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.

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.

The Problem With Prior Authorizations in Medicine

January 12, 2015 / Thomas Cohn, MD

The health insurance industry has developed a tool to control their costs and drive the providers and patients nuts. Originally the concept was used to help reduce the use of tests that were duplicates or unnecessary to provide good medical care. Now it has invaded into every corner of medicine, greatly increasing the cost to the medical provider in order to get approval for any test, procedure or medicine. To the patient and the provider, it just seems to be a nice way for the insurance companies to block care.

For patients with pain, many medications and procedures require prior authorization. It’s a timely process, filling out forms, calling a variety of people at insurance companies, writing down a number and making sure everyone has dotted the”I’s” and crossed the “T’s”. It certainly does not save any money and it costs a great deal of time. From a medical point of view, good practitioners tend to know what is appropriate and are not out to run up medical costs for their own profit. However, the rules always seem to favor the insurance company so they can keep more of your money.

Authorization Rules

Many of the rules that now exist surround the use of medications. The rules are usually written by a pharmacist and are based on drugs having similar modes of action. One generally assumed rule is that a patient must take a cheaper drug and the drug must fail in its use before a different drug can be used. The first problem with this is that professionals who do not treat patients and are not allowed to prescribe medications write the rules. They have no experience with patients, side effects and the need to run additional tests to check for problems. Many of the drugs recommended for pain, and are to be used first, are not even approved by the FDA for the specific condition. Some of the drugs have significant dangers, and may even be deadly. The state of Oregon required the use of Methadone, and suddenly the death rate from the drug skyrocketed. Pain experts warned against the move, but those who controlled the money did not listen.

The cost of medicine in the United States is a problem. Prior authorizations are really not the answer to control medical costs. Improved science and better knowledge would be a start. Furthermore, more control of the big pharmaceutical industry is necessary. They are making record profits, and on average they increased drug costs by at least 25% while inflation was 2%. The most important item would be a uniform medical record system, and all information on every person be kept in the same place. This simple tool would eliminate duplicate studies, questions about medications, and greatly ease and improve quality of care. It also would make it extremely easy to study particular diagnoses and solutions.

Chronic Pain: The Benefits of Exercise

January 8, 2015March 18, 2016 / Thomas Cohn, MD

Chronic pain is tough to deal with, and oftentimes it can seem like and endless cycle of pain, medications, and failed treatments. Since your chronic pain can be caused by hundreds of different issues, pinpointing the problem is key, and what works for some may not work for others. But one thing that most pain management specialists agree on is that exercise is beneficial for treating chronic pain.

Now you might be saying, “How is running going to make my chronic back pain any better? Staying still is pailful, moving is only going to make it worse!” We’re not saying you need to get off the couch and run 10 miles, but moderate exercise has been shown to lessen chronic pain symptoms. Just check out this study. As individuals exercised, their pain tolerance increased. While they still felt similar amounts of pain, their ability to cope with it improved.

Another reason exercise is beneficial is because it kickstarts your body’s release of endorphins. These endorphins help decrease discomfort during a workout, and their effects can linger after your exercise is complete. This process is known as “exercise-induced hypoalgesia.”

Regular Exercise

As I mentioned in my post “Practicing What You Preach,” I suffer from spondylolisthesis that affects the nerves in my back. I suffer back pain from time to time, but I know the best way to control it. Time and time again the best way to keep back pain from slowing me down is to incorporate aerobic exercises into my daily routine. It’s gotten to the point where my back aches if I don’t find time to exercise.

Stretching and exercise can alleviate chronic pain problems, so it’s important to find a workout that works for you. I can no longer run or jog, but I’ve found that long walks or a half hour on the elliptical works wonders. I pair the workout with anti-inflammatories, but I know there is no magic pill that will cure my pain without me putting in effort. Just like diet pills, you can’t lose weight simply by popping a pill, you need to pair it with nutrition and exercise.

There are a lot of reasons to avoid exercise, especially if you have chronic pain; you’re in too much pain, you don’t know what exercises to do, you don’t have the right equipment or you simply find it easier to stay seated. If you are truly interested in alleviating chronic pain, it starts with taking care of your body. Modern medicine is great, but it’s only one prong of the multifaceted approach. You can’t always cure chronic pain, but with exercise, you can help control it.