Gulf Coast Pain Management
Chronic Pain: An Under-Treated Epidemic

Tampa Bay Medical News
BY DIANE ROMANO

The Merriam-Webster Dictionary defines epidemic as “affecting or tending to affect an
atypically large number of individuals within a population, community, or region at the same time.”

An August 2003 survey by The Florida Pain Initiative (FPI), an organization consisting of a broad spectrum of healthcare professionals, confirmed that Florida has a pain epidemic, with four out of five Florida households containing at least one member who experienced regular pain.

The impact of the study showed that Floridians are substantially more likely to suffer from chronic pain or recurrent pain than the national average, with 75 percent of respondents saying they suffer pain on at least a monthly basis, compared to 57 percent of Americans in survey results released by Research America! in September 2003.

One might theorize that these numbers are a result of Florida’s sizable senior population; however, FPI’s survey found that individuals reporting chronic or recurrent pain were distributed across all age groups, with respondents between the ages of 30 and 49 representing the largest percentage of sufferers.

In addition to their physical trauma and emotional frustration, an April 2005 telephone poll by ABC News, USA Today, and Stanford University Medical Center added that two-thirds of those surveyed reported interference with mood, activities, sleep, ability to work, or enjoyment of life.

Despite the inestimable human suffering and societal costs of over $100 billion annually in lost productivity and medical care, patients suffering untreated, or under treated chronic pain abound.

Several reasons emerge for this continued state:

(1) Many primary care physicians (PCPs) lack the knowledge required to accurately assess symptoms and to diagnose the myriad of maladies that cause chronic pain, in order to treat it properly.

(2) Often, insurance company restrictions on physicians’ time spent with patients limits the time necessary to pursue productive questioning regarding pain symptoms, and places additional time constraints on the physician when the patient presents with comorbidity.

(3) Sometimes, PCPs delay in referring patients to specialists, which may negatively impact the outcome of the subsequent treatment.

(4) Some PCPs are unaware of newer technologies, or are unwilling to try alternative or complementary treatments that may be helpful.

(5) Reluctance of physicians to prescribe opioids for fear of legal ramifications, of having their licenses revoked, or of patient dependence.

The first step in pain management is proper assessment and accurate identification of the source of the presenting symptoms.

“We’ve got, literally, an epidemic of unrelieved pain and … there are a lot of people who aren’t getting adequate relief,” says June Dahl, PhD, Professor of Pharmacology at the University of Wisconsin School of Medicine and Public Health. “We don’t have any device — a pain monitor or something of that sort — that permits a clinician to measure the pain with an instrument.” Her recommendation: Ask and believe the patient’s report.

Experts who treat chronic pain say a valid assessment of the patient’s pain condition should include the following:

1. Initiation – when did the pain start? Did it coincide with the occurrence of a physical injury or emotional trauma?

2. Location – is it localized or widespread?

3. Duration – how long does it last? Is it episodic?

4. Sensation – what does it feel like? Is it burning, stabbing, buzzing, radiating?

5. Intensity – how would the patient rate it on a scale of 1 to 10?

6. Association – when does it hurt? Are there any particular activities or movements that worsen or lessen the pain?

7. Action – has the patient taken any action to relieve the pain? If so, did it work?

Based on the patient’s responses to these questions, the PCP should be able to determine the next step — whether it is imaging, medication, non-pharmacological treatment, or referral.

Acute pain should not be readily dismissed. Dahl says, “It has been established in several studies that unrelieved acute pain is a risk factor for the development of chronic pain problems … because the nervous system is not static, it’s dynamic, and it undergoes changes when it is constantly bombarded with noxious stimuli.” Effective treatment of acute pain assists in the prevention of chronic pain.

Glenn S. Fuoco, DO, an Interventional Physiatrist certified in Pain Management at Tampa Bay Orthopaedic Specialists in Pinellas Park, treats patients with subacute pain and acute pain. His approach is conventional — therapy and light medications. If the pain persists, he performs epidural steroid injections, facet joint injections, or radiofrequency ablations, based on the patient’s clinical presentation.

If the patient is still not progressing or requires an advanced procedure, such as spinal cord stimulation or intrathecal morphine pump, Fuoco refers to a multidisciplinary pain management clinic.

Frequently, diagnoses are missed because the PCP is unfamiliar with the symptoms of some illnesses. Consequently, the physician may label the pain as idiopathic or attribute the pain to being “in the patient’s head” because he or she is unable to identify the source.

Kathryn Padgett, PhD, co-founder and executive director of The American Academy of Pain Management says, “I think a lot of times, things like Complex Regional Pain Syndrome (CRPS) get missed by primary care doctors because they’re not as conversant with that sort of malady.”

CRPS, also known as Reflex Sympathetic Dystrophy (RSD) and as Causalgia, is a malfunction of part of the nervous system. Nerves misfire, sending constant pain signals to the brain. CRPS develops in response to an event the body regards as traumatic, such as an accident, a medical procedure, or even a minor injury such as a sprain or fall.

One identifying characteristic of CRPS/RSD is that the pain is disproportionate — more severe than expected — for the type of injury incurred. Other symptoms include persistent moderate-to-severe pain, swelling, abnormal skin color changes, skin temperature, sweating, limited range of movement, and movement disorders.

According to the Reflex Sympathetic Dystrophy Syndrome Association, CRPS/RSD may follow 5 percent of all injuries. Early and accurate diagnosis and appropriate treatment are essential to recovery; yet, patients typically report seeing an average of five physicians before being accurately diagnosed.

Ashraf Hanna, MD, of the Florida Spine Institute in Clearwater, past president of the Florida Academy of Pain Medicine, and Board Certified in Anesthesiology and Pain Management, says that CRPS/RSD is one of the most frustrating diseases to all specialists.

Early diagnosis and aggressive treatment with pharmacology/injections, physical therapy, and psychology are integral. “You have to do the medical management aggressively with sympathetic nerve blocks . . . We have to incorporate the physical therapy very aggressively from the beginning, otherwise they get diffuse atrophy; and they get significantly depressed from the chronic pain. It’s a very disabling disease,” says Hanna.

Because the PCP is usually the first doctor to see the patient, it is critical that he or she recognizes that persistent pain is frequently accompanied by depression, anxiety, and often the ultimate escape from mind-bending persistent pain — suicide.

Says Padgett, “Regardless of [the source of chronic pain], there is a process that one goes through when you realize that your life has been changed by this pain… The level of pain that you experience defines the boundaries of your life ... What happens is your world narrows down to your pain, and nothing more than that. And that’s just a horrible thing to have happen … It changes how you interact with the world.”

This multidimensional impact raises the question, “When should a PCP refer, and to whom?”

The resounding response from specialists interviewed as to when to refer was unanimous — as soon as possible. If the PCP is unable to identify the pain, or if the pain does not respond to the first course of treatment, refer the patient to the appropriate specialist or team of specialists. Time is of the essence.

This leads us to the second part of the question — to whom does a PCP refer?

“The best success comes when you use a multidisciplinary approach, when you have people from different disciplines with different knowledge and skills bringing what they know to bear on a particular patient’s problems,” says Dahl, the pharmacology professor.

Padgett adamantly shares that position, “If they have an interdisciplinary treatment team anywhere close to them – that is the gold standard… because the interdisciplinary clinics tend to look at the person’s main complaint in multiple layers. They look at the person as a whole person.”

Ideally, a complete interdisciplinary team trained in pain management may include:

· A physician (neurologist, physiatrist, or anesthesiologist with expertise in pain management)

· Registered nurse

· Psychiatrist or psychologist

· Physical therapist

· Occupational therapist

· Biofeedback therapist

· Family counselor

· Massage therapist

· Other trained pain management personnel, such as providers of alternative and complementary medicine (acupuncturists, herbalists).

“It takes a lot of different viewpoints and various healing therapeutics to join together to help an individual,” says Padgett.

Two practices in the Tampa area that incorporate a multidisciplinary approach are The Florida Spine Institute, where Hanna is on staff, and Gulf Coast Pain Management, led by Lynne Carr Columbus, DO, who is Board Certified in Anesthesiology and Pain Management.

“The whole problem from pain is dysfunction and disability,” says Hanna. “The whole goal is two things — to reduce the pain and get the patient to a more functional status . . . and we can achieve that by early identifying those patients and being aggressive with their treatment.”

The underlying philosophy of Hanna’s approach to chronic pain management is three-fold: a combination of pharmacology/injections, physical therapy, and psychology.

Medications target pain relief, physical therapy combats decreased mobility and muscle weakness and spasms, and psychotherapy addresses the depression that accompanies pain.

The Florida Spine Institute staffs a team of physicians who specialize in pain management, anesthesiology, physiatry, neurology, and orthopaedic spine surgery. They also maintain an imaging center, a surgicenter, and a physical therapy department onsite; and collaborate with several local psychiatrists and psychologists.

The procedures offered at the Florida Spine Institute range from simple trigger point injections, epidural steroid injections, facet injections, and botox injections (used for migraines), to radiofrequency ablations and nucleoplasty, and to more advanced techniques such as spinal cord stimulators and intrathecal pumps.

The institute also incorporates drug screening as a method for properly monitoring their patients who are being treated with opioids. Hanna says they are aggressive with medications as long as it is to the right patient, and they properly monitor it to ensure safety and proper patient selection.

Columbus also supports opioid treatments when properly indicated. Her Gulf Coast Pain Management staff includes an anesthesiologist (Columbus), a mental health counselor, a physician assistant, physical therapy, and manual therapy. She maintains a fluoroscopy suite where they perform the majority of their procedures, such as epidural steroid injections, and botox (used for neck pain, back pain, and headache management).

“That’s an off-label usage [of botox],” Columbus says, “but there are studies out there going on that will enable it to become an FDA-labeled usage. We get very good results with botox for whiplash injuries or migraine management.”

Columbus also sees her share of patients whose previous physicians have missed diagnoses. “I would say undiagnosed cancers are number one [referred for back pain],” she says. Others include vascular abnormalities [leg pain] and Lyme disease [headaches, generalized malaise, diffuse joint pain, arthritic symptoms], in addition to side effects from medications such as cholesterol-lowering agents, which can cause diffuse joint pain or muscle pain.

As with many specialists, Columbus advocates quick referral from PCPs to get pain under control and to increase the effectiveness of their pain management treatment by breaking the pain cycle. “The longer a patient feels pain, the more that pain signal is basically engraved into the spinal cord and the brain … Your brain then thinks that it’s normal to feel pain. And so that’s why they feel pain on a constant basis; and this is called central sensitization.”

Columbus says the whole point of pain management is to try and decrease central sensitization and break that cycle — give the brain a break, and let it feel what it’s like to feel normal again. The earlier that’s done, the better the patient outcome.

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Lynne Carr Columbus, D.O.