In March the Centers for Disease Control and Prevention released guidelines for prescribing opioids for chronic pain. The guidelines outline appropriate opioid prescribing to avoid overuse and addiction among chronic pain patients.
In the wake of a prescription drug epidemic in the United States, implantable chronic pain technologies are a way to steer patients away from oral opioids while still controlling chronic pain. These technologies include spinal cord stimulation and targeted drug delivery, more specifically Medtronic's RestorSensor SureScan MRI Neurostimulator and the SynchroMed II Drug Pump.
Douglas Beall, MD, chief of radiology services at Clinical Radiology of Oklahoma in Oklahoma City, and Richard Vaglienti, MD, of WVU Medicine Pain Management Center in Morgantown discuss pain management going forward.
Q: How might the recent CDC and FDA announcements impact you, your patients and your practice?
Dr. Douglas Beall: They haven’t impacted my practice very much. I do primarily interventional pain which tends to focus on using narcotics but only in conjunction with other methods of treating patients. We see acute, subacute and chronic problems and treat them with the least invasive option available. We continue until the combination of the least invasive treatment that help the patient accomplish the goal of pain relief.
A lot of the practices this affects are using opioids for chronic pain patients over a long period of time. The maximum prescription affects a large amount of patients who have undergone chronic medication management with opioids.
Dr. Richard Vaglienti: My concern as a pain physician is related to the guidelines perhaps leading to physicians undertreating pain. I’m not advocating high-dose opioids for chronic non-cancer pain, but in certain individuals such as terminally ill patients they are necessary.
I am a little discouraged but not surprised that many physicians are giving up the treatment of chronic pain with opioids completely. It hasn’t impacted our practice much because we didn’t go in to the high dosage range very often; we used opioids as a late resort. Now they are a last resort.
Q: Will these guidelines have a significant impact on your business model?
RV: The treatment of chronic pain is an expensive venture no matter how you do it, but a worthwhile venture. That is going to be where our focus is from now on. We will apply opioid sparing therapies and gather data to prove they are as effective as we know they are.
DB: A lot of the impact has to do with the types of patients who arrive at my practice. People often come with acute sciatica and I can treat them with acute epidural injections. For spinal stenosis patients, you can try simple injections, physical therapy or other conservative management and maybe a minimally invasive decompression becomes necessary.
There are a category of patients who can’t be treated surgically but fail other non-surgical options; for those patients we employ pain blocks like stimulation or targeted drug delivery. These options are popular for patients who have undergone treatment with narcotics for a while but persist in having chronic pain.
Q: What other solutions are available for treating patients with chronic pain?
DB: There are options we have to relieve pain if all other less invasive methods fail, including electrical methods for targeting the spinal cord to replace their pain sensation with other types of stimulations.
Targeted drug delivery is another option to put in a catheter into the spinal fluid and slowly inject medication into the spinal fluid. That way the medication hits the pain receptors at their origin. Opioids like morphine taken by mouth over time creates a woozy feeling and alters the patient’s reflexes. It can cause memory loss. But if you take the same medication in the spinal fluid, you can cut back the dose and this may help reduce some of the side effects.
RV: At the University of West Virginia, we are in the process of redesigning our entire outpatient pain program, and there is going to be a huge psychological component. The base of the program is pain physicians that do interventions and manage non-opioid medications as needed. We’ll do implantable devices such as SCS as needed. But a large portion of our patient population also suffers from depression and anxiety, which makes the chronic pain more severe. These programs are expensive, but cost-effective.
Q: Do you believe there will be differences in how opioid pain treatments are prescribed?
DB: There has to be. Chronic oral opioids are a significant problem and the deaths from chronic use and opioid overdose have exceeded automobile accidents. Some patients take more than they should because the higher the dose you have been on, the more you need to elicit the desired effect.
There is less of a difference between the therapeutic dose and the threshold where the overdose is possible when you are taking such a high dose to feel pain relief.
RV: Some physicians have given up their DEA numbers and refuse to deal with it. Others are practicing in a poorly controlled fashion and they’ll get in trouble. Those in the middle will adapt to whatever we are allowed to do. Oral opioids will move down the treatment ladder and other therapies will move up.
Q: How do you approach SCS, TTD and patients' oral opioids?
RV: We tell patients at the beginning of the selection process for an implantable devices that we will assist in tapering medications before the final surgical implantation occurs. They are aware of that from the beginning. The individual psychological evaluation tells them what to expect.
We explain the pump and stimulator to them and wean them off their meds before scheduling the appointment for the permanent implant. Once the patient has gone through the trial process and know the amount of pain relief to expect, it makes compliance with tapering much better.
DB: For targeted drug delivery, I don’t tolerate oral medications at all. Once we do the trial to decrease pain, we put in the pump and catheter, and then we can cut the trial dose in half. I tell patients only to use as much as they need, and when we turn it up we reduce oral medications by the equivalent.
For SCS patients, we are more lenient because the treatment uses electricity and isn’t another opioid. I’m less worried about an overdose risk for these patients.
Q: How could you leverage the announcements with your referral base and within the health system you represent?
RV: We are doing that through education. We are educating referring doctors, medical students and residents. We’re also involved with writing statewide guidelines for pain.
DB: I try to help colleagues and other physicians understand that getting the adequate pain relief through the least invasive techniques is important. Advanced pain management techniques are often poorly understood, not recognized and not employed enough.
I’ve had providers with questions about SCS and TDD because they aren’t adequately addressed in residencies and fellowships. I have patients who have heard about the techniques from a friend or on TV. Patient self-education is better for everyone. I want patients to receive an accurate diagnosis, know their options and research each option so they can make the best choice for their situation.
Q: What role can thought leaders play in influencing state legislators and government agencies?
DB: State legislators make decisions based on partial understanding of pain management. They also make decisions based on the groups with the largest lobbying activities. If you have an opinion to render, render that to the legislator that represents you in the appropriate federal or state body. The more legislators know about the activity, the more right decisions will be made.
RV: Being from West Virginia, ground zero for the overdose epidemic, we are fortunate that our state representatives and government agencies understand the problem and know pain needs to be treated. In a general way we are very fortunate that this is not just a unilateral problem — they know not prescribing opioids to anyone isn’t the answer, just as prescribing them to everyone wasn’t the answer.
This article is sponsored by Medtronic.