Here, five pain management physicians discuss the biggest issues in the field and how they will influence pain management going forward.
Vernon Williams, MD, medical director, Kerlan-Jobe Center for Sports Neurology, Los Angeles: We are still on the precipice of telemedicine, and it’s my prediction that in the next few years we will use telemedicine increasingly in pain management. Access to well-designed, practical and reasonably reimbursed telemedicine programs would allow us to “extend” the traditional patient visit by removing the barrier of geographic location. We would be able to evaluate patient response to a treatment, assess patients for side effects and make treatment adjustments that wouldn’t require patients to wait for follow-up appointments or require travel to our office. Every patient with pain has the potential to benefit from these kinds of advancements.
Scott Glaser, MD, co-founder, Pain Specialists of Greater Chicago: As insurers are faced with adding more and sicker patients to their rolls because of healthcare reform, they are more aggressive than ever about cutting costs through reduction in access to care and higher copays and deductibles. Those who suffer from pain are easiest to target. Insurance companies are doing their own “expert” analysis of the literature and denying treatments that even Medicare still pays for and which are supported by exhaustive scientific review of the literature performed by ASIPP and others. They are truly practicing medicine without a license because they do not understand the whole continuum of care for these patients and the unintended consequences of their policies that limit access to these pain relieving procedures. Most alarmingly, the consequences include an even greater use of narcotics, as this will be one of the only remaining options for treating pain. The increased narcotic use will lead to greater prescription drug abuse and death, which are already at epidemic proportions.
Now more than ever there is a need for appropriate training and credentialing for practitioners who want to treat pain. This is most important for patient safety reasons, as these procedures are minimally invasive but maximally dangerous because risks include paralysis, quadriplegia and death. Additionally, knowledge of the continuum of care prevents overuse and fraud and abuse through appropriate, algorithm-driven, interventional treatment. A full understanding and appreciation of all of the pharmaceuticals used to treat pain is vital to patient safety and good outcomes. This is especially true of narcotic painkillers, which have significant short- and long-term risks and need to be utilized only by those with a deep appreciation of those risks. Currently, there is only one board certification that covers all of these areas, the American Board of Interventional Pain Physicians. This is a grueling and exhausting examination process but diplomates are assuredly the interventional pain physicians with the highest level of knowledge in all of the areas of pain management — especially interventions and the long and short term risks and benefits of medication management.
Well-trained interventional pain management physicians utilizing procedures in a sequence based on scientific algorithms can identify the source of pain and reduce symptoms before the pain becomes chronic and debilitating. This is done while treating symptoms with safe medication management and educating patients about pain and prevention techniques. This education must be done by all members of the team involved in patient care, including physician extenders, therapists and nurses. This method of treatment for a lifelong condition is identical to the current treatment of other conditions such as coronary artery disease. Lifestyle adjustment, patient education, medication management and the use of minimally invasive treatments for exacerbated symptoms are the most cost-effective manner of treatment that also allows patients to have the most optimal quality of life.
Tim Canty, MD, Director of Interventional Pain Management, The Spine & Pain Institute of New York: The specialty as a whole is moving towards giving people minimally invasive options for pain relief that could ideally prevent them from needing a more invasive surgery. This is where we will continue to develop new procedures and technology. As a whole, I think pain management has really taken on a very important role in giving people options that weren’t available to them even 5-10 years ago. Other clinical trends in pain management include advanced radiofrequency therapy, which has been evolving and showing lots of promise. Spinal cord stimulation technology has also come a long way and now we are able to treat more conditions than before and create longer lasting results.
Scott Martin, MD, pain management specialist, Chapman Neurosurgical and Spine Institute, Orange, Calif.: Smart Drugs are the prescription pain medications of the future. These are medications that do more than just work for one type of pain. When a patient is suffering form multifaceted pain (somatic, neuropathic, psychogenic) as a result of trauma or multiple surgeries, my preference is to prescribe one Smart Drug as opposed to a cocktail of three or four drugs, each with multiple side effects and all most often with significant co-pays. Pharmaceutical companies are also working toward the development of more divergent-proof drugs. These are prescription narcotics that have tamper-resistant coatings or imbedded chemicals that prevent abuse (crushing, snorting, IV injection). I truly believe a more focused and collaborative effort between pharmaceutical companies and the Federal Drug Administration with support at the congressional level for new drug development and research will favorably change the prescription landscape for our future.
Kiran Patel, MD, Pain Management Physician, The Spine & Pain Institute of New York: Alongside the development of new minimally invasive pain procedures, there is a push from within and outside of the industry for evidence-based pain research. Pain medicine physicians want more evidence to support what we do. When you see patients, you want to be completely transparent about your decision-making process. We want to explain to patients what the evidence suggests and why it is helpful to them.
Pain physicians are also recognizing the misuse of opioids by patients and others in the community as a problem. As a result, we are trying to find ways to help patients without enabling them. It’s not to say that opioids are not indicated to treat some types of pain, but we have to look at all of our options — and how we can ultimately restore patients to function.
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