June 1, 2013
Volume 77, Number 6
What's New In... Pain and Prejudice: What’s New in Pain Medicine
Kieran A. Slevin, M.B.,B.Ch. Committee on Pain Medicine
Jane C. Ballantyne, M.D., F.R.C.A.
The specialty of pain medicine was born when anesthesiologists took their undoubted expertise in managing pain during surgery and critical illness into the realm of outpatient pain management. Anesthesiologists led the way in developing pain clinics and remain dominant in that the majority of specialists are still anesthesiologists (despite inroads from other fields) and accreditation to practice pain medicine is still overseen by the American Board of Anesthesiology. Is this a legacy we should be proud of?
To dismiss it quickly, let us start with the issue of overprescribing of opioids for pain. As a matter of fact, pain specialists tend not to be the most agregious prescribers. However, specialists must take responsibility for their role in promoting opioid treatment of chronic pain to unsuspecting community practitioners who did not have enough knowledge, or the right infrastructure, to manage this complex treatment. The result is an epidemic of prescription opioid-related abuse and death in the United States that has not been matched in any other country. In other countries, opioids are not used as widely or at such high doses as they are in the U.S.
It has been decades now since injections were first used to treat acute radicular pain and axial low-back pain. Although evidence supporting these procedures is weak, there has been a massive and steady increase in the use of these procedures.
One example of overutilization occurred in the case of the now rarely used IDET (intradiscal electrothermal therapy) catheter. This device allowed a flexible electrode to be introduced into the annulus fibrosis to relieve pain stemming from the neoinnervation of the annulus such annular tears allowed. Discogenic back pain, for which IDET was designed by the Saul brothers to treat, is often a diagnosis of exclusion and otherwise a relatively uncommon cause of axial low-back pain. The problem with overutilization in this instance was that payers attached a high RVU and dollar payment to the IDET CPTTM code, and the spike seen in cases performed far outweighed the incidence of symptomatic discogenic back pain occuring in clinical practice. The Centers for Medicare & Medicaid Services, and in turn the major payers, removed IDET as a covered service, and a worthwhile procedure performed in the correct patient was driven off the books by rogue practice patterns and unscrupulous physicians.
The field of interventional pain medicine continues to evolve with the use of new and emerging techniques, procedures and advanced technology becoming standard practice. As we incorporate these modalities into our practice, we will continue to look at patient outcomes data, realizing that in order to establish the efficacy of emerging procedures, early assessment is needed to prove the modality has real clinical value.
In the arena of neuromodulation, there are continued advances emerging such as AdaptiveStim technology in RestoreSensor™ that uses the same motion sensor technology found in smart phones to automatically adapt stimulation levels to the needs of patients with chronic back and leg pain, while reducing the need for manual programming changes. There is now newly available a 32-contact, 32-dedicated power sources spinal cord stimulator battery that allows patients with complex pain states who require multiple lead arrays to control their pain effectively with a single battery. The other obvious advantage of a 32-contact battery is to build redundancy into a treatment modality for pain conditions that may often extend or alter over time. Permanent implantable percutaneous paddle leads are also available and afford the patient the opportunity to have unidirectional wide coverage paddle lead stimulation without having to undergo an invasive laminotomy or laminectomy. Newer stimulation technologies are also being studied clinically. A prospective, randomized controlled clinical trial is under way with some 300 patients across 15 centers being enrolled throughout the U.S. Patients will cross over between two active spinal cord stimulation modes comparing conventional low-frequency spinal cord stimulation with high-frequency stimulation. The results may expand the group of patients treatable with spinal cord stimulation.
The minimally invasive lumbar decompression (mild) procedure now has an established base of evidence to support its role as a percutaneous alternative to open decompressive laminectomy and fusion for patients with significant ligamentum flavum hypertrophy who are unwilling or unable to undergo higher-risk open-spine surgery. Outcomes data on 45 patients were recently published in February and have shown that patients experienced sustained and statistically significant pain relief and improved functionality at two years.
As the focus on what drives health care resources continues to shift toward outcomes-based practice, as it inevitably will, those of us treating pain have a tremendous responsibility to show keen oversight to both the needs of society to have a larger, aging population relieved of pain, while at the same time preserving resources by using treatments that work and casting aside those that don’t. In order to do that, clinicians will have to incorporate some form of patient reported data tracking and collection tool into their practices either in the form of commercially available software products such as the DCS (dynamic clinical systems) product or by becoming part of a larger registry such as PROMIS, Pain Out or others. These tools can be used to help answer outstanding questions about long-term effects of older medications, including opioids, and can help establish the utility of newer medications with greater rapidity than simply waiting to observe a population effect, which was the way of the past. Further research is needed to identify appropriate-use criteria for interventional procedures as well as newer technologies in the area of neuromodulation to trial non-opioid pain medications for use in intrathecal pumps. We must also implement the recommendations of the IOM in expanding the use of self-management and primary care providers to treat the majority of pain patients, with specialists being reserved for more complex cases. The use of interdisciplinary care and research models should become the norm rather than the exception with real outcomes being used to direct longitudinal care. Only then can we hope to decrease the societal burden of chronic pain and transform care delivery to yield exceptional outcomes.
Kieran A. Slevin, M.B., B.Ch. is Co-director, Virtua Pain and Spine, Voorhees,
New Jersey, and Chief of Pain Medicine, Virtua Health System, Voorhees.
Jane C. Ballantyne, M.D., F.R.C.A. is
Professor of Anesthesiology and
Pain Medicine, University of