‘Like an orchestra’: Pain management moving toward holistic approach

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Logan resident Dawn Carter’s life changed in January 2015 following an accidental fall down a flight of stairs.

Originally diagnosed with just a concussion, complications from the injury now cause Carter to experience chronic nerve pain and migraines, in addition to seizures and memory loss.

“There is really nothing (my doctors) can do about my pain,” Carter said. “It hurts so bad (that) I feel like an electric eel is swimming throughout my body. It mainly starts in my wrist and works up my arms, up to my shoulders and down to my back.”

According to data gathered by the Institute of Medicine of the National Academies, 100 million Americans suffer from chronic pain conditions, affecting more people than coronary heart disease, diabetes and cancer combined.

Fortunately, treatment options for both chronic and acute forms of pain have evolved from the over-simplified, pharmaceutical heavy days of the 1970s, said Dr. Brian Richardson, who specializes in pain management at Logan’s Southwest Spine and Pain Center.

As pain management evolves, so too does the form it takes. The new standard of care in pain management is that of the holistic approach, or the treatment of a patient’s pain with the combined help of general practitioners, physical therapists and psychologists.

“The way I like to describe treatment to my patients is that it’s like an orchestra,” Richardson said. “Say you’re watching “Les Miserables” live onstage, but the only instrument in the score is a trombone. Alone, that might not be very pleasant. But if you’ve got cellos, violins, saxophones and clarinets, it’s going to sound a lot better and be a much more pleasant experience. It’s the same concept with pain management. Now, we’re using multiple tools to help diagnose, address and fix a problem.”

The physical, mental, social approach

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Physical therapist Swen Sandberg, who has been rehabilitating outpatients through Intermountain Healthcare at Logan Regional Hospital since 2013, said pain management has been working towards the “biopsychosocial” model of treatment over the past few years.

Often abbreviated as BPS, the approach gives equal weight to the physical, mental and social aspects of any given disease.

Sandberg said research studies have shown the effectiveness of the BPS style, with patients showing better recovery results when cared for holistically instead of by a single entity. The results are shifting the way pain management is being approached and introducing an increase in collaboration between medical professionals.

Sandberg predicted that within 10 years, insurance companies will start to provide better reimbursement to patients that are exploring the holistic style of care as opposed to consulting with just a single medical professional.

“The research is backing it up,” Sandberg explained. “It’s the model that Intermountain Healthcare is working towards as well. You can see that it’s the direction that health care is going.”

Richardson said although collaboration with other doctors may sometimes be challenging to coordinate because of varying schedules, he echoed that the increase of experience and evidence confirms it as the new medical standard for pain treatments.

“Not only is the approach important, but it’s absolutely critical,” Richardson said of his regular communication with other doctors. “It’s no longer just giving patients a painkiller. When you look at one modality versus someone also using physical therapy and working through coping skills with a psychologist, that type of multi-modal approach has by far and away been proven to be the most successful.”

Restoring function

Richardson said one of the most common misconceptions regarding treatment for pain is the assumption that doctors will simply prescribe pain medication, but medication isn’t the core of treatment. Instead, the focus lies first on diagnosing the problem itself and then exploring ways to restore function in pained areas.

“Communication with the patient about what the goal is for treatment is before we begin,” Richardson said. “From there, we can manage expectations and work together on the same page.”

While short-term pain relief may be a priority depending on the needs of the individual patient, not all patients may need to be prescribed medication depending on their treatment plan. Richardson used the example of an 80-year-old woman slipping in her bathtub and suffering a compression fracture. In this case, a low dose analgesic may be prescribed to help relax the pain, but the patient would receive an MRI and a back brace first, while also meeting with a physical therapist. A procedure may be recommended if the fracture doesn’t heal naturally from there.

However, if pain medication is in the best interests of the patient, Richardson said enough is prescribed to meet the patient’s needs.

Every 30 days, Richardson would meet with the patient to determine how the treatment is progressing before processing a refill on any prescription.

“It’s rare that you have people with legitimate pain problems that don’t stick with the prescribed regimen,” Richardson explained. “It’s much more common to see people that want to get better.”

Sandberg, the physical therapist, said treatment is on a spectrum between restoring function and pain control. Working towards one end may be able to provide for a solution on the other end, however.

“Very rarely does a patient present without some form of pain,” Sandberg explained. “As therapists, what we do is try to address what’s causing the pain. Sometimes, unless you reduce stress on the joint or the structure, it won’t get better no matter how many pills you take. But other times if we can reduce the pain enough, we can work towards ways to restore that function.”

Sandberg said that many of his patients are on some form of pain medication, but the majority of his modalities aren’t related to pain medication. Instead, he may use ultrasounds or electrical stimulation on the affected areas to retrain the nerves to induce a proper pain response, or provide stretching or traction to joints and tendons to invoke chemical responses that help to relieve the pain.

Sometimes, techniques as simple as changing posture can help relieve pain without turning to medication.

Ending the stigma

Both Sandberg and Richardson acknowledge that there is a certain stigma surrounding chronic pain conditions that may cause patients to not enter treatment. For some, it may be a case of affordability, although Sandberg said that many physical therapy patients may be able to seek treatment for low or no cost regardless of their insurance status. For others, it may be a doubt that doctors really believe their claims of pain.

“Anybody would be frustrated if they got the response, ‘There’s nothing wrong with you,’” Sandberg said. “Sometimes there is a stigma that you may be faking it, but for doctors that notion is completely unacceptable. That can’t exist in the medical community. Pain is taken at face value. Just because there isn’t visible damage now doesn’t mean that there wasn’t damage at some point.”

Richardson said advances in pain management clinics over the past 15 years alone are countering the old notions of simply receiving pain pills.

“We’re committed to finding out what is causing pain and why,” Richardson said. “It can sometimes be a challenge, but once they come through the door and realize what we’re trying to accomplish, that perception changes rapidly.”

Acute vs. chronic pain

Pain takes many forms, which means that professionals like Richardson and Sandberg treat patients on an individual basis to best suit their needs.

“Sometimes the pain is an acute pain, which is here and now,” Richardson said. “For example, you may have a patient who has tweaked their spine tossing a bale of hay and now has nerve pain. If we can treat these conditions quickly enough, we may be able to phase out that pain completely. But with chronic conditions, expectations may need to be reevaluated. Sometimes pain just can’t be cured — there may not be one thing to fix that will stop it from coming back.”

For chronic patients, the involvement of a psychologist can be beneficial, helping patients to learn effective coping strategies regarding the control of their pain. In the cases of psychosomatic pain, which is pain that is caused by the brain’s misinterpretations of nervous system responses, psychologists can also help to reduce the pain or eliminate it entirely.

Sandberg said chronic pain is often the result of a previous injury where the problem is a maladaptive nerve response instead of lingering damage, in which the nerves are unable to register pain in the correct fashion.

“These people may still be in pain because their nervous system hasn’t been able to register the pain response appropriately,” he explained. “To help, we retrain the nervous system through modalities like exercise or electrical stimulation.”

Sandberg said his first sessions with chronic pain patients are often educational, defining the difference between acceptable levels of pain and non-acceptable ones.

“For many, pain is associated with discomfort,” he said. “But there can be different levels of pain that can be improved upon through therapy. For chronic pain patients, the pain may never completely improve, but the function can make progress.”

Exploring alternatives

Aside from the patient’s prescribed regimen, some patients may also choose to supplement their care with other forms of therapy. Richardson said it isn’t uncommon for patients to ask about options such as chiropractic care, massage therapy and acupuncture. Richardson said he encourages proactivity in his patients, noting it as a sign of the patient’s desire to reach to the heart of the problem.

“If someone is willing to explore other functions in addition to their treatment, that means they’re obviously interested in getting better,” he said.

Sandberg said these alternative care options should be weighed on a cost-to-benefit ratio.

“Is it worth the cost? Does it help, or do you feel like it helps?” he said. “Things like herbal medicine or foot zoning may not have as much evidence that they’re helpful, but if the patient is feeling better, we never discourage that. The mind is a powerful thing when it comes to pain control. If you believe that it’s helpful, then it’s helpful.”

Sandberg also encourages patients to explore the options as long as it doesn’t conflict with their current treatment.

“I think proactive searching is important,” he said. “It shows good coping skills. Those patients seem to do really well. If I have a patient that comes in and hasn’t tried anything on their own, I might refer them to a psychologist.”

Original Article Here by Clayton Gefre

Don’t Call Them Pill Mills: Pain Management Practices Recoil at Bad Rap

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Imagine comparing The New York Times to the National Inquirer. Or Lawrence Olivier to Fabio. Or Van Gogh to Thomas Kinkade.

What Are Pill Mills?

Lawmakers and law enforcers have been cracking down recently on clinics, as well as doctors and pharmacies, that illegally or irresponsibly dispense prescription narcotics. These clinics, known as “pill mills”, sell prescription drugs to those who have no medical need of them, or in excessive amounts, and have directly contributed to many of the recent restrictions that have been placed on the distribution and availability of prescription drugs. Although they can be found all over the country, they have made most notable headlines in Florida and Texas, which the Drug Enforcement Agency believes to have the greatest numbers of mills.

“The typical pill mill,” says Vinod Malik,  a West Coast physician with several board certifications and the director of PRC Associates for 11 years, “you walk in, no appointment needed, no evaluation by a physician, you pay cash, you get your prescription, and you go home.”

How are Pain Management Clinics Different?

A pain management clinic (in the general legal definition) is a facility providing pain treatment options or that has at least one doctor licensed to prescribe controlled medication for pain. Pain clinics are subject to legal rules and standards, such as being licensed, being subject to inspection by the board and the state, employing licensed staff, etc. Prescription pain medication is regulated by federal law, so doctors who prescribe it “without a legitimate medical purpose or outside the usual course of medical practice” can be charged with drug trafficking. At “pill mills”, the doctor, pharmacist, or other operators sell these medications to people without valid medical reason, or in large quantities, making a significant profit for themselves in the process. People even travel from out of state to purchase medication from these mills. This flood of powerful and easily-accessible drugs has contributed to a significant rise in street usage of and addiction to narcotics; overdosing on prescription drugs is now the second-leading cause of accidental death in the United States.

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One particular Palm Coast pain management practice, as Kavita Sharma, a pain management doctor, prefers to identify it (rather than a mere “clinic,” because “no one can walk in and say, I want to be seen today”), couldn’t be further from that. No walk-ins are accepted. It’s a referral-only practice. It’s an elaborate, “interventional” pain management operation staffed by board certified doctors, each with at least two board certification, each predisposed to shun pills, each dealing directly and exclusively with his or her patients without the intercession of nurse practitioners or physicians’ assistants.  The four doctors have privileges at all Florida Hospital facilities. Pill mill doctors not only would generally be denied such privileges: they’d be segregated from the rest of the medical community, which doesn’t want to be associated with them.

“Pill only” therapy generally goes against the doctors’ principles and medical philosophy: they’re there to cure patients of their pain or their dependence on narcotics, not to feed it. And they do so mostly through “interventional” means such as injections, radiofrequency ablations, and other, equally tongue-twisting procedures that pill mill patrons have no use for.

Patients are required to sign a narcotic agreement and submit to urine tests to ensure that they’re following their prescribed regimen. If any diversion is detected, it’s a sign that the patients are either abusing the drugs or selling them. If, for example, they’ve been prescribed certain pills but their urine doesn’t show that they’ve been using them at the correct dosage, they’re not in compliance with their narcotic agreement.

“If they don’t comply with that they get fired,” Sharma says. “You actually discharge the patient if they don’t comply with or fail a narcotics screening.” She adds: “Word on the street is, if you want your pills, don’t go top these doctors. They won’t write prescriptions for it.”

The general public has been made little aware of the challenges posed by pill mills or of the important nuances and differences between pill mills and pain management practices.

In response, some states have now placed limits on the amount of drugs doctors can prescribe, which some argue has made it more difficult and expensive for people who actually need them to obtain them. Either way, doctors engaging in criminal activity with their prescriptions at pill mills have made even legitimate doctors subject to closer scrutiny.

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Signs that a facility may actually be a pill mill include not requiring a physical exam, x-rays or medical records before being prescribed drugs, being able to pick your preferred medication, being directed to “their” specific pharmacy, and treating pain solely with pills. Pill mills also tend to open and close very suddenly, as an attempt to evade law enforcement.

So pill mills, for now, continue to thrive, feeding addictions—and damaging the reputation of the legitimate and necessary pain management profession.

Original articles here & here