Trying to find the right mix of medication, non-pharmacologic modalities, and tempered expectation is a delicate balancing act that many physicians – from primary care providers to pain specialists – face under the glare of rising opioid and heroin addiction nationwide.
Coming out of an age where there is a ‘pill to fix what ails you,’ John R. Schneider, MD, MA, founder and medical director of Comprehensive Pain & Neurology Center, said it’s time to change the collective mentality.
“Our grandparents would complain about their sciatica and their lumbago, but they still went to work, and they were still functional. One of the things I really try and emphasize with our patients is to grasp the concept that we’re not going to eliminate all of their pain, but we’re going to try to focus on their functioning and take the edge off the pain.”
Schneider, who has a master’s in psychology, was working on his doctorate in that field when he decided to pursue his medical degree. He is one of the few pain specialists in the state board certified in both pain medicine and in neurology. With his background, Schneider is keenly aware of the link between depression and chronic pain and the risk of addiction.
“At the end of the day, I think what we’re dealing with is a patient’s ability to cope with their situation,” he said. Schneider also noted, “I think we’re one of the only private practices, at least in Middle Tennessee, that has a clinical psychologist on board. We utilize her for our opioid risk assessments to help stratify which patients are at high risk and which are at low risk for opioid abuse and misuse.”
While opioids remain a mainstay of pain management, Schneider said there are a number of options for utilizing adjuvant therapies, encouraging activity and self-management, and dealing with the coping mechanism of having some level of pain. He also noted that not all opioids are created equally. “Some of the opioids prescribed have a little more activity in the mu receptors in the brain,” he said, adding these lead to “chemical coping” in some patients but require ever-increasing dosages to maintain a level of relief.
By the time patients arrive at a pain specialist after referrals from primary care physicians and surgeons, most have been in pain and on chronic opioid therapy for quite a while. However, Schneider noted, “A lot of the medical evidence points to the fact that opioids aren’t that effective long-term. We know there are certain limits and certain risks with dosages so we try and do as best we can at adding adjunctive medications.”
That said, he doesn’t dismiss opioids as part of a comprehensive pain management strategy. Schneider said for the last two decades, the pendulum swung too far to the left in terms of overprescribing opioids, but there is now some concern there will be an overcorrection.
“I do think there’s a role of opioids, but you’ve really got to keep an eye on the patient and the function,” he said. “It comes down to education – educating your colleagues, educating the patient on the proper use and role of opioids.”
Schneider – who is a founding member and current secretary of the Tennessee Pain Society, treasurer of the Tennessee Society of Interventional Pain Physicians, and a member of the TennCare Drug Utilization Review Committee – said increased awareness of addiction issues combined with new innovations in neuromodulation technology and new medications in Phase 2 & 3 clinical trials also provide more treatment options. Perhaps one of the most powerful tools is education to help patients recognize the diminishing returns that come with long-term opioid use and tolerance to the medications and to enhance self-management efforts to improve overall functionality.
He continued, “We are an interventional practice. Some of these steroid injections, nerve blocks … these types of things … can help alleviate pain. One of the criticisms we get is these things aren’t curative. They’re not surgical procedures. They are interventions that are meant to give a duration of relief. And if patients can get several months to maybe a year of relief with a certain procedure, well that’s great.”
Other options include utilizing medications like the anticonvulsant gabapentin or pregabalin for the management of neuropathic pain syndromes. “It’s really important to know what type of pain your patient has. Is it nociceptive or is it neuropathic?” Schneider queried, noting that answer impacts medication choice.
He continued, “Along those lines, some of these muscle relaxers – and in particular, Soma – we will not prescribe in our practice. We feel like it’s more sedating than anything, and that’s the last thing you want is for some of these patients to be is sedentary.”
Schneider said his partner Mark Bilezikjian, MD, who is double board certified in physical medicine and rehabilitation and in pain medicine, is very focused on educating patients on the need for self-management and movement. Schneider said the practice hopes to add physical therapy to their offerings in the near future. “It’s an important role,” he said. “The key is really getting patients active.”
The practice is also in talks with a nutritionist to help patients adopt a lifestyle that could result in a healthier weight that might relieve some of the strain on muscles and joints. However, Schneider said, “The problem is always reimbursement.” He noted it took a year to get the practice’s psychologist credentialed with many insurers despite evidence that shows about 85 percent of patients with chronic pain also have anxiety and depression.
Although evidence backs a multimodal approach to managing pain, Schneider said medication, which is the cheapest route, remains attractive to payers. Changing the culture will require an across-the-board effort of physicians, payers, patients and politicians. However, he concluded, “With the new technology and new medications, there’s hope on the horizon.”
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