Northern Virginia Magazine’s Top Doctors 2015 List
If you live with chronic pain, you are not alone. According to the Institute of Medicine (IOM), 100 million Americans have what is known as “persistent pain.” And while there is no cure for chronic pain, a multidisciplinary approach can help put the pieces together so patients can get back to living their lives.
By Sarah Markel
Pain is both a symptom and a disease. Acute pain is a symptom. It starts with an incident—say, an injury or an infection—and usually resolves over time. Chronic pain is different, says Dr. Prashanth Mally, a pain specialist at Kaiser Permanente’s Tysons Corner Medical Center. “Acute pain becomes chronic at three to six months. When it becomes chronic, it can become a disease.”
Chronic pain is a disease that can affect any part of the body. According to the National Institutes of Health, the most common types of chronic pain include low-back pain, headaches and joint pain. The knees, shoulders and neck are especially
vulnerable to pain, particularly in older adults. Neuropathic pain—pain that comes from damaged nerves—affects people with diabetes, viral infections and some autoimmune diseases. Cancer patients experience some of the most unrelenting types of pain. Even parts of the body that no longer exist can send pain signals to the brain, known as phantom limb pain.
Pain tolerance differs by person; what might be an annoyance for one could be disabling for another. It is even difficult for doctors to measure pain. “Pain itself is a complicated thing,” says Bob Twillman, director of policy and advocacy for the American Academy of Pain Management. “It’s not as if we have a lab test or a scan that tells us how much pain someone has.”
Pain is hard to measure because it comes in a variety of sensations: burning, stabbing, aching or throbbing. Pain statistics themselves are notoriously difficult to pin down. While the IOM estimates that 100 million Americans live with chronic pain, other studies have pegged that number closer to 39 million. “It depends on the definition,” says Twillman. “The 39 million is what we are starting to call high impact pain to distinguish between everyday aches and pain versus those who have pain almost every day.”
Yet for all the variation, one universal exists: when pain hits, everyone wants it to stop.
Something for the Pain
Unfortunately, there is no magic bullet for chronic pain. “It’s a complex problem and everybody keeps looking for a simple solution to that problem,” says Twillman. Instead, pain specialists frequently take a multidisciplinary approach to both figure out the source of the pain and restore function.
For most people that starts with the primary care physician. Dr. Paul McClain, assistant chief of adult primary care at Kaiser Permanente’s Fair Oaks Medical Center, notes that he typically treats patients with conservative interventions first. This can include acetaminophen, low-dose non-steroidal anti-inflammatory drugs (NSAIDs), anti-depressants, or recommending stretching, physical therapy and acupuncture.
In some cases, however, especially with older populations who are at risk of intestinal bleeding, low-dose opioids are the best option. When used correctly, narcotics can be highly effective for certain kinds of pain. As Dr. McClain points out in an email: “In some situations, studies have shown that low-dose opioids may be safer than NSAIDs.”
Until recently, doctors could prescribe low-dose opioids for long-term use, phoning in prescriptions that included multiple refills. In October 2014, however, the Drug Enforcement Administration (DEA) put new rules in place about how the most commonly prescribed class of opioids, hydrocodone products, can be prescribed. (See below.) Now, when providers prescribe anything containing hydrocodone, for example Vicodin or Percocet, they must give patients a “wet-ink”—or paper—prescription and follow up with an evaluation.
“This adds hydrocodone to a category other opioids were already in,” says Ken Whittemore, vice president of professional and regulatory affairs for Arlington-based Surescripts, the nation’s largest electronic prescribing network. “Because hydrocodone was so widely prescribed the impact will be significant.”
For example, it will make life more complicated for people who rely on these drugs for pain management. “It’s obviously going to suck up a lot more time. It’s going to make doctor’s offices more crowded. And it will drive up the cost of healthcare,” says Twillman.
In Virginia, some of the hassle will be reduced by the fact that the state allows electronic prescriptions for controlled substances. According to Whittemore, at the time of the hydrocodone products rule change, 66 percent of Virginia pharmacies were set up to accept e-prescriptions for controlled substances. That is better than the national average.
Many providers feel that the recent change in regulating common narcotic pain medications is appropriate. “This is an overdue adjustment which will better protect our patients from misuse and addiction,” says Dr. Thomas Nguyen, interventional pain management specialist at Virginia Spine Institute in Reston.
And the fear of addiction cuts both ways. Some people who are at low risk of addiction refuse to try narcotic pain relief. “I have patients that have severe arthritis and are hesitant to try medication due to the stigma of addiction,” says Dr. Nguyen, who points out that it is always important to balance the risks of any drug with the potential benefits.
Information Matters
By the time a person sees a pain specialist, he or she has usually tried a couple of medications without success. Dr. Greg Fischer, medical director of chronic pain management at Inova Fairfax Hospital and a pain management specialist at Horizon Spine and Pain Specialists, says that if patients come from outside the Inova Health System, he asks for consent to look at their previous records. “It’s very important to have information on what a patient has tried before,” he says.
Doctors in Kaiser’s pain management program say that one of the benefits of their integrated system is the ability to see a patient’s entire health history and put together a holistic treatment plan that involves a multidisciplinary approach. “If you just use one tool to help with pain, you are not going to get a good reduction to pain,” says Dr. Mally.
The Next Step: Injections
After assessing new chronic pain patients, most specialists will explore injections, usually one that includes a mix of corticosteroids and local pain relief. This, as Dr. Nguyen explains, serves the double-purpose of both confirming the diagnosis—if the local anesthetic stops the pain, the specialist knows he or she targeted the correct pain source—and delivering a steroid to the injury to reduce inflammation and pain.
When a steroid injection is successful, patients might experience several months of relief and continue to receive regular injections. “If a patient doesn’t experience relief,” says Dr. Nguyen, whose practice also uses other types of injections, “we re-evaluate other possible origins of pain. The human body is very complex and many pain generators often mimic each other.”
Other injections can include saline solution and hyaluronic acid, which are also injected into joints and tissues. Botox injections can be used for pain of the neck and shoulders, although recent research is questioning their value for migraine.
Whatever the treatment, most doctors also refer their patients to physical therapy. In fact, some practitioners argue that physical therapy benefits everyone and has value as a preventative measure. And patients have an important role to play in this.
Dr. Fischer says that pain management is different from other forms of medicine where physicians can treat a patient—for example, with antibiotics—and the problem is resolved. “Exercise is vital,” he says. “A lot of what we do in pain management is try to get people pain relief so they can exercise, rehabilitate themselves and get to a better level.”
Unfortunately, many people fear exercise will make their pain worse. Dr. Nguyen says this stems from the long-held belief that rest was the ideal cure for pain. “Now the recommendation is to get the body moving again and get the muscles retrained.” A 2014 meta-study examining research into non-invasive pain treatments confirmed this, noting that exercise therapy was “the most effective method for relieving low back pain.”
Not All in the Head
Chronic pain is more than a physical sensation. It can a ect mood, triggering anxiety and depression. It can a ect concentration, appetite and sleep, debilities that in turn can lead to a host of negative health e ects. “Sometimes the depression can cause acute pain to become chronic pain,” says Twillman, who formerly worked as a clinical psychologist. “Sometimes the chronic pain wears you down to where you become depressed. It becomes a vicious cycle after a while.”
Twillman calls it a chicken-and-egg dilemma and points out that, either way, working on mental health issues can have a huge impact on pain management. A good deal of research has shown the benefits of meditation, yoga, cognitive behavioral therapy and antidepressant use for pain. Dr. Mally even points out that classes where people learn about and share tips for pain management can he helpful.
That is why doctors often refer patients to behavioral health specialists to help them cope with secondary symptoms of chronic pain. Research has shown a link between inflammation in the body and depression. The theory is that inflammation actually triggers depression. A few anti-inflammatory medications, like Celebrex, have antidepressant applications.
One of the key goals of behavioral health interventions, however, involves teaching people not to believe negative thoughts about their pain. “A lot of people have a pattern called catastrophizing,” says Twillman. One typical catastrophic thought is that the pain is awful and will never go away. “Before long, it really is really awful.”
Instead, mental health experts help patients reframe their thoughts, manage stress and generally cope better with chronic pain. Deep breathing, progressive muscle relaxation and meditation can both ease pain and help patients think about their pain differently. “It’s a lot of pieces to work on,” admits Twillman. “But what patients are able to do to help themselves is tremendously important to this.”
Alternatives to Surgery
When pain continues and a patient does not benefit from other interventions, many assume that surgery is the next step. But Dr. Niteesh Bharara, an interventional pain specialist at Virginia Spine Institute, says that before considering surgery, he urges his patients to continue to explore conservative options. “The common perception is that after surgery, you will be pain free.”
That is not always the case. Research has since shown that it is frequently not effective. While knee replacement patients enjoy a 90 percent success rate, in one study, about half of patients who had surgery for back pain continued to experience pain, and in some cases, had more pain, after surgery.
Instead, interventional pain specialists like Dr. Bharara are exploring techniques for healing damaged tissue, rather than simply repairing it. Stem cell therapy shows promise in treating what is commonly known as degenerative disk disease. That is when the disks between the joints in the spine shrink and harden. Virginia Spine Institute recently enrolled five patients in a Phase 2 FDA trial examining the efficacy and safety of injecting adult stem cells into painful disks. “To date this is effective,” says Dr. Bharara, who points out that the majority of patients experience significant reduction of pain and improvement in quality of life. “Although,” he adds, “at this point, it’s too early to tell how effective it’s going to be in the long term.”
Platelet-rich plasma is another promising pain intervention. Favored by professional athletes, this treatment involves taking a person’s own plasma and using centrifuge to concentrate the number of proteins—known as growth factors—before injecting it into back into the damaged tissue. A study conducted in the Netherlands found that for patients with tennis elbow, platelet-rich plasma was more e active than a steroid injection. While not covered by insurance, a handful of pain clinics and sports medicine
specialists in the region o er this treatment. “It’s very effective for the appropriate patient. We have used it to return professional athletes back to the playing field with great success,” says Dr. Bharara.
Better diagnostic tools such as functional magnetic resonance imaging and diagnostic ultrasound are also helping doctors zero in on the source of pain rather than relying on trial and error to figure out why a person is in pain. Dr. Bharara says this represents the future of pain medicine. “Right now, most treatments for pain are palliative in nature. On the horizon, we are going to be seeing more treatments that heal the area without surgical intervention.”
Putting It All Together
Even with these changes, however, physical therapy, behavioral health interventions and complementary treatments like acupuncture and massage, plus lifestyle changes will continue to be an important part of chronic pain management. “You still have to put the pieces together,” Dr. Bharara says.
Twillman calls this the “biopsychosocial model” of pain management: “Partly its biological, and we need to address it with medicine or surgery. Partly is psychological, and we have to deal with the thoughts and feelings that are associated with it,” he says. “It’s also social. Pain management is not something that happens to a person who has pain, it’s something that happens with a person who has pain.”
Dr. Nguyen agrees: “The most common misconception is that you are going to be sentenced to a life of narcotics and disability if you have pain. That’s not the case,” he says.
Instead, by taking an active role in managing their pain and working with a multi-disciplinary team of providers who look at pain from all angles, it is possible to become active again. Even if some pain is still present. “Although we cannot guarantee absolute resolution of pain,” says Dr. Nguyen, “we can guarantee that if you work with a good pain physician, your quality of life is going to be much improved.”
Curbing Prescription Drug Misuse
Opioids are a synthetic form of opium that bind to receptors in the brain and change the way the body perceives pain. While they provide pain relief, they come with a risk of addiction and abuse, particularly when patients are not carefully monitored. The Drug Enforcement Administration calls these drugs “the most addictive and potentially dangerous prescription medications available.”
One particular opioid, hydrocodone, sold as Vicodin and Percocet when combined with acetaminophen, was the most prescribed drug in the country in 2012. Experts say this is because the Controlled Substances Act of 1971 originally classified hydrocodone products as a Schedule III drug, meaning prescriptions could be phoned in to pharmacies. There was a perception that hydrocodone products were less dangerous than other options because they were in the same category as cough syrup. “It became the thing that most people used when somebody had pain. It was convenient,” says American Academy of Pain Management’s Bob Twillman. According to the Centers for Disease Control and Prevention, this fueled addiction and alarming overdose rates.
In October 2014, 15 years after a physician suggested the drug be re-categorized, the DEA shifted hydrocodone to the more restrictive Schedule II. Regulators hope this move will reduce the supply of hydrocodone products that can fall into the hands of people—particularly young people—who use opioids to get high.
Misuse of prescription drugs is a problem in Virginia, particularly in the southwest counties of the state. There were 818 prescription drug-related deaths in Virginia in 2011. In addition, 11 percent of young people in the state admitted in a national survey to having used prescription drugs for non medicinal purposes in 2010-2011. Last July, a Woodbridge physician, Samaad Oraee, was arrested on two counts of prescription fraud as part of a law enforcement effort to reduce the illicit supply of prescription pain medicines.
Virginia is on the forefront of reducing what is known as doctor shopping through the deployment of an online prescription monitoring database. The database, which is interoperable with 15 other states, provides information for all benzodiazepine and opiate prescriptions written in Virginia. The program seems to be working; in 2012, the number of people filling multiple prescriptions for the same drug from different doctors dropped dramatically from the previous year. By July 2015, all prescribers in the state will be required to use the database.
(February 2015)