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Chronic pain can affect
every part of a person's life. Whether it's pain caused
by cancer, back problems, or more elusive disorders
such as myofascial pain or shingles and PHN, a comprehensive
pain management center can offer the most effective
treatment.
Four
years ago, Carole Dunscombe’s typical day involved
taking a prescription medicine to take the edge off
chronic deep bone pain; having two or three good hours;
then spending the remaining time in bed trying to deal
with the pain. Today, she has a homemade soup business;
runs errands; and enjoys life with her husband, Bill,
and service dog, Brennan. The difference, she says,
is finding a specialist in pain management who developed
an individualized plan for her.
Mrs.
Dunscombe’s source of pain, avascular necrosis,
resulted from long-term use of steroids to treat another
condition, intercranial hypertension. Avascular necrosis
occurs when bones are deprived of an adequate blood
supply, and the condition can cause tremendous pain
at the joints and loss of joint function (See
the Summer 2003 HealthLink article, "Pain in the
Hip? Don't Ignore It!). Conservative
treatments are available, but in Mrs. Dunscombe’s
case, the avascular necrosis had progressed to where
she needed her left hip and both shoulder joints replaced.
It was when Mrs. Dunscombe was hospitalized for an infection
at her hip prosthesis site that she was referred to
Dr.
Andrew Kaufman, today an assistant professor of
anesthesiology at New Jersey Medical School and director
of The Comprehensive Pain Management Center at University
Hospital.
“Dr.
Kaufman literally gave me my life back,” says
Mrs. Dunscombe, who lost vision in one eye because of
the intercranial hypertension and uses a wheelchair
as result of intense radiation therapy to treat cervical
cancer. “He developed a pain management plan that
was effective and factored in who I am as a whole person.
He took into account my energy level, my marriage, and
my home life. He wasn’t just treating bone pain.”
After
exploring a range of pain management possibilities,
Dr. Kaufman prescribed a controlled-release opioid,
oxycodone (OxyContin) for her. As a registered nurse
(although no longer practicing), Mrs. Dunscomb was well
aware of OxyContin’s reputation. “It’s
an effective pain reliever that’s received a lot
of bad press. Yes, OxyContin can be abused, and it can
be addictive,” she says. “But taken as prescribed,
OxyContin can also be a miracle drug.”
An
Emerging Specialty
Pain
is neither new nor uncommon. Surgery, injury, or disease
can trigger pain. At any given time, an estimated 25
million Americans are suffering acute pain, which is
typically relieved in less than three months. Another
50 million people in this country endure chronic pain
that lasts longer than three months—often, for years.
Pain affects more than the individual: marriages, family
relationships and friendships, and even the workplace
bear its impact. According to a 2000 Gallup Organization
survey, 83 million people say pain curtails their participation
in activities, and 36 million people have missed work
because of pain.
People
in pain turn to a host of medical professionals for
relief, often with mixed or poor results. The emergence
of a relatively new medical subspecialty, pain management,
may change that. Most pain management specialists are
anesthesiologists. Dr. Kaufman was an operating room
anesthesiologist, but decided to follow his interest
and now treats only pain management patients. “My
own father had pain for many years from a neck injury,
so I know the toll that pain can take and how difficult
it is to watch a loved one in pain,” he says.
“I enjoy practicing pain management medicine and
making a difference in the lives of people in pain,
a truly underserved population.”
Currently,
the American Board of Medical Specialties recognizes
only one board certification in pain management—that
conferred by the American Society of Anesthesiologists.
Physicians who are board certified in pain management,
such as Dr. Kaufman, have undergone specialized training
and passed a board exam. “Specialists in pain
medicine have insight into pain and the modalities to
treat it that are beyond the expertise of many other
physicians,” says Dr. Kaufman. “That’s
not a criticism. An orthopaedic surgeon may excel in
the operating room but not know how to look for certain
patterns of pain.”
The
majority of Dr. Kaufman’s patients are referred
by other physicians. “By the time many people
see me, they’ve already been to several physicians
who’ve been unable to find the cause of their
pain,” he says. “And while it’s ideal
when the source of pain can be determined, it’s
not a prerequisite for pain relief. We can manage the
symptoms without knowing why they occur.”
One
of Dr. Kaufman’s patients was referred after years
of unexplained head and jaw pain. The woman had been
to a dentist, a specialist in temporomandibular joint
(TMJ) disorder, and an ears, nose and throat doctor,
all with no definitive diagnosis or pain relief. Dr.
Kaufman took a full medical history, conducted a physical
exam, and asked a series of questions about the woman’s
pain: When did the pain start— What adjectives describe
the pain (throbbing, shooting, etc.)? What makes the
pain better or worse? He assessed whether any further
studies, such as an MRI or CT Scan were needed. Dr.
Kaufman’s diagnosis: myofascial pain syndrome,
pain from “spasm” of selected muscle bundles
that make up larger muscle groups. Dr. Kaufman identified
the trigger points and injected local anesthetic deep
into those points. Within two weeks of the treatment,
says Dr. Kaufman, the woman’s chronic pain was
gone.
Relief
from Shingles-Related Pain
Shingles,
a reactivation of the same virus that causes chicken
pox, generally affects the elderly. It’s a condition
for which pain often is undertreated, says Dr. Kaufman.
The second time around, the virus infects the nerves
and can be more painful than itchy. Even after the shingles
rash has healed, about 10 to 15 percent of people develop
postherpetic neuralgia (PHN), pain that results from
nerve damage caused by the virus. The pain from shingles
and PHN can last for weeks, months, and even years.
There is one FDA-approved drug specifically for PHN,
gabapentin (Neurontin). For patients who need additional
pain relief measures, there are topical treatments and
sympathetic nerve blocks.
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© 2004 Medtronic
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© 2004 Medtronic
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Spinal cord stimulation
has been used for thirty years (introduced in 1967),
to diminish pain in patients. It is extremely beneficial
to patients with certain types of low back and lower
extremity pain. Although it's exact mechanism of
operation remains unclear, it appears to work by
blocking transmission of pain fibers.
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“Some
shingles patients try these treatments and still have
excruciating pain,” says Dr. Kaufman. “In
these difficult cases, spinal cord stimulation (SCS)
can be helpful. With SCS, a small device is surgically
implanted under the skin. Low levels of electrical stimulation
interrupt the pain signals to the brain.” SCS
has been found to be helpful for shingles patients and
can be used with other types of neuropathic pain.
Medicine
and More
Of
the many ways to relieve pain, medication is probably
the best known by the public. And yet, not all medications
that relieve pain work the same way or are effective
in treating different types of pain. Non-steroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen relieve pain and inflammation.
A non-aspirin pain reliever like acetaminophen can tackle
pain but does not reduce swelling. Medicines not originally
developed to treat pain have been helpful in pain management;
some anti-seizure medications, for example, help relieve
“shooting” pain.
Although
narcotic drugs can be addictive, Dr. Kaufman believes
they have a role in pain management. “Narcotics
can be very useful in the treatment of chronic pain,”
he says. “However, their use requires careful
patient selection, education, and follow-up by a physician.
You can’t just throw pills at a patient and hope
for the best.”
A
comprehensive pain center offers more than prescriptions.
Take the treatment of lower back pain. Arthritis, muscle
strain, and herniated discs (when the center of the
disc is pushed out, irritating a spinal nerve) are the
most common causes of lower back pain. Physical therapy
can be prescribed alone or with other treatments. Many
of the modalities focus on the nerves, which carry pain
messages to the brain. Nerve blocks, such as epidural
steroid or facet joint injections, are a mainstay treatment
for many lower back problems, says Dr. Kaufman. To relieve
the nerve irritation and inflammation of a herniated
disc, for example, a steroid and a local anesthetic
are injected into the epidural space nearest the affected
nerve. The outpatient procedure takes only about 15
minutes, and it provides relief for some people lasting
anywhere from a few days to several months.
Other
non-invasive treatments for lower back pain include
Transcutaneous Electrical Nerve Stimulation, or TENS,
and radiofrequency ablation. With TENS equipment, a
mild electrical current is painlessly delivered through
the skin to specified nerves. TENS is believed to work
by blocking pain messages or releasing endorphins, the
body’s natural pain relievers. Radiofrequency
ablation uses radio waves to heat, or burn, a problematic
nerve. This destroys the nerve, thus interrupting pain
signals. It usually takes at least six months for the
nerve to grow back. Patients who have had physical therapy
during the interim may not experience the same level
of pain as before.
Treating
Cancer Pain
Dr.
Kaufman has a special interest in providing pain relief
to cancer patients. Cancer pain can be caused by the
cancer itself or as a result of cancer treatment. Regardless
of the source, cancer pain is treatable. “One
of the biggest fallacies is that if you have terminal
cancer, you have to be in pain,” he says. “Just
because there’s no cure doesn’t mean the
patient has to suffer.”
Medications
ranging from over-the-counter drugs, such as aspirin
and ibuprofen, to opioids like codeine and morphine,
are the foundation of pain relief for many cancer patients.
Oral medications can ease pain, but some are only effective
a few hours at a time. When the pain is chronic, the
patient may benefit from an implanted pump that continuously
releases pain medication. Even when the cancer patient
is taking a long-acting pain reliever, he or she can
still experience breakthrough pain, a brief, yet severe,
pain episode. Quick-acting drugs, such as immediate-release
morphine tablets, can help manage breakthrough pain.
There
are also specialized pain management treatments for
some types of cancer. Pancreatic cancer, which has a
poor prognosis, can cause a very painful condition,
chronic pancreatitis. For some pancreatic cancer patients,
a procedure known as a celiac nerve block, which destroys
inflamed or irritated pancreatic nerves, provides excellent
pain relief.
The
Full Court Press
The
complexities of pain sometimes require a team approach
that includes professionals in a wide variety of fields.
For example, people who are in pain—especially chronic
pain—do not have the same quality of life as others.
They can become depressed or need assistance with family
issues. A mental health professional can help work through
some of the problems that pain patients face. Dr. Donald
Ciccone, an assistant professor of clinical psychiatry
at New Jersey Medical School, has an interest in the
role of stress in chronic pain and can help patients
learn coping skills and deal with pain-related issues.
Dr.
Kaufman believes that complementary treatments such
as acupuncture and chiropractic medicines can benefit
some patients. In the ancient Chinese medical art of
acupuncture, sterile, thin needles are inserted into
the skin at areas corresponding with the patient’s
pain. One theory as to why acupuncture can bring relief,
according to the National Institute of Health’s
National Center for Complementary and Alternative Medicine,
is that it increases the flow of the body’s endorphins.
Chiropractic
medicine’s mainstay treatment, spinal manipulation,.is
based on the belief that when the spine is out of its
natural position, it affects the nervous system and
causes pain. By a hands-on technique, the misalignment
can be corrected and the pain alleviated. These services
are offered, when appropriate, to Pain Management Center
patients through referral to outside practitioners.
When
conservative pain management measures are not effective
or there’s another possible reason for a person’s
pain, such as a tumor, Dr. Kaufman will refer patients
to his colleagues—usually neurosurgeons or orthopaedic
surgeons—at University Hospital. “In those
instances, I continue to work with the other doctors.
We take a team approach to relieving a person’s
pain,” says Dr. Kaufman.
Finding
Relief
Both
professionally and personally, Elizabeth Gramer is well
acquainted with pain. She was a registered nurse for
25 years at a veterans’ hospital, 15 of which
she worked on the oncology unit and gave lectures on
pain. It was Mrs. Gramer’s volunteer work as a
firefighter, however, that gave her the first-hand knowledge.
While
fighting a fire in 1999, Mrs. Gramer hit a concrete
wall with a sledgehammer, tearing her left rotator cuff
off the bone. In hindsight, it’s now clear to
Mrs. Gramer that the right arm was injured, too. After
the firefighter sought medical help for her right shoulder,
doctors found it was so severely dislocated that the
blood flow was being cut off. In what she describes
as “an orthopaedic nightmare,” it’s
taken three surgeries to repair the shoulder. She still
needs surgery for her right hand.
In
the meantime, however, Mrs. Gramer has experienced excruciating
pain. “I was uncomfortable all the time,”
she says. “I tried a gamut of medicines and treatments,
but they either didn’t make a difference or made
me feel sick. “
When
Mrs. Gramer finally went to Dr. Kaufman, she experienced
what she describes as “another level of care.”
The 43-year-old is on a regimen that includes physical
therapy and Percocet, a combination of oxycodone and
acetaminophen. “Dr. Kaufman has coordinated my
pain management as I’ve gone to different hospitals
for surgery,” she says. “He has a remarkable
ability to understand the many ways pain manifests and
how to control it.”
***
Not
that long ago, people like Mrs. Dunscombe and Mrs. Gramer
were told to “deal with the pain.” But,
with the emergence of the pain management specialty,
that doesn’t have to be the case today. There
are new pain management tools and a new attitude toward
treating pain within the medical community.
To arrange
for a consultation with Dr. Kaufman at the Comprehensive
Pain Management Center at University Hospital, call
973-972-2085.
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