According to the CDC, over 50 million Americans are currently living with some type of chronic pain. We all know the struggles of trying to manage a patient’s pain while at the same time avoiding the unnecessary use of opioids or other treatments.
Dr. Ibrahim started by discussing four types of pain: acute, chronic, neuropathic, and nocioceptive. Acute pain is typically the result of an injury and lasts up to 3-6 months; it tends to get better as the tissue heals. Chronic pain sets in after 6 months and no one knows exactly why. Nocioceptive pain occurs when tissue damage occurs, whereas neuropathic pain occurs with nerve damage.
Chronic pain should be treated in a step-wise pattern. First-line treatment should include acupuncture, physical therapy, chiropractics, and anti-inflammatories. TENS units, gabapentin, and muscle relaxants can also be used. TENS units and acupuncture work by tricking the brain away from the pain.
Second-line treatment includes injections, such as steroids. Opioids are usually considered second-line treatments and come with many risks, including addiction and bone loss. Radiofrequency ablation, often used for arthritis, targets the nerve and can last a whole year. It is usually done under radiographic guidance. It can also be used for neck, back, and hip pain as well as in joints that have been replaced. Third-line therapies include pain pumps. These deliver small amounts of opioids directly into the spinal canal. The risk of addiction is reduced, but device problems can create the need for surgery to remove it. Surgery is sometimes another option. However, it creates scar tissue and risks the pain getting worse over time.
Another procedure to consider that is often an alternative to surgery is spinal cord stimulation. It was first used about 50 years ago. It is used for both lumbar and cervical radiculopathy and can help patients reduce or get off pain meds. The advantage of this procedure is that it is minimally invasive and reversible. Leads are placed in the epidural space and a battery in the buttock area. It works by interrupting the pain signal so that it never gets to brain. Studies show a significant reduction in pain scores, decreasing from an average of 8.6 down to less than 3. A trial is done first in the office or surgery center. Over the next 5-7 days, the patient does their usual activities. If it is effective (ie, pain is reduced by 50%, there is a reduced need for pain meds, or the patient can return to certain activities), a permanent stimulator is implanted.
A patient shared his story of having a spinal stimulator implanted. For years, he suffered chronic low back pain and was on high doses of pain medication. He had surgery and injections with nothing helping him very much. He was having great difficulty walking. Almost immediately after he had the trial stimulator implanted, he had remarkable improvement in the pain and eventually returned to pre-pain functioning.
While the US focuses on the opioid crisis, many patients are not being offered reasonable alternatives to treat their pain for many reasons. Many physicians are unaware of the availability of these therapies or how they work. Patients are equally in the dark about the existence of these therapeutic options. Perhaps, the reason lawmakers are unable to curb the crisis we are facing is that they are doing nothing to help patients in pain. Policing doctors’ prescribing habits will not have any significant reduction on patients’ pain scores. We need emphasis on alleviating pain and getting more education on treatment modalties to the general public.
Doctors need to learn more about the latest therapies and how many of them can avoid surgeries that may not help in the long term. We now have doctors whose main job is treating pain and knowing how all these options can be utilized. It is no longer acceptable medical treatment for primary care doctors to just prescribe opioids for chronic pain. Rather, we need to know when to refer pain patients to those more specialized.
This event was indeed educational for the patients present; however, I suspect I am the one who received the greatest benefit.