The HSS Multidisciplinary Approach to Pain Control

1. What is pain and how is it evaluated?
2. Pain Management in Spine Problems
3. Pain Medications and Implications
4. Use of Narcotics

Stephen A. Paget, MD: My name is Dr. Stephen Paget. I'm the Physician-in-Chief of the Hospital for Special Surgery, and it is a pleasure today to introduce to you Dr. Seth Waldman, who is the Director of Pain Medicine at Hospital for Special Surgery and Assistant Professor of Anesthesiology. Dr. Waldman is an experienced, knowledgeable person who has a tremendous focus on the control of pain in patients, so as to allow them to live their lives as they wish.

Dr. Waldman, what causes pain?

Seth Waldman, MD: Well, we don't know exactly what causes pain. It's a condition that is really whatever the person who is having the experience says it is. Sometimes it's obvious in someone who has had a surgical procedure, and sometimes not quite so obvious where we may or may not find some kind of a physical abnormality that can account for the symptoms. It always affects all areas of the experience. It affects the way in which they use the medicine, their relationship with their families, it affects their progress in the recovery of their disease.

Stephen A. Paget, MD: Are there many different types of medications that control pain today?

Seth Waldman, MD: We have a lot of different medications, a lot of different techniques, certainly even more than we had even ten years ago. There are a lot of medications that we use, such as narcotic medications. But there are many newer medications which were formerly prescribed by the condition, such as certain epilepsy medicines, certain blood pressure medications, and anti-inflammatory medicines, of course, that can be used for the control of pain symptoms. There are procedural techniques that can be used for pain control both in the post-surgical setting and in the chronic setting. There are injection procedures, sometimes of anti-inflammatory, or anesthetic procedures, sometimes denervation procedures to anesthetize certain areas of the body for a long period of time.

Stephen A. Paget, MD: Do patients have to tolerate pain these days?

Seth Waldman, MD: I think that it is not acceptable for someone not to have their pain adequately evaluated and not to have attempts made at treatment. There are many people to whom we can give substantial and complete relief. But I think that most people should expect that they should at least be able to achieve some degree of control, if not complete relief, of their symptoms.

Stephen A. Paget, MD: And how do you determine what types of treatments to use in what person after they refer to you?

Seth Waldman, MD: Generally, what happens is that we see the patient for examination and for an interview after they have been referred to us by their primary care physician or by their specialist. The evaluation takes different paths, depending on what the source of the pain is. Sometimes we will need the patient to have additional testing and additional radiographic studies. Sometimes we refer them to other kinds of physicians or nonphysician medical specialists who may have expertise in areas that relate to their pain, such as rehabilitation medicine, psychiatry or psychology, people who are behavioral specialists. And we are now increasingly also referring patients to integrative care specialists such as brachytherapy, massage therapy, acupuncture and so on, homeopathy.

Stephen A. Paget, MD: So the therapy is individualized to the patient, their lifestyle, their needs, and their perception of pain.

Seth Waldman, MD: It unfortunately is not possible to have one treatment for any particular kind of pain even if the pain syndrome is the same from person to person. The person's experience of pain really is completely unique to the individual, and we have to treat them as an individuals. And so we do very often come up with a different treatment regimen depending on who the patient is and what the situation is, how they perceive the pain, and how it is impacting them.

Stephen A. Paget, MD: As director of the program, most of the patients who come to you with pain have what problems?

Seth Waldman, MD: The majority of patients we see in this hospital have musculoskeletal problems. The majority of them are musculoskeletal problems that relate to some kind of spinal pathology, nerve injuries, mechanical abnormalities, such as scoliosis, for example, or disc herniation. We do see a number of patients who have other painful conditions, such as rheumatoid arthritis, but the spectrum of pain management is much wider than it is in our practice mainly because of the specialty of this hospital. But it also can include, in other places, management of cancer pain, management of headache pain, management of pelvic pain, etc. Predominately, we see people who have some sort of nerve injury or spinal pathology.

Stephen A. Paget, MD: So for a moment, let's focus on spine problems. A patient comes to you who has had surgery and failed to be improved by surgery or they want to avoid surgery, either because they don't want to think about it or they have medical problems that would direct their doctor not to recommend surgery. What modalities, what therapeutic options do you have, and how do you move from the more benign, simpler ones to more invasive or stronger ones?

Seth Waldman, MD: A lot of it depends on where, frankly, the patient is coming from, where they have been evaluated, and what kinds of information we already know about them. Many of the patients we see have already had the benefit of having an evaluation. We have a very clear idea of what is happening to them, other than someone who, for example, has not had surgery but might need it or someone who has already had and failed to be improved by surgery.

In situations in which the evaluation has not been done appropriately by our standards, then we would repeat parts of their evaluation to make sure that we have a good handle on what the situation was prior to evaluation. There are many techniques which may be available, and it depends, in many cases, on how long the pain problem has been going on, how sure we are of the etiology of the problem, where it is coming from. There is a number of techniques, including spinal injection procedures. Many of these are injections of anti-inflammatory medicines into the spinal canal, or into the structures surrounding the spinal canal to anesthetize them temporarily, for diagnostic purposes or to alleviate pain by relieving inflammation and nerve pressure.

There are destructive neurologic procedures which can, for the long term, anesthetize parts of the spine. This is called radiofrequency denervation. These include implantation devices, such as spinal cord stimulation, and implantation of infusion pumps for the delivery of anesthetics -- narcotic medications directly into the spinal fluid. These are some of the procedures that can be done for pathology of the spine.

There is a host of medications that can be used, and by the time we are seeing patients for evaluation, especially nowadays, they have usually been through at least some medications commonly used for chronic pain. But there are usually medications that they have not yet explored or medicines that have not been used to their full effect. We try to design a program beginning with things that are less invasive and less risky and moving up to some things that are more involved. Those are the many injection-type procedures, which do bear somewhat more risk.

We try to make an assessment very early on about the emotional/behavioral impact the pain is having on the patient, because we would like to get an intervention to help the patient cope with those symptoms. We want to help the patient develop good strategies for the future, should they have recurrences of pain. We try to get those things in place earlier, with some kind of behavioral treatment, either with the psychologist or psychiatrist.

We try to begin the process of rehabilitation, if possible, right away. Usually we have to go through some period of time during which we are addressing the patient's symptomatology, because patients usually have been referred for physical therapy, but were unable to tolerate it because of the pain. So we have to improve them in some way and then begin the rehabilitation regimen for them.

Pain Medications and Implications

Stephen A. Paget, MD: Could you go over the spectrum of medications from the mildest to the most potent, giving specific names and the pluses and minuses related to that character of medicine?

Seth Waldman, MD: It is hard to list the category of medication and say that some categories are more benign than other categories because, of course, there are side effects and complications associated with all of them.

The most commonly prescribed would be anti-inflammatory medications, which we use not only for their effect in reducing inflammation, but also for their effect specifically as analgesic medicines. These are the common anti-inflammatory such as ibuprofen, Motrin-type drugs, and the full spectrum of not only over-the-counter drugs but prescription-strength anti-inflammatory medicines, including Celebrex, Daypro, Voltaren - a lot of very common medications. Of course, most are associated with some very well-known side effects, not only on the liver and kidneys, but also bleeding side effects.

There are other medicines that we use for the so-called nocioceptive pain, which comes from stimulation of a pain receptor out in the periphery. The majority of those medicines is some form of narcotic medication. Narcotic medications range from simple, fairly common narcotic medications that are combination drugs, such as Tylenol with codeine, oxycodone with Tylenol (Percotet), and hydrocodone with Tylenol (Vicodin).

There are the mild narcotics, to the long-acting, more potent narcotic medications, such as Dilaudid and Fentanyl. Fentanyl comes in a transdermal system.

And there's methadone, long-acting morphine. There is a variety of considerations in that kind of therapy, in some ways a risky thing to embark on, but it can be extremely effective. In many ways, this is the class of medicines that we know way more about than any other family of medicines, because we have a vast history with them.

The other medications that we use are so-called adjuncts to these more traditional medications. They are medicines that we were initially prescribing mainly for certain types of neurologic pain. And they would include neurologic pain syndromes from an injury that we could document and knew about, and neurologic pain syndromes from an injury that we really poorly understood, certain kinds of post-surgical pains, certain headache pains, pains from other injuries to the nervous system such as post-herpetic neuralgia, which is aneurologic injury from a virus, Trigeminal neuralgia. These medications tend to be things that block the processing of pain or block the transmission of pain at other levels. They are commonly certain antidepressant medications, such as amitriptyline or nortriptyline, known by the bran names Elavil and Pamelor.

But there is a variety of other medicines, both old and new, that have similar effects on the way the brain processes pain and on the way the spinal cord transmits the pain signal. We have a burgeoning proof of anticonvulsant medications formerly used in the treatment of epilepsy, which have found areas of use in other fields of medicine. For example, the most commonly used medication, probably worldwide now, for neurological pain is gabipentin (Neurontin). And all of the medications that have followed - new medicines for the treatment of seizure disorders - have been tested as medications used for the treatment of neurological pain. This is primarily because the mechanism of neurological pain is some form of injury, either one that we are able to see with our current technology or one which causes the nerve membrane to be unstable in some way out in the periphery, in the hand or in the leg or some place in the spinal cord or the brain. And that instability is causing the nerve to fire when it is not supposed to fire. In effect, it is a seizure disorder of the sensory nerve, and the effect on the patient is that they perceive that correctly as a painful sensation. And we can control it by alternating stability of the nerve. So we use many medications that are in that family of epilepsy-type drugs.

Other medications that are also adjuncts are things that don't fall into a particular class. They are medicines that are between the antidepressants, narcotics. The most common of these is called Ultram or Ultraset. And there are medicines that block the autonomic nervous system. We use certain commonly blood pressure medications, such as terazosin, which is Hytrin, or clonidine, which is known as Catapres. These medications block parts of the nervous system that cause autonomic control in certain areas. Those parts of the nervous system sometimes are responsible for generating or modulating pain, and we can control those as well.

Very often we will see a patient who is on a combination of these medicines. We can limit the side effects by using small doses of different medications, trying to block the nerve transmission at varying levels to the spinal pathway into the brain.

Use of Narcotics

Stephen A. Paget, MD: When patients hear about the term "narcotics", they are afraid of becoming addicted. Could you address that issue?

Seth Waldman, MD: First, let me say the use of the word "narcotic" is really a legal definition. A narcotic agent is something that has implications for how law enforcement prosecutes the use of substances that people take recreationally, and they don't just include things that are opioid- or morphine- like medicines, which is what we are talking about. But that class also includes other medicines that we don't so much prescribe for pain and those are marijuana-based chemicals, hallucinogenic drugs, LSD and so on.

Really, what we are talking about is the family of narcotic medicines that are opiate medications, opioids, and those are morphine-type drugs -- both synthetic and naturally occurring medicines that we use and have used for many thousands of years as pain medications. As I said before, we know a lot about the kinds of things that can happen to you when you use opoid medications and morphine-type medicines. It is common for people to develop such things as tolerance or dependence on the medications.

The issue of addiction is a very specific symptom. An addiction is a behavioral disorder. It may start with a legitimate use of medication, but it is something that is analogous in some ways to alcohol abuse. It doesn't occur with everybody who takes a drink of alcohol. There are people who have a genetic tendency toward that, probably a behavioral tendency towards that and probably a situational tendency towards that.

What we, as physicians who are prescribing these medicines, can do is to try to identify people who may be at risk for developing an addictive disorder from the initiation of narcotic or opioid therapy and to try to manage the situation so that such behavior is least likely to occur. That is why it's important to recognize that beginning opioid therapy in a patient is not something that can be undertaken lightly. Many people do start on opioid medications at very low levels and, after a period of time, over several physicians, the patient begins to have a problem. And it is not recognized by any one of their doctors, and that is all the more reason why these situations need to be managed in a multidisciplinary fashion. And they need to be very, very up front with people about the risk.

The risk of addiction for somebody who has no history of addiction disorder, is being monitored well, is getting appropriate medicines, long-acting opioids medicines for the right reason, is extremely low.

Stephen A. Paget, MD: Do patients try to avoid the use of opioid medications because of fear of addiction?

Seth Waldman, MD: There are many patients, of course, who refuse to take opioid medicines for just that reason, sometimes in situations where they really may have benefited. The use in society also waxes and wanes with the popular culture. There has been a tremendous pressure over the past 15 or 20 years to liberalize the use of opioid medicines, not only in this country but worldwide, and that has very legitimate roots in the fact that pain was, and still to an extent is, under-treated. We have a situation now, in 2002, where opioid medicines are dispensed much more widely, but there is still an under-treatment of pain. And I believe the difference is that there is a lack of recognition of the importance of monitoring and of the effects of these medications. So opioid medicines are good in the right person when given in the right way and monitored properly. They can also be very, very bad and very destructive when given in the wrong situation and/or not monitored properly.

Stephen A. Paget, MD: Finally, what take-home lessons for the physician and the patient should be delivered about the modern treatment of pain?

Seth Waldman, MD: I think that we have a lot that we know now about the mechanism of pain that we did not know even ten or fifteen years ago. We have a lot of medications that need to be gone through in a methodical, rational way. It is not acceptable to be denied evaluation of your pain. That does not mean that people should rush to demand the use of opioid medication, because certainly that is also inappropriate But in terms of general care, everyone has a right, I believe, to have their symptoms addressed in a rational way. And they should have an expectation that there is going to be a certain level of thoroughness in that.

From the patients' standpoint, they should realize that they may not necessarily require only a surgical procedure, only an injection, only a pill. Treatment may include other things such as behavioral treatment, or the involvement of a number of doctors participating together to make sure that the situation is controlled well and produces a good outcome.

Stephen A. Paget, MD: One last point, OxyContin has received a great deal of press recently. Is it a medicine that should be avoided in every situation, or are there some situations in which it is an appropriate medication to use?

Seth Waldman, MD: OxyContin is absolutely an appropriate medication to use in certain circumstances. It is one of a number of long-acting narcotic medications, opioid medications, that we have. It is the same, as far as the brain is concerned, as using a long-acting morphine drug, a long-acting fentanyl drug, which is a Duragesic patch, or any of a variety of other long acting narcotics, such as methadone, which have all worked quite well in the control of chronic pain.

The problems surrounding OxyContin had to do with two things. One was due to the way in which this drug was developed -- as an adjunct for primary care physicians and surgeons who needed a drug which was a little stronger than their usual medicine but not a morphine-type drug, not a methadone-type drug, which has a negative stigma. The use of this drug spread very rapidly, to a certain degree appropriately, and so a tremendous amount was available through normal medical practice. And I think that the degree of monitoring was less than ideal, because it is really something that should be reserved for a situation of chronic ongoing pain. In that situation, regardless of what kind of physician is prescribing it, they should have the prerequisite training to recognize diversion issues, recognize addiction issues, consider the alternatives, and closely monitor the patient over time.