Doctors seek ways to manage pain without dangerous drugs
CAPITAL REGION Last fall, St. Mary’s Healthcare in Amsterdam opened a clinic to treat an ailment that’s as old as humanity itself: pain.
Since then, the clinic has drawn a steady stream of patients, about 20 a day, and those numbers are growing, according to Dr. Jason Steindler, the physician hired to head the Pain Management Center.
When they arrive, they undergo a detailed assessment, rating their own pain, as well as their potential for drug addiction.
“We talk about their condition, what their treatment options are,” Steindler said. “If you have pain, you should get a diagnosis, and treatment for it.”
The people who walk through his door at St. Mary’s Memorial Campus on Route 30 have been struggling and failing to manage and relieve their pain, Steindler said.
“I see people who are not very happy,” he said. “Most of my patients have already seen four physicians before they see me. They have a complaint that they feel has never been adequately addressed. … Some people spend their whole adult lives trying to find out why something hurts. They call a pain management clinic because the answers aren’t easy to come by.”
Steindler’s main goal is to help his patients feel better. But the Pain Management Center has another purpose: reducing dependence on opioids such as Hydrocodone and Oxycontin, a class of drugs better known as prescription painkillers.
In recent years, addiction to prescription painkillers has exploded. According to a 2012 U.S. Centers for Disease Control and Prevention policy brief, drug overdoses in the U.S. have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, most of which were caused by prescription drugs, specifically opioids.
“The quantity of prescription painkillers sold to pharmacies, hospitals and doctors’ offices was four times larger in 2010 than in 1999,” the policy brief says. “Enough prescription painkillers were prescribed in 2010 to medicate every American around the clock for one month.”
“There are so many other medications to consider for the treatment of pain,” Steindler said. “I have a responsibility to the community to limit the number of [prescription painkillers].”
Overall, he said he’s been impressed with how “frugal and responsible” the local medical community is when it comes to prescribing opioids, though “some people are prescribing excessive amounts of pills.”
Pain management is a young but growing field.
About a decade ago, the American Board of Medical Specialities recognized pain management as a subspecialty of medicine, according to Dr. Charles Argoff, who directs the Comprehensive Pain Center at Albany Medical Center, which opened in 2007.
“Pain management has moved to a level where people at the highest levels of the academy have realized that you need specialized training to do it,” Argoff said. “We now realize how important pain is. Health care practitioners have traditionally and tragically been undertrained to accept the challenge of attempting to treat pain. Many leave their training without knowing how to comprehensively assess pain.”
Technically, all physicians hear complaints of pain and suffering, but Steindler and Argoff underwent specialized training to treat pain. Steindler completed a pain management fellowship at Wayne State University in Detroit, and Argoff was certified in pain management by the American Board of Psychiatry and Neurology.
“Pain is the No. 1 symptom that results in any of us having to see a health care provider,” said Argoff, who co-authored the 2010 book “Defeat Chronic Pain Now!”
Vic Giulianelli, CEO of St. Mary’s, said it decided to create a pain management clinic in response to requests from its primary care physicians.
“Many physicians were saying that we really need someone who can manage chronic pain,” he said. “The primary care physicians have expertise, but not the same level as someone like Dr. Steindler.”
Giulianelli said that Steindler’s services are in demand.
“He’s gotten very busy very quickly,” he said.
Ellis Medicine does not have a pain management clinic, but the hospital’s neuroscience center helps people suffering from back and neck pain feel better through its rehabilitation program, according to Jeffrey Winacott, director of neurosciences.
“Our goal is to help the patient manage their pain and restore function that has been impaired by injury or illness,” Winacott said in an email. “Some of the main strategies in managing pain revolve around individualized plans of care that target the specific needs of each patient and often involve a combination of treatments,” such as physical therapy, medication and surgical interventions.
Steindler said that the most common ailments he sees are chronic neck and back pain, but that the complaints people present run the gamut.
“I’ve treated shingles and traumatic nerve injuries,” he said. “People come to me with strange pains. They might say, ‘My right leg feels like it’s burning.’ ”
Argoff said his patients also have arthritis, HIV, nerve damage from diabetes and chemotheraphy-induced neuropathy — pain and numbness in the hands and feet.
Treating people with chronic pain is not easy. Both Argoff and Steindler emphasized that the roots of pain are complex, and that what works for one patient might not work for another. Their approach to treatment is multidisciplinary with a range of options, from medicine and surgery to alternative remedies such as acupuncture and yoga, considered.
They noted that certain medications, such as anti-seizure drugs and anti-depressants, are known to reduce pain, and that relatively new procedures and technology, such as a spinal cord stimulator, can also provide relief. A spinal cord stimulator is a small pulse generator that is implanted in the back and sends electrical pulses to the spinal cord.
“If you have pain, you should get a diagnosis and get treatment,” Steindler said. “My approach is, ‘What is your diagnosis and how can I help you without resorting to high-dose opioid therapy?’ ... People were not meant to be on high-dose opioids for life. There are drawbacks to long-term opioid therapy.”
“If all you know is Vicodin, that’s all you know,” he said. “But there’s a much greater palate [of treatments].”
Argoff said that when opioids fail to relieve pain, many wrongly assume they should just take more.
“Maybe the opioids are not working,” he said.
The drawbacks to prescription painkillers include:
u Tolerance — For some patients, the effects of prescription painkillers diminish over time, and achieving the same results requires taking an ever-increasing amount of the drug.
u Respiratory depression — Opioids can slow a person’s breathing rate to dangerous levels.
u Hormonal abnormalities — Long-term use of opioids can result in lower hormone levels, which can result in sexual dysfunction.
u Hyperalgesia — In some patients, opioids can increase sensitivity to pain.
Steindler said that most people aren’t aware of the side effects of prescription painkillers.
“I make it my job to educate them,” he said.
Steindler said that prescription painkillers can be an appropriate form of treatment, but not for the vast majority of people.
“There are some people who need opioids to handle pain,” he said. “But in America, we consume 80 percent of the world’s opioids.”
Prescribing painkillers isn’t something Steindler does lightly, even for those who need it: Patients taking pain pills as part of their treatment regimen sign a contract, and can be asked to undergo urine testing at any time.
The process is similar at the pain center at Albany Medical Center, where patients sign something called an understanding, agree to submit to random urine tests, and are asked to contact the pain center if they are having more pain. Argoff said that sometimes patients are found to be abusing opioids, and their prescriptions are terminated. One young man, he said, was recently informed that he could no longer take pain meds after testing revealed problems.
“We continued to treat him, but we said, ‘[Opioids] are not going to work for you. They’re not safe,’ ” Argoff said.
The man’s treatment regimen also included use of an anti-inflammatory patch and physical therapy.
Set to go online in August is the state’s new I-STOP database, which will make the prescription histories of patients available to doctors, pharmacists and law enforcement in real time. Doctors and pharmacists will be required to check a patient’s record before filling or issuing a prescription for a narcotic painkiller, and all prescriptions must be electronically submitted.
Argoff said the goal is to reduce the number of people who are abusing prescription painkillers.
“There are people who are trying to bamboozle us,” he said.
According to the CDC, almost all prescription drugs involved in overdoses come from legal prescriptions, while very few come from pharmacy theft.
“However, once they are prescribed and dispensed, prescription drugs are frequently diverted to people using them without prescriptions,” the agency notes. “More than three out of four people who misuse prescription painkillers use drugs prescribed to someone else.”
Kathleen Riddle, who serves as public policy chair for the New York Association of Alcoholism and Substance Abuse Providers, said that abuse of prescription painkillers is “an epidemic at this point,” particularly among young adults between the ages of 18 and 25.
Riddle said that it’s easy to obtain prescription painkillers.
“I go to the dentist, and I get an enormous amount of Vicodin, which I never take,” she said. “I might take one or two, but not the whole thing.”
The Institute of Medicine estimates that chronic pain affects about 100 million American adults — “more than the total affected by heart disease, cancer and diabetes combined,” the organization wrote in a 2011 report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research.”
“Pain represents a national challenge,” the report says. “A cultural transformation is necessary to better prevent, assess, treat and understand pain of all stripes.”
The report recommends that the U.S. Department of Health and Human Services develop a comprehensive plan to help “the vast multitude of people with various types of pain.” This plan should include measures to better educate people about pain and how to manage it, improve pain assessment and management in the delivery of healthcare services and research pain itself.