Managing patients with persistent pain can be one of the more frustrating aspects of primary care. Maryland Physician explores new treatments and when to refer to a pain specialist by speaking with three Maryland experts: Paul W. Davies, M.D., board-certified in Pain Management and Anesthesiology; Ira D. Kornbluth, MD, board certified in Pain Management and Physical Medicine and Rehabilitation; and Lauren P. McNeal, L. Ac., Dipl. Ac., a licensed and board-certified Acupuncturist and Herbalist.
Pain specialists have come a long way in their understanding of how pain signals are transmitted and processed, and they have a growing arsenal of interventions to keep patients from becoming chronically impaired. New medications, improvements in existing procedures like Spinal Cord Stimulation (SCS) and complementary medicine (including acupuncture, Reiki and therapeutic massage) join existing methods of combatting pain.
New pharmaceuticals, forms and combinations
A dizzying array of new pharmaceutical options is providing greater relief for patients suffering with pain. Newer medications include opiates that attempt to thwart or diminish misuse. Oxecta, just approved by the FDA this summer, is the first immediate-release Oxycodone HCl medicine designed to discourage tampering by making it difficult to crush or dissolve it.
Pain management physicians also are using antidepressants, anticonvulsants and seratonin and norepinephrine reuptake inhibitors (SNRIs) to treat select types of pain. “Cymbalta and Savella have revolutionized the treatment of fibromyalgia and, when used off label, other pain conditions,” says Dr. Davies. “Pain and depression typically go hand in hand, and these medications work on both conditions at the same time.”
Dr. Davies adds, “Lyrica, is another relatively new medication, not dissimilar to Neurontin. It has had a profound impact on our management of fibromyalgia and many painful conditions, eliminating or reducing the need for narcotics.” Lyrica is also FDA approved for the treatment of diabetic peripheral neuropathy and post herpetic neuralgia. Many doctors use it off label to treat different forms of neuropathic pain with excellent results.
Newer ways of ingesting or applying existing medications, such as Fentanyl, include “lollipops” and submucosal tabs – highly potent forms of this opiate indicated for patients with breakthrough cancer pain.
“We’re also now able to provide more localized treatment for many types of pain, which helps to minimize side effects,” comments Dr. Davies. “A good example is Qutenza, which has been shown effective in treating neuralgias such as shingles with a patch that lasts up to three months.”
Systems Minimize Abuse, Addiction
Abuse and addiction are major societal problems that often are used interchangeably, but are very different. Whereas abuse refers to those who use medications for something other than their intended medical purpose, addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use.
Dr. Davies describes the multi-step process pain specialists use to minimize abuse and deter addicts. ‘First, we do an initial urine drug screen to rule out street or other drugs for which they don’t have a prescription. We also review the patient’s medical records, checking for evidence of a medical problem in an MRI or other procedure. Second, we check pharmacy records to determine if other doctors have prescribed narcotics or other medications with abuse potential. In the last year, the new electronic pharmacy database has allowed us to take an incredible leap forward in evaluating a patient’s medication use history. Third, we conduct frequent ongoing drug screens. When appropriate, we conduct a criminal record check. The benefit of sending patients to a pain management office is that our staff are trained to do these things.”
Dr. Kornbluth notes, “Pain management physicians have a renewed focus on recognizing and monitoring patients to prevent abuse. We require patients receiving opiates to sign an agreement, then we perform drug testing to monitor and prevent abuse. If the test is concerning, the patient probably won’t be allowed into the practice, and if they become non-compliant, they’re discharged.”
The patient may not be the one abusing medications. Cancer or elderly patients may have relatives that sell their medications on the street. “The problem is really society at large,” Dr. Kornbluth adds. “It’s a shame that some referring physicians still have the misperception that pain physicians contribute to the addiction problems in society.”
Dr. Davies concludes, “Doctors have to consider the health of their community, not just the health of their patient, when treating pain.”
Advances in Spinal Cord Stimulation
Both physicians believe that spinal cord stimulation is being underutilized by referring doctors. “When a patient fails to respond to medications and other more conservative measures, spinal cord stimulation (SCS) can be very helpful,” says Dr. Davies. “Primary care physicians should be aware of its potential to treat peripheral neuropathies and back pain.”
SCS is commonly used for:
- Neuropathic pain in upper and lower extremities, i.e., diabetic peripheral neuropathy
- Complex regional pain syndrome (CRPS)
- Back and neck pain
“The battery life of these devices is much longer than it used to be and we can now cover broader areas,” says Dr. Kornbluth. “There are new arrays of electrodes that address all of the conditions listed above. Patients can recharge the SCS at home and use it for many years. An advantage of this procedure is that we can conduct a trial prior to implementation of the device. The device can then be implanted in patients that get good results. Studies have shown that these procedures improve return to work, increase sleep and decrease opioids.”
When to Refer to a Pain Management Physician
Studies demonstrate that patients whose pain is managed early do better. “The medical community now recognizes that if pain is not treated aggressively early on, it has a poorer long-term outcome. Many patients benefit from referral to a pain specialist, as we offer more comprehensive therapies,” Dr. Davies observes.
Patients should be referred when:
- They require anything more than a short course of narcotic medications
- An acute or sub-acute problem could be remedied with interventions (i.e., sciatica)
- They have ongoing chronic pain
“If a patient has back pain, for instance, there’s a lot we can do instead of just continuing their medications. That often allows them to avoid surgery,” notes Dr. Kornbluth.
Does Acupuncture Work?
Dr. Davies and Dr. Kornbluth believe strongly that adjunct therapies, such as physical therapy, Reiki, therapeutic massage, and acupuncture, play an important role in pain management. This article limits discussion to the role of acupuncture.
After suffering for decades from Western skepticism, acupuncture has become a validated approach to treat pain. NIH studies have demonstrated its value for back and knee pain. As a result, more major insurers are covering acupuncture for a number of pain conditions. “I’m a proponent of acupuncture, especially when you have a localized myofascial problem or persistent, intractable pain after a procedure,” says Dr. Kornbluth.
Lauren McNeal knows first hand the pain relief that can be provided. She became an acupuncturist about 10 years ago after she found that it was effective in treating problems she suffered in an auto accident. She states, “It helped my back and neck pain tremendously, so I became a convert.”
When to refer for Acupuncture
McNeal believes doctors should consider a referral to acupuncture for virtually any type of pain. “They may want to consider acupuncture as a base-line referral before or with physical therapy to address any mobility, function or pain issues.”
Acupuncture is more effective when started early, though McNeal acknowledges that many patients are referred only after months of suffering. “We can achieve an excellent success rate if the pain is treated within three months, but we often see people years after the initial pain.”
Ideally, McNeal says, refer for acupuncture prior to injecting a steroid or any numbing agent, as they slow the body’s ability to respond to treatment.
“Acupuncture also can manage chronic pain, reducing the ongoing need for medications,” states McNeal. ‘It may be considered prior to surgery, and can speed post-op recovery by reducing inflammation and resolving the trauma it causes. Combining acupuncture with physical therapy and/or nutritional supplements is an ideal way to treat back pain, increasing patients’ mobility and function.”
Acupuncture takes time to demonstrate results and the frequency and duration of treatment vary with the type of problem. McNeal explains, “Someone with chronic headaches may be seen once a week for a longer period, while a patient with acute back pain may be seen twice a week for two to three weeks. The longer the condition has been present, the longer it takes to reverse it. But generally, we see a significant difference in four to six sessions.”
Proper Credentials are Important
“It’s important to get a practitioner with good credentials and a proven track record,” says Dr. Davies.
McNeal concurs. “Most acupuncture schools provide a masters level of education. The practitioner should have both a state license and board certification in acupuncture and have passed the National Acupuncture Boards. Maryland does not require that you pass the national boards to practice acupuncture, which most patients and doctors don’t realize. The MD state credential is displayed as “L. Ac.” and the national credential is displayed as “Dipl. Ac.
“My advice is to have an open mind, she concludes. Try it before you decide it doesn’t work. Western and alternative medicine work nicely together.”
Paul W. Davies, MD, pain management physician, is the founder and CEO of Advanced Pain Management, a multidisciplinary pain management practice with locations in MD and Washington, DC.
Ira D. Kornbluth, MD, MA, FAAPMR, CIME, pain management physician and physiatrist, is the founder of SMART Pain Management in Westminster and White Marsh.
Lauren P. McNeal, L. Ac., Dipl. Ac., board-certified Acupuncturist, Herbalist and founder of Chesapeake Acupuncture & Healing Arts, LLC in Annapolis.