Vernon Williams, MD, medical director, Kerlan-Jobe Center for Sports Neurology, Los Angeles: The way I see it, the application of wide ranging technological advancements to pain management is the biggest area of development today. For example, the significantly improved quality of ultrasound imaging combined with dramatic decreases in size and cost of the equipment (all due to technological advancements) make ultrasound an excellent tool for diagnosis and guided injections. The technology is being applied to pain management, resulting in improved ability of pain physicians to provide safer, less expensive care without exposure to radiation. If we are interested in performing specific types of injections, it provides an inexpensive alternative to using X-ray and CT scans for diagnosis or fluoroscopy for guided injections.
Another example of technological advancement applied to pain management is use of tablets in the office such as iPad. I think this has significantly improved physicians’ ability to use EMR in the clinic and can dramatically raise the level of patient education. There are lots of apps available that allow us to show patients pictures and animated images of the anatomy or procedures. We can literally walk them through their diagnosis and treatment. I believe this kind of improved education and patient insight results in improved treatment outcomes.
Scott Glaser, MD, co-founder, Pain Specialists of Greater Chicago: One of the greatest challenges facing pain management is the efforts to rein in medical costs through reducing access to care. The life-changing minimally invasive procedures which are performed by interventional pain management doctors are being threatened nationally by the Patient-Centered Outcomes Research Institute and Independent Payment Advisory Board. These features of the healthcare reform bill place decision making about funding these procedures in the hands of “experts” insulated under the executive branch from legislative oversight. Procedures which control pain will be an easy target for them to reduce access to care because pain is difficult to measure and some of these treatments remain controversial.
There is ample scientific proof to support these procedures and their efficacy but they continue to be under attack by physicians and groups whose motivations are suspect based on their lack of expertise in the field and their funding sources. The American Society of Interventional Pain Physicians and particularly their leader, Laxmaiah Manchikanti, MD, have highlighted these threats and are leading the way making legislators aware of them.
A clinical trend is the advent of neuromodulatory techniques for the treatment of chronic pain, which will someday rank with discovery of penicillin as far as the clinical significance. Neuromodulation is the electrical stimulation of the spinal cord or peripheral nerves to change or modulate the patient’s experience of painful impulses to improve their quality of life. Tolerance does not develop to this treatment modality as it does with all pharmaceutical treatments for pain. It has been a game-changer in the treatment of pain, especially neuropathic pain related to nerve or spinal cord damage, and has secured its place in the pain management armamentarium. It can be test-driven by the patient prior to permanent implantation and permanent implantation is a minimally invasive procedure that does not alter the biomechanics of the spine, which enhances its attractiveness as a clinical option. Many patients and their physicians are even looking at this as a non-surgical alternative treatment for sciatica because of the more favorable risk/benefit ratio.
Tim Canty, MD, Director of Interventional Pain Management, The Spine & Pain Institute of New York: Minimally invasive lumbar decompression is definitely a key development in pain management. It signifies a change in the paradigm for how we treat spinal stenosis, making a new option available that might be more effective and longer lasting than injections. It could potentially be as effective as surgery with less risk of serious complications. We’re still figuring out how that fits in the whole treatment plan. We feel the studies coming out have already shown it may have an important intermediary role between injections and surgery, and it could be a great option for patients’ serious medical problems who can’t tolerate surgery.
Our practice is also now able to coordinate comprehensive treatment plans to make sure patients are getting the full complement of therapies they need. The multispecialty comprehensive approach is more effective than just coming at the problem from one angle. If we can address all factors of the patient’s condition, we are able to improve their quality of life and also demonstrate a cost savings when patients get better more quickly. In assuming this role, pain management specialists act as gatekeepers to make sure patients are getting the comprehensive treatment plans as we work hand-in-hand with other specialists. At our practice, this takes the burden off the primary care physicians who work with us.
Scott Martin, MD, pain management specialist, Chapman Neurosurgical and Spine Institute, Orange, Calif.: One of the most exciting things coming out of pain management today are the tools to combat the increased scrutiny of our profession. The abuse of pain medication is rampant; there are articles suggesting prescription medications are the number one problem of abuse afflicting the US population. Fortunately, there are institutional movements to aid physicians and pharmacists in the fight against divergence. CURES (a state of California Prescription Drug Monitoring Program) is an Internet-based system that allows providers to audit prescriptions and is updated on a weekly basis at the corporate pharmacy level. The system is not foolproof, as it is updated weekly. When patients are truly divergent, visiting three to four doctors over the course of 48 hours, they fly under the radar and are not flagged in the system until it is too late.
Holding divergent patients accountable is a priority for the longevity of the practice of Pain Medicine. Moreover, it takes a team approach to identify divergent patients. CURES is an excellent example of a state wide divergence program, however with the recent downturn in the economy, the expense and coordination it takes to make a program like this successful for every state is a barrier to entry. Further, there are still gaps in pharmacy and provider communication and pharmacy to pharmacy communication as all do not have a seamless and transparent system that is updated daily, and available to all providers. Fortunately, the ground work is being laid, and progress is being made. And the real winners are the patients who are truly suffering from acute and chronic pain, and are not divergent. State and privately funded divergence screening tools will keep the growing trend of narcotic abuse at bay and convince congress that continued funding for pharmaceutical research for pain management is vitally important.
The second type of development we are seeing is in advent of technology-based applications for patient education. Tablets such as the iPad, with supported educational, pharmaceutical, and even surgical applications foster better patient understanding of their disease process and the treatments we as pain providers are planning to render in efforts to maintain their quality of life. The widespread use of the electronic medical records has brought a level of transparency, efficiency and standardization to the medical visit. This has allowed providers the ability to engage patients’ health issues as effectively on vacation in Napa Valley as they would in their Leguna Beach office.
Kiran Patel, MD, Pain Management Physician, The Spine & Pain Institute of New York: Over the past several years, the field of pain medicine has shifted its focus from symptom management to improving functionality. Treatment goals are centered around restoring patients to an active lifestyle. Most recently, there has been an increase in minimally invasive pain procedures. These procedures offer a short recovery time and allow patients to quickly resume their daily activities. Minimally invasive lumbar decompression, spinal cord stimulation and new applications of radiofrequency ablation comprise some of these potentially “surgery sparing” procedures.
Related Articles on Spine Pain Management:
5 Points on the Success of Spine Pain Management in the Future
5 Points on the Role of Pain Management in Spine Care
5 Steps in Creating a Balanced Pain Management Center
