Chronic Pain Treatment: A Growth Industry

January 28, 2015January 18, 2016 / Thomas Cohn, MD

A recent article suggested that treating pain is a “growth industry”. In reality, pain treatment has been terribly under-treated, and we are now just starting to figure out that we need to start providing more care. The statistics are clear. Over 40% of the population suffers problems associated with chronic pain. If we recognize how large the problem of pain is, then obviously, we can start increasing the number of treatments for the problems. The article is based on information from Minnesota claim data.

It should not be shocking that we have been seeing an increase in expenditures and number of treatments being performed for those suffering from pain. The true shock is the ignorance we have about the lack of treatment provided for one of the biggest health problems. It is not surprising that from 2010 to 2012, the number of procedures performed for pain increased by 13%. The shock should be that most people are unaware of how severe the problem of pain is and the total lack of government support to guide research toward solutions.

New Solutions

Chronic pain can be a devastating problem, and studies show that it affects nearly half of the global population. The headlines often talk about problems with prescribing opioids and the subsequent drug abuse. We should not be surprised then when we see physicians trying different approaches including more interventions and injections to treat pain problems. With our awareness of problems with drug abuse, and the huge number of people having pain problems, it should be no surprise that expenditures for pain patients may be increasing. Maybe this should actually be applauded, that the underserved are getting some more attention, and we should be asking if we are spending enough yet.

Since chronic pain is such a major problem, more money is definitely needed to be spent on research and treatment. There is virtually no federal research dollars being directed toward pain. Unlike cancer or diabetes, there is no office in the National Institute of Health that is directed toward research for pain despite the size of the problems. If there is a concern about the increase in dollars being spent on pain management, then we need to seriously look at quelling those concerns. Data only tells us we are spending more money on a pain. The real issue is why are we spending a lot more money on this problem and not finding better solutions.

Acupuncture – Is it Effective for Treating Pain?

January 26, 2015January 18, 2016 / Thomas Cohn, MD

Acupuncture has been around for centuries and has been a part of Chinese medicine as a modality to treat a number of conditions. It is based on ancient theories of the body having flow patterns of energy. In the body there are 12 meridians for flow of energy and acupuncture either blocks bad energy flow or promotes the flow of positive energy. The placement of needles in certain places is to decrease bad pain and improve the flow energy promoting pain relief. Those who trust in acupuncture say it can treat numerous different conditions. Western medicine first was exposed to these interventions in the early 1970’s when China opened up to the western world.

Western research initially tried to discover how acupuncture worked by attempting to identify flow patterns and meridians. They looked at MRI scans to see if they could see changes in the brain scans, and none were seen initially. The research turned to studies to see if treatment with acupuncture was better than a fake treatment with only sham placement of needles, and they compared it to no treatment at all. Unfortunately, both traditional and “sham” acupuncture worked equally well, and both worked better than no treatment for many chronic pain conditions. Studies in the early 2000’s showed that for chronic low back pain, acupuncture did work better than no treatment and did have extended benefits lasting a year with increased functional ability.

So How Does it Work?

The question of how and why acupuncture worked was puzzling to researchers. A neuroscientist from the University of Toronto was responsible for making the first discoveries of how acupuncture worked. Initially, animal studies showed that acupuncture blocked painful sensations to the paw of the animal, however it took about 20 minutes for this to work. This was about the same time that it took opioids to become effective, and this researcher had the insight that there might be some relationship, like it stimulated the body’s own substances to act as a natural pain reliever. Now researchers have also found that the chemical adenosine increases with acupuncture, and this is another endogenous pain reliever.

Through the use of functional MRI scans, researchers can look at the brain in real time and view activity changes of various areas. Acupuncture has effects on the hypothalamus and amygdala, areas of the brain that control fear and influence pleasure. The scans have also identified that acupuncture promotes connectedness throughout the body.

Over time, acupuncture is now being better understood. It stimulates several of the body’s own compounds that help prevent pain. It also helps in the appropriate interpretation of signals. Furthermore, studies have shown it to be effective for low back and neck pain, at least in the short term. There is also data showing it can be helpful for headaches and osteoarthritis. It does not work for everyone, but there is at least some clear scientific evidence of how it works and there are reasonable studies showing its effectiveness.

Can Wearables Reduce My Chronic Pain?

January 21, 2015January 18, 2016 / Thomas Cohn, MD

The CES, more commonly known as the consumer electronics show, is the place where new electronic devices are displayed every January in Las Vegas. The latest show has just finished, and of course there are a bevy of new toys available. One item that was presented was the Quell; a similar non-electric version is making the rounds as a commercial on TV. The Quell device straps on the calf and delivers a small current to the area to stimulate the branches of the sciatic nerve in the leg, while the TV strap version just puts pressure on the nerves. The claim for both of these wearables is that they can take care of back pain radiating into the leg, and in the case of the Quell, it can cure any pain in the legs.

The reality is that these machines will work on about 30 percent of the people who use them. This is an absolute guarantee. It is the same number of people that a placebo (an inert sugar pill) will work for positively. Otherwise, the science behind these devices is limited. Stimulating a nerve in the periphery can change the brain’s ability to perceive signals coming from the same part of the body. However, the brain is very good at recognizing the vast variety of signals it does receive from all over the body, and this is what allows the body to function as well as it does in a variety of situations. The likelihood that the Quell can superiorly trick the nervous system is small.

We already have peripheral stimulating systems, known as TENs units, that have been around for years, and with improved electronics, they have become smaller, easier to use, and have sophisticated stimulation patterns. Electrical stimulation has been around since the late 1800’s for use in medicine. Physical therapists have used a variety of electrical stimulation devices to help control pain and improve function since the end of World War I. The unfortunate truth is that all of these devices only work in a small percentage of people, at the most 50 percent. When they do work, they can be very helpful controlling a variety of painful conditions. These units can usually be tried in physical therapy for about a month, and if they work, then they can be purchased. These devices at least have sound science behind them, and can be purchased at a reasonable price if they work for you.

These latest devices hyped at the CES or on TV are probably best left alone. These are examples of magical cures for conditions, and we know there is no magical solution. If pain is an ongoing condition in your life, find a good medical practitioner who can diagnose the problem and lead you to a solution that will work. The problem did not likely suddenly appear, and good solutions are unlikely to make the problem magically disappear.

Safety First: Surgical Centers vs. Pain Specialists

January 19, 2015January 16, 2015 / Thomas Cohn, MD

Recently there was an article on whether having a procedure done in a surgery center is safe. In the world of pain management, some practitioners only do procedures in these facilities (or hospitals) while others do most of their procedures in the office. Surgery centers can handle more complex procedures, and can typically handle a deeper level of sedation. In pain management, surgery centers can be beneficial for complex procedures such as implants, but often they rarely are necessary. Sedation for a pain management procedure usually does not need to be very deep, and should be able to be done without a surgery center.

The safety of a surgery center and a procedure in reality is no better than the quality, skill, and experience of the practitioner. After spending more than 20 years performing complex spinal procedures, as well as teaching courses to other physicians, it is the ability of the physician that really matters. Surgery centers are often profit centers for the physicians working in them. Furthermore, a physician who sedates most patients for procedures is often using the sedation to cover for a technique that may cause pain. A skilled interventionist should be able to do most procedures with a local anesthetic and ensure they are practically painless. The use of sedation for many practitioners is a crutch to reduce the need to talk to the patient and to perform the procedure with the least painful technique.

Pain Medicine Safety

In pain medicine, the most common injections – spinal and joint related procedures – should be able to be done quickly and comfortably. The main issue that most practitioners should be treating is the anxiety of the patient. Light medication to treat the anxiety can often be given orally. For longer procedures, IV medication is sometimes easier to use. Universally, procedures that are painful are most often due to the technique and experience of the provider. Experience often allows the practitioner the knowledge of how to perform a procedure when a patient presents a more complex situation.

In the end, safety of a center is dependent on the practitioners. If the provider does not fully know what they are doing or the best techniques, the patient is more likely to have issues with the procedure. Further, if the patient is significantly sedated, the patient will not react when the practitioner does something wrong, making it more likely that significant damage may occur. The best physicians will always care most about the patient and the problem, not the payment they might receive from doing an intervention. The best physicians have years of experience, are board certified, and have an intense, loyal patient following. Skill and experience help keep a patient safe and make a procedure safe and effective. Errors in pain management procedures are generally rare. Surgical centers and sedation are not important in patient safety; the quality of the practitioner is the most important variable.

Study: Chronic Pain Linked To Activation of Brain’s Glial Cells

January 14, 2015 / Thomas Cohn, MD

A new study published in Reuters Health suggests that doctors may soon have another area to target when it comes to treating chronic pain: your brain’s glial cells.

Researchers said their study indicated that patients with chronic pain often show signs of glial cell activation in areas of the brain that modulate pain.

“Glia appears to be involved in the pathophysiology of chronic pain, and therefore we should consider developing therapeutic approaches targeting glia,” said Dr. Marco L. Loggia, of Massachusetts General Hospital. “Glial activation is accompanied by many cellular responses, which include the production and release of substances (such as so-called ‘pro-inflammatory cytokines’) that can sensitize the pain pathways in the central nervous system. Thus, glial activation is not a mere reaction to a pain state but actively contributes to the establishment and/or maintenance of persistent pain.”

Glial Study

To test the theory that chronic pain sufferers experience activation of brain glia, Dr. Loggia and his team analyzed data from 19 patients with chronic low back pain and 25 non-chronic pain volunteers. After analyzing translocator protein (TPSO) levels associated with the activation of brain glia, researchers found:

Protein increases were significantly higher in patients with chronic low back pain than in the control group.

There were no brain regions in which the control group experienced a higher protein presence than the chronic back pain group.

“It’s important to stress that although TSPO upregulation is a marker of glial activation and therefore of a pro-inflammatory state, animal studies suggest that its role is actually to limit the magnitude of glial responses after their initiation, thereby promoting the return to pre-injury pain-free status and recovery from pain,” said Dr. Loggia. “This means that what we are imaging may be the process of glial cells trying to ‘calm down’ after being activated by the pain. Thus, subjects with low levels of pain-related TSPO upregulation on activated glia may be less able to adequately inhibit neuroinflammatory responses, and have a more exaggerated response that ultimately leads to more inflammation and pain.”

Dr. Loggia continued:

“No objective biomarkers exist to determine if somebody is in pain (i.e. you can’t just hook someone up to a machine to see if they’re experiencing chronic pain). Thus, this study – aside from suggesting glia as a therapeutic target for pain – is important as it may provide an important step toward the identification of objective biomarkers for pain conditions.”

He concluded by saying knowledge of human glial activation had been limited, prior to the study.

“In animal studies we know that glial modulators, which limit glial activation, can potently inhibit or reverse pain,” Dr. Loggia said. “However, evidence of glial involvement in human pain has been very limited until now. Observing glial activation in humans has important potential implications for the development of new therapies based on glial modulation. Seeing that glial activation really happens in patients will provide the rationale to justify a more aggressive exploration of this therapeutic route, and identify which patients are more likely to benefit from these types of therapies.”

Related source: Reuters, Scientific American