevated dose is a temporizing measure during reduction, not a maintenance strategy.
We strongly discourage it and do not do so as a routine practice.
We may use baclofen or metaxalone for spasticity-related pain, and clonidine to facilitate opioid reduction in patients presenting on high doses.
We do not independently prescribe benzodiazepines or stimulants alongside opioids. Where a benzodiazepine is clinically necessary, the patient is under direct psychiatric care and the psychiatrist is the prescriber. Rare exceptions — on the order of four times per year — include one or two tablets for severe claustrophobia during MRI. Stimulants are essentially not prescribed, other than occasionally as a temporizing measure in obstructive sleep apnea pending sleep specialist care. Patients on opioids are otherwise prohibited from sedative use under their agreement.
We treat medication as a bridge, not a destination. Tapering is not the withdrawal of support; it is the measurement of the body’s improved self-regulation as the pharmacological noise is removed.
Tapers are calculated from clinical stability, progress in physical therapy and movement, and metabolic markers — never arbitrary schedules. Gradual reduction allows the nervous system to adjust, minimizing withdrawal and rebound. Cognitive and psychometric screening runs throughout, and if physiology indicates the timeline needs adjusting, we adjust it.
Tapering depends on active participation in metabolic and nutritional optimization, movement and physical therapy, and behavioral health. Related reading: sleep and endogenous pain control.
Participation is mandatory, not advisory:
- At least 12 physical therapy sessions per year.
- Ongoing psychological counseling for opioid harm reduction — we have an in-house clinical psychologist.
- Metabolic health testing and nutritional/lifestyle coaching.
Failure to participate is grounds for discharge, because the care no longer meets the criteria for medical necessity. Background: metabolic inflammation and pain.
All patients on long-term controlled substances are seen in person every two weeks. We deliberately do not dispense more medication than a patient could foreseeably overdose on at one time, which keeps global dose low and surfaces aberrant behavior quickly.
We do not provide telehealth. 0% of patients at either location are telehealth-only. The sole exception was the mandatory COVID-19 shutdown period.
We see patients five days a week — four at the Woodson office, one at Bridgeton.
We operate a strict electronic-prescribing-only policy.
- We do not accept or issue verbal orders or telephone prescriptions.
- All authorizations transmit electronically from our secure EHR directly to the pharmacy.
This maintains a clean, immutable audit trail and ensures every authorization is tied to a documented, ongoing medical necessity assessment. If you receive a verbal or telephoned prescription purporting to originate from this clinic, it did not come from us — please contact us immediately.
Every patient signs a binding medication management agreement before treatment:
- No sharing, selling or trading medication; no illicit substance use.
- A single designated pharmacy for all prescriptions, with advance notice of any change — this is our principal control against pharmacy shopping.
- No controlled substances from any other provider without informing us first.
- Responsibility for safeguarding medication; lost or stolen medication is not routinely replaced.
- No early fills.
All patients prescribed opioids receive overdose awareness education and naloxone training.
Violations result in immediate discharge without refills or continuation of care. That includes deceptive behavior, obtaining controlled substances from other providers, illicit substances or non-prescribed sedatives on testing, and absence of prescribed medication on testing.
Where diversion or aggressive behavior is suspected, we report to the DEA or other regulatory agencies as appropriate.
Directly and quickly — that is the intent. We welcome in-person meetings with any pharmacist who would like one, and we routinely call pharmacists ourselves when questions arise.
Clinic: (314) 481-5000. For urgent pharmacist queries, Dr. Padda can be reached directly on (314) 852-5500 — pharmacists are encouraged to text this number — or at seva@padda.com.
If you have concerns about a specific prescription, contact us and we will review that patient’s current risk stratification and treatment progress with you.
Tell us. We act on it immediately.
Patients sometimes present appropriately in clinic and behave quite differently at a pharmacy counter, where their guard is down. That information is genuinely not available to us otherwise, and we regard it as clinically significant. Credible reports of aberrant behavior result in termination of the treatment relationship — we have no interest in continuing to treat a patient who may be diverting or misusing medication.
We consider this a core part of your corresponding responsibility and ours, and we would rather hear from you early than late.
Our DEA-registered address is 4477 Woodson Rd, Suite 100, St. Louis, Missouri 63134. Our second location is 12174 Natural Bridge Road, Bridgeton, Missouri.
Any correspondence directed to our former Chippewa address is out of date; that location is no longer a registered address with the Drug Enforcement Administration. Please update your records.
Dr. Gurpreet Singh Padda, MD, MBA, MHP is board certified in Interventional Pain Management, Pain Medicine, Anesthesiology, Addiction Medicine and Obesity Medicine, and holds MoCA certified rater status (USPADGU710792792-01).
He is President of the Missouri Society of Interventional Pain Physicians, lectures nationally for ASIPP, and serves on faculty for a psychiatry and addiction residency program.
The practice group is the Center for Interventional Pain Management, with three providers. We contract with substantially all medical insurance plans and are not excluded from Medicare or Medicaid. No nurse practitioners or physician assistants are supervised, and Dr. Padda does not practice under a supervising physician.
To get a feel for the practice, see our clinical education series or the Padda Institute YouTube channel.
Receptor mechanism: Birdsong WT, Arttamangkul S, Bunzow JR, Williams JT. Agonist binding and desensitization of the μ-opioid receptor is modulated by phosphorylation of the C-terminal tail domain. Mol Pharmacol. 2015;88(4):816–24. PMID 25934731. Opioid-induced hyperalgesia: Angst MS, Clark JD. Anesthesiology. 2006;104(3):570–87. PMID 16508405; Higgins C, Smith BH, Matthews K. Br J Anaesth. 2019;122(6):e114–e126. PMID 30915985; Mercadante S, Arcuri E, Santoni A. Opioid-induced tolerance and hyperalgesia. CNS Drugs. 2019;33(10):943–55. PMID 31578704. Endogenous opioid system: Clauw D. Hijacking the endogenous opioid system to treat pain: who thought it would be so complicated? Pain. 2017;158(12):2283–4. PMID 28957836 (editorial). Long-acting formulations and outcomes: Ray WA, Chung CP, Murray KT, Hall K, Stein CM. JAMA. 2016;315(22):2415–23. PMID 27299617; Miller M, Barber CW, Leatherman S, et al. JAMA Intern Med. 2015;175(4):608–15. PMID 25686208 (both observational). Counter-evidence: Chu LF, D’Arcy N, Brady C, et al. Analgesic tolerance without demonstrable opioid-induced hyperalgesia. Pain. 2012;153(8):1583–92. PMID 22704854.