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.

Control Chronic Pain With Healthy New Year’s Resolutions

January 2, 2015 / Thomas Cohn, MD

Every New Year’s Day, many of us make resolutions of what we like to change in our lives. When making New Year’s resolutions, we should work on changing things that would improve our lives. If we are like 40% of Americans who have pain, then there are many things in our lives we can do improve our quality of life.

The first resolution is that you can “manage” your pain and move forward in life. Pain has physical and psychological components, and we can control the cognitive, interpretative parts. When pain becomes chronic, there are normal sensory signals going to the brain that are being perceived as pain. The pain does not change, and you feel it regardless if you are moving or if you are doing nothing. Stop doing nothing, move forward, and get busy. If you are busy, you will not have time to worry about the pain, and you will feel better.

The second resolution is part of the first; get regular exercise. Start slowly and work up to a significant level. Two things must be done, stretching and strengthening, and aerobic conditioning. To tolerate more activity, having adequate muscle strength is essential. Core muscle strength is necessary. These are the muscles of the trunk including your abdomen, along the spine, and those about the pelvis and hips. These are muscles that we normally do not specifically work on and most everyone needs guided training to get started. With strengthening, stretching the muscles daily keeps them from becoming too tight and allows them to maintain normal function. Cardiac health is also necessary. This is done through traditional exercises, like walking, running or biking, in order to increase the heart rate. Aerobic exercise helps burn more calories and control weight.

The third resolution is to lose weight and get close to your ideal body weight. Excess weight stresses the body, especially the muscles and joints. Fat also has been shown to produce compounds that cause inflammation, and those who have pain already do not need to promote more pain within their bodies. If we eat healthier, we tend to feel better and have more energy. Mentally, being close to ideal body weight also promotes a better self image. We can control what we eat, and if we eat healthier, there are many rewards.

It is a new year. Step forward and start taking control of your life. Choose wisely and start doing the things that will improve the quality of your life. Stop making excuses for your behavior and change the bad and reward yourself for the right stuff. Start tracking your diet and exercise, and stick to the plan. Use a fitness tracker and pay attention to diet. If you need help, work with your health care providers. Start now and make positive changes in your life.

The Prevalence of Pediatric Chronic Pain

December 29, 2014January 18, 2016 / Thomas Cohn, MD

Pediatric chronic pain is a growing problem in the United States. According to recent statistics, 1 in 5 children between the ages of 7 and 18 report that they have weekly headaches, and nearly 1 in 10 experience regular abdominal pain. Additionally, 14 percent say they frequently deal with back pain, and four percent are plagued by musculoskeletal pain.

The biggest concern, however, may be that more children are experiencing chronic pain on a regular basis. According to research published in the journal Pediatrics, the number of children admitted to the hospital due to chronic pain rose from 143 in 2004, to 1,188 in 2010 – an increase of 831 percent. With a growing need for pediatric pain treatment, it’s no wonder that more than 30 hospitals nationwide have opened pediatric pain centers of the past few years. These centers provide children with:

Specialized care

Acupuncture sessions

Unique exercise facilities

Sleep specialists

Extensive outpatient therapy treatment

“Kids may be having more pain than in previous generations, but physicians are also more attentive to it and doing more about it,” said Dr. Navil Sethna, clinical director of the rehabilitation center at the Mayo Family Pediatric Pain Rehabilitation Center, one of the top pediatric pain centers in America. Clinics like the Mayo Family Center focus on treating difficult chronic conditions, like fibromyalgia, frequent migraines or ailments resulting from a virus or other injury.

Dr. Lonnie Zektzer, director of the children’s pain and comfort care program at Mattel Children’s Hospital ULCA, said he’s referred children to the Mayo Family Center, and those types of clinics are growing in demand.

“Such programs are becoming more of a trend because they’re so badly needed.”

Pain Management vs. Pain Cure

For many of these facilities, curing the pain is the ultimate goal, but that’s not always possible. Instead, these clinics focus on helping children manage their pain and strengthen their bodies so they experience a gradual reduction in pain over time.

“We teach them how to handle any pain that comes from getting jostled in a hallway or gym class,” said Jenna Duckworth, an occupational therapist who works at the Mayo Family Pediatric Rehabilitation Center.

Judy Gaughan, a nurse and clinical coordinator at the same facility echoed Duckworth’s sentiments, saying, “The treatment goal is to maintain and regain function, not a complete alleviation of pain.”

The center notes that nearly 90 percent of children who finish their program still experience pain symptoms, but the majority report a gradual reduction over several months as they return to normal life.

A 2012 study also shows that the center is improving chronic conditions in children without heavy reliance on painkillers. Nearly all of the 56 children admitted to the program during its first year were taking fewer prescription pain medications 10 months after discharge, the children on meds were usually on a non-addictive preventative drug, and 30 percent weren’t on pain meds at all.

Related source: Boston Globe