Not Every Pain Study Should Be Taken As The Truth

radiofrequency lesioning spineYears ago when first entering into the world of medicine, I thought that if a study appeared in a leading scientific journal then it would have to have been a good scientific study. As an undergraduate and in my medical student years I was never really taught how to read a paper and analyze it for its quality. Over the years more articles stopped making sense, and as one would delve into the details, it often became clear that many studies that were published were just bad research.

Often if one knew something about the subject being studied, either the conclusions were obvious or they were not clearly defined such that the answer found may not really have a true correlation to the problem. Good medical studies are often very hard to perform. If you are not very careful, the answer will be junk, even if it is published in a good medical journal. Recently, this has occurred in a major medical journal.

Insurance Sponsored Studies

A recent study in the Journal of the American Medical Association (JAMA) was published with the finding that radiofrequency lesioning does not work in the lumbar region. Unfortunately, this again was a seriously flawed study and on top of everything from a research perspective, it was an insurance sponsored product. The pain societies across the world have been surprised and highly critical of the poor quality of the research and conclusions drawn in this paper.

If one has done their research, they would see that there are multiple excellent studies supporting the use of radiofrequency techniques for some specific uses. This technique has been around since the 1970’s and good equipment and understanding was established in the 1990’s. The technique is very successful for removing a nerve pathway for sensation feedback from facet joints. The science has been proven in detailed and has benefited thousands of pain sufferers. It is a common treatment for facet pain in both the neck and lumbar region and is highly successful when diagnostic blocks done first are indicative of pain relief.

This type of intervention has also been used for a number of other things including knee joint problems, sacro-iliac joint pain, and a variety of peripheral nerve problems and lumbar disc issues. All the other areas treated have had less success due to complex nerve locations. Lumping all radiofrequency treatments together and saying that they do not work is a true disservice to medicine and the patients. Further, since the JAMA is a highly regarded journal, the editors should have more closely scrutinized the study for its validity. Understanding the anatomy in the body also makes a huge difference; nerve location for most areas of the body can be highly variable from person to person and therefore it may be difficult to be successful in severing a nerve with limited ability to visualize its location.

Pain is a very complex sensation in the human body. The overall perception of the stimuli is based on the interpretation of signals in the brain. The brain may actually be receiving signals from multiple structures but interpreting them all as similar and from one location. Eliminating one piece of the signal may be sufficient to solve a pain problem. If the signals are coming from multiple locations, eliminating just one part of the signal may not change the brain’s perception of pain. The joints along the spine have very well defined sensory nerves and feedback; If the pain is from this structure it can be clearly determined and successfully treated. The discs and sacro-iliac joints have poorly defined sensory feedback, trying to eliminate the signals from these regions is still a matter of study. If the editor of JAMA used some critical thinking, the poor quality of the study would have been easily seen and the disservice of its publication could have been avoided.

Radiofrequency management of pain can be highly successful. It is definitely a science with some very technical variables that impact its success. To use this as a tool in pain management, understanding its science, capabilities, risks and benefits is necessary. It is well proven to work in certain situations. A good clinician can maximize radiofrequency effectiveness for a variety of problems but it does have limits. It is not experimental but it does have its inherent challenges in its ability to safely remove enough nerves to relieve pain. If you have pain, a good board certified pain physician can often help a patient find strategies that may lead to more successful management of your symptoms.

Doctor Killed For Not Prescribing Pain Pills To Patient

pills doctor killedLast week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated.  Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.  

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.

The Benefits Of Being An “Old School” Doctor

old school doctorSince I have been in practice, medicine has changed drastically over the years. Technology and improved practice standards have given way to great changes in the care of patients. When I first started in medicine, there were no electronic charts, most notes were handwritten, and computers were not a standard part of practice. CT scans were relatively new and the MRI scan was not yet invented. Medical students were trained to do a comprehensive history and then a physical exam. Part of the history had to include a detailed account of how the condition the patient has had developed over time. Another part was a detailed exam, including looking at the patient, often with minimal clothes obscuring the body. These are very simple things – listening to a story and looking at the patient.

Unfortunately, many doctors have lost the skill to be able to evaluate a patient. Oftentimes the patient has a classic story to tell and it fits exactly to a particular medical problem. Just spending a couple of minutes listening and asking some questions will lead you to the solution, and it probably matches a common or uncommon medical problem. After many years in practice, looking and listening to a patient tells most of the story of what is wrong.  Adding a physical exam will fill in the missing parts most of the time. The fancy diagnostic studies usually are a confirmation of the problem.

Relying On Technology

Many doctors are now trained using technology. The patient history is on the computer and the first thoughts are what do the studies indicate. If the picture (imaging) shows problems, then that must be what is wrong. Treating a test or picture can be okay, but the body has a remarkable way to adapt to changes, and the true problem is usually more complex then the picture and the way to navigate to a solution is to stop and ask the patient what is wrong, then correlate to an exam and picture.

Last week being old school paid off. A new patient showed up at my office frustrated that she had years of pain and no explanation. The patient had been everywhere, including the Holy Grail –The Mayo Clinic – and still no answer on what was wrong. The patient did have a confusing history, but it was important and the details gave the clues. Watching the patient walk and looking at her legs and arms was truly remarkable. The patient was in her 20’s and was significantly weak with loss of muscle bulk.

She had a significantly abnormal exam and likely had a serious muscle and nerve disorder. If the previous physicians only took the time, they would have figured out there was a problem and could have guided the patient towards better solutions years ago. Now, hopefully the patient can get the right diagnosis and help. It may take time and a few more tests, but an answer can be found. One of the best skills a doctor can have is the ability to listen and look at a patient. It is simple, but medicine has changed and doctors are rarely paid to take the time to do the basics.

5 Things People With Chronic Pain Want You To Know

chronic pain knowLiving with chronic pain is difficult enough before you add in the stigma you have to deal with from other people. Hopefully your friends and family members are sympathetic to your condition, but even they don’t fully understand what you’re going through. Today, we want to share five things that people with chronic pain want you to know about their condition.

What We Want You To Know

Here are five things that patients with chronic conditions wish others knew about their condition.

We don’t want to be in pain

This may sound obvious, but sometimes people think individuals are just playing up their pain to get attention. Trust me, they’d trade all the attention in the world if they could live a pain free life. If they are talking about their pain, it’s because they want you to try and understand what they’re going through, not because they are craving attention.

Just because we don’t show it, doesn’t mean we’re not in pain

We put on a brave face and go about our daily life, but just because we’re smiling doesn’t mean we’re not in pain. Chronic pain patients often try to mask their pain because they don’t want to be seen as weak or injured, and some are great at hiding their pain. But that doesn’t mean we don’t feel it with each step.

Keep reaching out

It’s impossible to predict when a flareup is going to occur, so if we say we can’t make it out to the mall or we cancel on movie plans at the last minute, we’re not trying to avoid you. We’re just dealing with a lot of pain and we’d be miserable, but we love that you’re reaching out. Keep texting and calling us, because we really do want to hang out. Don’t assume that we’re intentionally trying to avoid you, because we’re not.

We’re not in it for the drugs

We don’t want to be taking pain pills, but sometimes they are the only thing that makes it bearable to get through our physical therapy session. We’re not just popping pills and hoping the problem gets better, we’re actively working towards finding a solution through a combination of therapy techniques.

We’re not lazy

What’s easy for some is a huge burden to others. When chronic pain is at it’s worst, even getting out of bed in the morning can be difficult. Again, we’d trade anything for the chance to live without constant pain, but life doesn’t work like that. We’re not using chronic pain as a way to get out of work or doing chores. We’re trying our best, even if it doesn’t look like it.

Overprescribing Opioids Is A Problem In Our Own Backyard

opioid problems mnNew findings published in the Annals of Surgery suggests that clinicians at the Mayo Clinic in Rochester were routinely writing opioid prescriptions for surgical patients that exceeded regulatory guidelines currently being drafted by the state of Minnesota. The findings also uncovered significant differences in opioid prescribing among the Mayo clinics in Rochester, Arizona and Florida, as well as within surgical procedures.

Study senior author Elizabeth Habermann, who also serves as the scientific director of surgical outcomes research at Mayo, said the findings help highlight where improvements can be made.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Opioid Overdoses In America

According to the Centers for Disease Control and Prevention, the number of deaths involving prescription opioid overdoses have nearly quadrupled since 2000. In fact, more than 90 people died each day from either a prescription opioid or heroin overdose in 2015 alone.

Study co-author Dr. Robert Cima said doctors have been so focused on ensuring patients have their pain minimized as much as possible after surgery that they often don’t consider the possible long-term side effects of the prescriptions they’re filling.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said Dr. Cima, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

I have no doubt that the Mayo Clinic will adhere to the new guidelines being drafted at the state level in short order, but this story speaks to the larger issue of just how unregulated opioids are at some of the nation’s best hospitals. And if it’s happening there, you can bet it’s happening to a larger degree at lesser care centers.

However, these findings do cast light on the problem and should help push us towards a solution, but it’s not necessarily going to come from the top down. It needs to start with doctors. We need take time with each patient and push them towards active treatment techniques instead of passive treatments like opioids. Opioids certainly have their role in pain management, but they shouldn’t be over-relied on, as it appears they are.