For the estimated 116 million Americans suffering from chronic pain, proper pain management can improve functionality and quality of life as well as reduce pain, but pervasive myths can hinder treatment. Some of these myths are believed by patients while others are perpetuated by physicians.
Scott Glaser, MD, DABIPP, president of Pain Specialists of Greater Chicago and a board member of American Society of Interventional Pain Physicians, and Steven P. Cohen, MD, director of medical education for the pain management division at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center, discuss eight myths surrounding pain management.
1. Narcotics are inherently bad. This myth has been supported by recent headlines after the release of the Center for Disease Control report that found almost 15,000 Americans died from prescription opioid overdose in 2008. The issue is not that cut-and-dried, Dr. Glaser says.
"Narcotics aren't good or bad; they're a treatment option with risks that need to be appreciated, communicated, and dealt with," he says. "They're not inherently evil, and doctors who prescribe them aren't evil. For some folks, they're life savers. It enhances their quality of life without adverse side effects. It's easy to lose sight of that fact in the pandemonium surrounding the epidemic of prescription drug abuse."
Dr. Cohen says the important thing is to prescribe drugs based on individual patients. For example, an older patient with cancer pain might respond well to opioids, but a young patient with back pain is at a higher risk for developing tolerance or even hyperalgesia, a condition that makes the body more sensitive to pain.
"It's like everything else; these things have to be determined on a case-by-case basis," he says.
2. Advisory board and guideline committee recommendations are the gold standard. Both the Independent Payment Advisory Board and the Patient-Centered Outcomes Research Institute were created under the Patient Protection and Affordable Care Act to reduce the cost of healthcare without affecting coverage or quality. Many interventional pain management physicians, including Dr. Glaser and ASIPP's chairman of the board and CEO, Laxmaiah Manchikanti, MD, think they should be repealed.
"I think it is a myth perpetuated by well-meaning folks at the highest levels of government that a group of epidemiologists and non-practicing physicians and statisticians can come up with appropriate recommendations for billions of people when the issue of best treatment isn't even settled in medical literature," Dr. Glaser says.
Dr. Cohen, who oversees numerous clinical trials, says advisory boards and guidelines committees are the "lowest level of acceptable evidence."
"Many reach different conclusions based on the same articles evaluated with different criteria," he says. "It depends a lot on the perspective [of the members]. The best guidelines consist of recommendations from a multidisciplinary group, including multiple specialties, private practice, military and government."
3. All back pain is the same. This myth is found among patients, some primary care physicians, and multiple specialists, Dr. Glaser says. Primary care physicians and specialists such as neurologists don't have the knowledge of the causes or the tools to treat back pain which leads them to lump lower back pain in to one broad category rather than attempt to understand the unique causes. Dr. Cohen calls this a naïve statement and says distinguishing different types of back pain is essential to determining treatment.
"Perhaps the broadest and most critical categorization is to differentiate between mechanical pain and nerve pain," he says. "This is a really important categorization because it affects treatment at all levels."
Dr. Glaser says there are many different structures that can cause back pain such as the intervertebral joints, the sacroiliac joints and effects on the nerves traversing these joints. Other causes include failed back surgery syndrome and the sequelae including adjacent level disc disease, destabilization and nerve damage. The prescribed treatment for each cause of back pain is different.
4. MRI always results in a back pain diagnosis. While MRIs can provide objective information about back disorders, such as degenerative disc disease and bulging discs, they rarely point to the cause of the pain because of the incidence of these findings in the normal population increases with age. Dr. Glaser says many issues that show up in an MRI might have been present before the patient experienced any pain.
"MRIs actually have very low sensitivity for diagnosing pain," he says. "Degenerative disc disease is so common in human beings that if you do MRIs on asymptomatic 50-year-olds, 90 percent will have some findings consistent with a degenerative disc disorder."
Dr. Cohen, who will be releasing a large, randomized trial on MRI use next month, says MRIs don't improve outcomes and don't affect decisions. They have very low specificity and are poorly correlated with pain and treatment outcomes.
5. Pain management is only epidurals. Dr. Glaser says interventional pain management specialists have developed different treatments — including injections, nerve blocks and neurolytic procedures — for different sources of pain.
"Pain management has evolved as a subspecialty because of the advancement and knowledge of the causes of pain through advances in our knowledge in anatomy and the sensory innervation of the joints in the lumbar spine," Dr. Glaser says.
6. Surgery is an easy fix for back pain. This myth comes from a hope that surgery can cure back pain, but often there is no cure for back pain, Dr. Glaser says.
"It can be made asymptomatic, but you can't stop degenerative disc disease," he says. "You can only minimize the symptoms."
Dr. Cohen says most studies show that in patients with back pain extending to legs or neck pain extending into the arms, surgery works temporarily. For the first six months, patients are better off than they would have been without surgery, but that benefit wears off after two years.
"First of all, it doesn't work in everyone," he says. "Even if it works, it may not improve long-term outcomes."
Like all surgery, back surgery has its share of risks, Dr. Glaser says. Oftentimes, the risk is not worth the benefit for this elective procedure, he says.
"Back surgery is associated with a high risk of failure," he says. "Even a microdiscectomy can be associated with rapid onset of epidural fibrosis or scarring. Surgery for back pain is always an elective procedure unless there's compression of the spinal cord or nerve roots, which is actually extremely rare."
7. Only three steroid injections can be given per year. This myth has no foundation in science, say both Drs. Glaser and Cohen. Some conservative pain management physicians still believe and treat based on this myth. A steroid injection is not like taking an oral steroid, Dr. Glaser says. With an oral steroid, consistent dosing means increased risk for a whole host of health problems such as cataract formation, glaucoma and osteoporosis. Because the steroid is injected, the medicine more or less stays put, he says. The same risk isn't there.
Dr. Cohen says the decision to do multiple injections should depend on how the patient responds. If the patient gets 100 percent relief from one injection, there's no point in doing more, he says. If a patient fails to obtain relief from the first injection, it might make sense to do a second injection in a different manner, such as using a different approach or a higher volume of medication, he says.
8. Anybody can do pain management. There has been a movement to allow nurses and physician's assistants to perform some pain management procedures. Last year, the Supreme Court of Louisiana ruled that pain management is a medical practice and needs to be performed by physicians. ASIPP also tried to get a similar bill passed in Illinois.
"The fact is that there are risks," Dr. Glaser says. "These procedures are minimally invasive but maximally dangerous. We're working very close to the spine. A nurse or physician's assistant or a physician without appropriate training should not be allowed to perform these procedures."
Just because someone can be taught to perform pain management procedures, such as epidural steroid injections, doesn't mean they should, Dr. Cohen says.
"The truth is you can teach somebody to do an epidural steroid injection, you can teach them to put a screw into a bone, but that doesn't constitute the practice of medicine," he says. "The important thing is to know when something is indicated. Anyone can take an appendix out, but you need a lot of experience to know when the treatment is indicated, and how to identify and treat complications."
Related Articles on Pain Management:
Pieces of the Puzzle: Creating a Multidisciplinary Approach to Pain Management
7 Trends Affecting the Future of Pain Management in Surgery Centers
Healthcare Reform and its Effect on Pain Management: Q&A With Dr. Laxmaiah Manchikanti of the American Society of Interventional Pain Physicians
Scott Glaser, MD, DABIPP, president of Pain Specialists of Greater Chicago and a board member of American Society of Interventional Pain Physicians, and Steven P. Cohen, MD, director of medical education for the pain management division at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center, discuss eight myths surrounding pain management.
1. Narcotics are inherently bad. This myth has been supported by recent headlines after the release of the Center for Disease Control report that found almost 15,000 Americans died from prescription opioid overdose in 2008. The issue is not that cut-and-dried, Dr. Glaser says.
"Narcotics aren't good or bad; they're a treatment option with risks that need to be appreciated, communicated, and dealt with," he says. "They're not inherently evil, and doctors who prescribe them aren't evil. For some folks, they're life savers. It enhances their quality of life without adverse side effects. It's easy to lose sight of that fact in the pandemonium surrounding the epidemic of prescription drug abuse."
Dr. Cohen says the important thing is to prescribe drugs based on individual patients. For example, an older patient with cancer pain might respond well to opioids, but a young patient with back pain is at a higher risk for developing tolerance or even hyperalgesia, a condition that makes the body more sensitive to pain.
"It's like everything else; these things have to be determined on a case-by-case basis," he says.
2. Advisory board and guideline committee recommendations are the gold standard. Both the Independent Payment Advisory Board and the Patient-Centered Outcomes Research Institute were created under the Patient Protection and Affordable Care Act to reduce the cost of healthcare without affecting coverage or quality. Many interventional pain management physicians, including Dr. Glaser and ASIPP's chairman of the board and CEO, Laxmaiah Manchikanti, MD, think they should be repealed.
"I think it is a myth perpetuated by well-meaning folks at the highest levels of government that a group of epidemiologists and non-practicing physicians and statisticians can come up with appropriate recommendations for billions of people when the issue of best treatment isn't even settled in medical literature," Dr. Glaser says.
Dr. Cohen, who oversees numerous clinical trials, says advisory boards and guidelines committees are the "lowest level of acceptable evidence."
"Many reach different conclusions based on the same articles evaluated with different criteria," he says. "It depends a lot on the perspective [of the members]. The best guidelines consist of recommendations from a multidisciplinary group, including multiple specialties, private practice, military and government."
3. All back pain is the same. This myth is found among patients, some primary care physicians, and multiple specialists, Dr. Glaser says. Primary care physicians and specialists such as neurologists don't have the knowledge of the causes or the tools to treat back pain which leads them to lump lower back pain in to one broad category rather than attempt to understand the unique causes. Dr. Cohen calls this a naïve statement and says distinguishing different types of back pain is essential to determining treatment.
"Perhaps the broadest and most critical categorization is to differentiate between mechanical pain and nerve pain," he says. "This is a really important categorization because it affects treatment at all levels."
Dr. Glaser says there are many different structures that can cause back pain such as the intervertebral joints, the sacroiliac joints and effects on the nerves traversing these joints. Other causes include failed back surgery syndrome and the sequelae including adjacent level disc disease, destabilization and nerve damage. The prescribed treatment for each cause of back pain is different.
4. MRI always results in a back pain diagnosis. While MRIs can provide objective information about back disorders, such as degenerative disc disease and bulging discs, they rarely point to the cause of the pain because of the incidence of these findings in the normal population increases with age. Dr. Glaser says many issues that show up in an MRI might have been present before the patient experienced any pain.
"MRIs actually have very low sensitivity for diagnosing pain," he says. "Degenerative disc disease is so common in human beings that if you do MRIs on asymptomatic 50-year-olds, 90 percent will have some findings consistent with a degenerative disc disorder."
Dr. Cohen, who will be releasing a large, randomized trial on MRI use next month, says MRIs don't improve outcomes and don't affect decisions. They have very low specificity and are poorly correlated with pain and treatment outcomes.
5. Pain management is only epidurals. Dr. Glaser says interventional pain management specialists have developed different treatments — including injections, nerve blocks and neurolytic procedures — for different sources of pain.
"Pain management has evolved as a subspecialty because of the advancement and knowledge of the causes of pain through advances in our knowledge in anatomy and the sensory innervation of the joints in the lumbar spine," Dr. Glaser says.
6. Surgery is an easy fix for back pain. This myth comes from a hope that surgery can cure back pain, but often there is no cure for back pain, Dr. Glaser says.
"It can be made asymptomatic, but you can't stop degenerative disc disease," he says. "You can only minimize the symptoms."
Dr. Cohen says most studies show that in patients with back pain extending to legs or neck pain extending into the arms, surgery works temporarily. For the first six months, patients are better off than they would have been without surgery, but that benefit wears off after two years.
"First of all, it doesn't work in everyone," he says. "Even if it works, it may not improve long-term outcomes."
Like all surgery, back surgery has its share of risks, Dr. Glaser says. Oftentimes, the risk is not worth the benefit for this elective procedure, he says.
"Back surgery is associated with a high risk of failure," he says. "Even a microdiscectomy can be associated with rapid onset of epidural fibrosis or scarring. Surgery for back pain is always an elective procedure unless there's compression of the spinal cord or nerve roots, which is actually extremely rare."
7. Only three steroid injections can be given per year. This myth has no foundation in science, say both Drs. Glaser and Cohen. Some conservative pain management physicians still believe and treat based on this myth. A steroid injection is not like taking an oral steroid, Dr. Glaser says. With an oral steroid, consistent dosing means increased risk for a whole host of health problems such as cataract formation, glaucoma and osteoporosis. Because the steroid is injected, the medicine more or less stays put, he says. The same risk isn't there.
Dr. Cohen says the decision to do multiple injections should depend on how the patient responds. If the patient gets 100 percent relief from one injection, there's no point in doing more, he says. If a patient fails to obtain relief from the first injection, it might make sense to do a second injection in a different manner, such as using a different approach or a higher volume of medication, he says.
8. Anybody can do pain management. There has been a movement to allow nurses and physician's assistants to perform some pain management procedures. Last year, the Supreme Court of Louisiana ruled that pain management is a medical practice and needs to be performed by physicians. ASIPP also tried to get a similar bill passed in Illinois.
"The fact is that there are risks," Dr. Glaser says. "These procedures are minimally invasive but maximally dangerous. We're working very close to the spine. A nurse or physician's assistant or a physician without appropriate training should not be allowed to perform these procedures."
Just because someone can be taught to perform pain management procedures, such as epidural steroid injections, doesn't mean they should, Dr. Cohen says.
"The truth is you can teach somebody to do an epidural steroid injection, you can teach them to put a screw into a bone, but that doesn't constitute the practice of medicine," he says. "The important thing is to know when something is indicated. Anyone can take an appendix out, but you need a lot of experience to know when the treatment is indicated, and how to identify and treat complications."
Related Articles on Pain Management:
Pieces of the Puzzle: Creating a Multidisciplinary Approach to Pain Management
7 Trends Affecting the Future of Pain Management in Surgery Centers
Healthcare Reform and its Effect on Pain Management: Q&A With Dr. Laxmaiah Manchikanti of the American Society of Interventional Pain Physicians