Pain Management - Carrying The Torch
Chronic pain is a challenge for those who hurt. Medical professionals also are constantly searching for ways to treat this elusive physical state.
For nearly 30 years, Dennis Pace has been searching for relief from his lower back pain. It hasn't been easy.
The optometrist, 53, has tried rest, ibuprofen, acupressure, chiropractic, a muscle relaxant prescription, physical therapy, stretching and strengthening exercises, and cortisone injections. He's tried remedies from his family doctor and a pain specialist, too, with varying degrees of success. He's had X-rays and an MRI, but they failed to identify the source of his hurt.
Finally, Pace has learned what works for him. He moves his body slowly and avoids any actions that can lay him flat for days.
"I had to learn to trust what I had learned about myself at least as much as I trusted any doctor," says Pace, a resident of Beulah, in northern Michigan.
What Pace has been through may sound extreme, but his experience is more common than one might think. Pace is among the 100 million American adults who have chronic pain, according to estimates in Relieving Pain in America, a 2011 report from the Institute of Medicine, the national adviser on improving health. That works out to about 44 percent of the country's adults, and their nagging pain costs nearly $635 billion each year in medical treatment and lost productivity.
With numbers like that, Washington considers pain a national public health problem. That's why the 2010 Patient Protection and Affordable Care Act has directed the institute to develop a new blueprint for health care that includes a viable solution to the pain problem.
The Institute of Medicine says pain management is challenging for patients and health professionals — and there needs to be a better approach.
First and foremost, the institute says there needs to be a fundamental change to how we think about pain in order to do a better job of preventing, assessing, treating, and understanding it.
In other words, pain management isn't just about taking a pill. It urges primary care doctors to collaborate with pain specialists, who have specific training and knowledge on how to deal with pain that other medical professionals don't necessarily have.
The institute also says federal research dollars are in short supply and likely to decrease. Still, last July the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health, started a new research program to study the brain's role in pain, and how factors such as emotion, attention, environment, and genetics affect how we feel it. Those who deal with chronic pain, the institute says, should always be encouraged to know their bodies and to understand their chronic conditions.
Dr. Cain Dimon, director of the Beaumont Center for Pain Medicine, agrees. "You have to give these people strategies for self-management," says Cain, who has a special certification to treat pain.
At Beaumont that may mean combining Western treatments — like medication, physical therapy, psychological treatment, and more advanced procedures done by a doctor — with complementary medicine.
Dimon may suggest acupuncture, Reiki therapy (to increase a person's "life force energy"), or guided imagery (a relaxation technique) to help patients redirect their thoughts and decrease the stress caused by pain.
Dimon says patients are open to trying alternative therapies. "The common thing I hear every day is 'doc, if it'll help my pain, (I'll try it).' "
The NIH's center for alternative medicine tracks evidence-based research on the use of non-Western therapies. So far, acupuncture, massage, spinal manipulation, and tai chi appear to be beneficial for various pain-related problems, the center reports.
Seong Ahn, a certified acupuncture practitioner, says that most of her patients at Integrated Therapy Works in Shelby Township have arthritis or neck or back injuries, although she's not prone to using such labels.
"In Chinese medicine we don't deal with diagnoses," she says. "We believe that energy (Qi or Chi) flows through the body but sometimes it gets stuck and pain results. The goal is to free up the energy so it will flow and there will be no pain."
Dr. Walid Osta, head of the pain service at Harper University Hospital, who like Beaumont's Dimon is board-certified to treat pain, says most patients often need more than one method of treatment to find a measure of relief.
"The advantage of combining one or more treatments is that you decrease the chance of having side effects from one therapy," says Osta. He often has to add psychological treatment, including medication and talk therapy.
"Anybody with chronic pain is likely to have anxiety or depression," he says. "It may be because of the pain or it may be because of other things."
The anxiety or depression that Osta refers to may stem from anger at the medical profession if a patient is feeling mistreated, or from fear that his doctors have missed something that's doing additional damage but is not being addressed, such as cancer, says Dr. Michael Sytniak of the Providence Hospital Pain Management Center. It may also mean the patient is not adapting to life with pain — and hopes he's just one doctor away from finding the right treatment for relief.
"Unfortunately, chronic pain exists longer than the healing process," says Sytniak, who is a psychologist. "You need to have some hope that you'll find ways to live well."
It's important for doctors to tell people with chronic pain that it's OK to do the things they love if they just take it easy — even if it exacerbates the pain. That way, people such as Pace can do the things that make them happy — and happiness decreases pain, Sytniak says.
"It's just something with how the brain functions," says Sytniak. "The brain can't pay attention to too much stimuli at once."
While he didn't need to see a psychologist, longtime Detroit-area radio personality Jim Harper felt depressed when he started having lower back pain about two years ago. Harper's back started to spasm when he reached for his ringing phone one morning after a few days of riding a recumbent bike.
Harper, 59, now gets relief by performing exercises prescribed by a Beaumont physical therapist and, when his pain edges up to six or seven on a 10-point scale, he gets injections of an anti-inflammatory medication by a doctor at the hospital's clinic. Like Pace, he's learned to limit his physical exertion while still enjoying activities like walking for exercise in his Birmingham neighborhood and learning to weld and shape metal to restore classic cars he owns.
"At first, it's disappointing and you tend to feel a little sorry for yourself," Harper says. "But then you realize it's part of life. I'm very grateful that this is my only area of limitation."
Pain clinics like those at Beaumont, Harper, and St. John Providence — Henry Ford Health System and the University of Michigan also have them — are another sign that health care is now taking, and treating, pain seriously.
But doctors say that the widespread abuse of highly addictive opioid prescription medications is complicating pain clinics' work. Abuse of and addiction to prescription medications such as OxyContin, Vicodin, and Dilaudid are so prevalent that doctors have to guard against patients who want prescriptions to get high or to avoid the misery of withdrawal.
They are also wary of creating any new addicts.
"The question I ask myself is how do we differentiate the ones who are going to use them properly and those who are going to abuse them," says Beaumont's Dimon.
He uses a combination of a patient profiles, written tests, urine checks, monthly visits, and queries to the state's prescriptions database to help identify potential problems. "We do all those things before we even write a prescription," Dimon says.
Both Dimon and Osta use advanced techniques that include pain medication injections directly to the site of a nerve or implants that use electricity to block pain signals from reaching the brain.
Even newer techniques are surgical procedures that are capable of destroying pain-sensing nerves.
Jean McDonnell had a spinal cord stimulator implanted last summer that emits regular bursts of electricity to ease the lower back pain that's dogged her for more than 15 years.
One of the pain medications she's used is morphine, which she has been able to wean off. She also has pain higher up, in her neck.
"I love it," says McDonnell, 67, a retired licensed practical nurse who lives in Highland, of the implant near her hip that's about the size of a pack of gum. "I wish they had one for my neck."
One other, highly controversial treatment is medical marijuana, which is legal in Michigan, 17 other states, and the District of Columbia.
Neither Dimon nor Osta are licensed to prescribe medical marijuana. Dimon says even if he were, he's not comfortable prescribing high-grade pain medications if he knows a patient is using medical marijuana because of possible interactions. He also doesn't want to endorse smoking anything.
"I tell them that if they want to be on marijuana, that's OK," Osta says. But he won't prescribe narcotic pain relievers for such patients because that would jeopardize his drug-prescribing license.
Despite those general concerns, the medical establishment's attitude on use of medical marijuana for pain is changing and becoming more acceptable.
In California, the Center for Medical Cannabis Research conducted the first clinical trials of smoked marijuana in more than 20 years.
As a result, it reported to the state legislature in 2010 that there is evidence that cannabis is promising for treating pain from injury or nerve pain, and possibly for painful muscle spasticity due to multiple sclerosis.
Some of the patients in the center's studies used marijuana as an add-on when they still had pain after trying a wide range of standard medications.
The Institute of Medicine supports clinical studies on medical marijuana for people with pain from nerve damage or spinal cord injury, those with chronic pain that causes insomnia, patients taking opiates after surgery (to see if it relieves nausea and vomiting from these strong painkillers), people with AIDS-related pain, and others.
The America Medical Association's Council on Science and Public Health largely agrees with the institute, and disparages the "patchwork" of state medical marijuana laws as inadequate for its "appropriate clinical use."
The American College of Physicians supports medical marijuana pain research as well, and goes one step further. It urges the federal government to look at re-assessing marijuana's current status as one of the most dangerous drugs — along with heroin, LSD, and ecstasy — and "strongly supports" safeguards against penalties for physicians who prescribe medical marijuana under state laws.
The acceptance of medical marijuana, along with pain clinics, high tech surgical procedures, and the federal government's acknowledgment of the pain problem, could mean that one day chronic pain will be a thing of the past. The medical community says we're getting closer — and for those who suffer, it's welcome relief.
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