By David Gibbons
Pain management was pioneered by a Seattle anesthesiologist, Dr. John Bonica, in the 1970s, and its growth into an organized, accredited medical specialty was mostly shepherded by his colleagues in the field. So you would imagine these doctors to be masters of the numbing effects of various painkilling drugs. While this is true to some extent, it is also part of a popular misconception of that passive, white-coated figure who clamps on the knock-out mask and hovers over your inert corpus for hours while the “real doctors” perform their miracles.
As Sanjay Bakshi, M.D., a prominent pain doctor, pointed out, “Anesthesiologists are actually hands-on physicians who perform various procedures such as nerve blocks.” Bakshi started his pain management practice in 1996, and in 2003 founded Manhattan Spine & Pain Medicine, P.C., which now has five locations in the New York-New Jersey metro area. “I can tell you that even back then, in the 1990s, people didn’t know much about pain management.”
Over the past 20 years, it has rapidly evolved into a multidisciplinary, holistic approach wherein drug therapy supplements many other treatments, including physical therapy, acupuncture, meditation, Chinese herbal medicine, injections, implants and minimally invasive surgery. And the drug therapy itself has become much more multidimensional; Pharmacology of Pain, a 2010 book aimed at health professionals, emphasizes “multimodal analgesics,” the simultaneous use of more than one family of pain relievers. It also covers the issues of tolerance, dependency and addiction.
Bakshi figures that about 60 percent of his patients suffer from back pain. “The good news is most of them get better with some over-the-counter medications after a couple of weeks,” he said. “If the pain goes on beyond six weeks, we need to look at other options. We take a ‘step-wise’ approach.”
The least risky, least invasive procedures—and the simplest, safest medications—are tried first. If they don’t work, a decision is made to move on to more difficult, complicated treatments.
The most commonly prescribed medications for chronic pain are NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (e.g., Motrin, Advil) and naproxen (e.g., Aleve), many of which are also available over the counter. Muscle relaxers might also be prescribed, possibly steroids, and then, if necessary, opioids, so called because they act on the same receptors as opium. The term encompasses the naturally occurring alkaloids morphine and codeine, semi-synthetics such as hydrocodone and oxycodone and synthetics such as fentanyl. Antidepressants and anti-seizure drugs may also used to treat chronic pain.
With little hesitation, general practitioners have prescribed morphine to combat acute or chronic pain for more than a century. The luxury of benefiting from a specialist who knows and understands all the options—including opioids, aka narcotics—is relatively new. Still, there are concerns that these powerful analgesics can do worse than just knock you out.
“Opioids are effective in a large number of situations but at the expense of troublesome or even life-threatening side effects,” said Dr. Pierre Beaulieu, one of the editors of Pharmacology of Pain. “The complexity of pain targets is now obvious, and no one magic bullet will be able to address them all.”
A 1999 survey sponsored by the American Pain Society found that 82 percent of people taking so-called narcotics experienced side effects. Those included drowsiness (61 percent), dry mouth (51 percent), upset stomach (35 percent), nausea (31 percent), constipation (30 percent) and confusion (21 percent). According to government estimates, nearly 2 million people per year in the U.S. abuse prescription painkillers; accidental overdose of these drugs is now considered a significant cause of death among adults.
“I think opioids are a good treatment modality, but like any other class of medications, it has to be tailored to the patient,” said Bakshi. “For example, if you have an 80-year-old woman who has pain from spinal stenosis, you might prescribe a small dosage so she can avoid surgery and resume her normal activities. If you have a young patient and start by prescribing large doses, of course they could have problems.” Lower doses and long-acting medications are preferable.
“Addiction is certainly a problem,” he said, “and it’s not necessarily a function of the medication but of the patient. People become alcoholics because they have an inherent personality issue that makes them susceptible. The same is true for opioids.”
The bottom line with painkillers is that patients need to follow their prescriptions to the letter and communicate honestly with their doctor. Good, responsible doctors prescribe opioids in a cautious and conservative manner. Setting a trial period and/or starting with a smaller dosage, then adjusting as necessary, are two examples of this, as is clearly spelling out the possible side effects alongside the benefits.
At Manhattan Spine & Pain, Bakshi and his colleagues have a robust informed consent policy and follow the guidelines of the American Society for Interventional Pain Management in prescribing narcotics. Patients are required to sign a form indicating they understand all of the risks and have fully disclosed their medical history.
They also must agree to random monthly urine or blood tests. This helps weed out anyone who might be diverting their medications or “shopping around” for multiple prescriptions.
“There are certain red flags,” said Bakshi. “If there is a history of alcohol or drug addiction, I would not put a patient on long-term narcotics.” He added that doctors can now use confidential online services to double-check a patient’s medication history. Another red flag is a patient who ups his or her dosage unilaterally.
“In the pain management specialty, we have a lot of different tools available,” said Bakshi. “It’s not just medications. It’s a combination that includes physical therapy, injections and other procedures. You really have to tailor the treatment to the problem and find the most effective way to deal with it. That’s what we do.”
Pain-relief procedures that were once considered exotic or last-resort—implanting an electrical spinal cord stimulator is a good example—are becoming much more routine and indeed are pushing potentially worrisome drugs back into the category of final options.
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