3 Day scripts a good idea?
With Governor Hogan’s Heroin and Opioid Prevention, Treatment and Enforcement Initiative being announced in early 2017 there has been a lot of talk recently about the appropriate number of days a narcotic prescription should been written for.
An informative and timely article, dated January 28 2017, written in the Frederick News Post by Frederick physician Dr. Julio Menocal, addressed many of the issues relating to narcotics and opioids prescribing he suggested that a 3 day rule be instituted. One of our Frederick and Leesburg based pain doctors Dr. Chirag Sanghvi and our senior staff have pondered this suggestion.
The opioid epidemic is a very real concern. As the Surgeon General pointed out in his letter to physicians dated August 25 2016, “Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly – almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed.”
However, expecting your internal medicine/ primary care physician to have the tools to manage genuine long-term chronic pain is unreasonable considering the huge variety of ailments they skillfully treat and juggle daily.
What are the unintended consequences of the 3 day narcotic/ opioid script?
There are many complexities involved in treating pain responsibly. The proposed three-day rule certainly addresses the need for increased monitoring of opioid and narcotic prescriptions.
However, will this rule itself achieve the desired outcome?
With the assumption that terminally ill patients, such as patients with cancer, would not be subjected to the three-day restrictions we must also look at the unintended consequences this rule may trigger:
- Large burdens on waiting rooms and provider schedules as patients fill the books with prescription refill, UDS screen and pill count appointments,
- Additional monthly cost for patients who pay co-pays for every visit,
- Increase in overall health care costs (which may be passed on to all patients eventually),
- Emotional stress on genuine patients who feel they are being treated like drug seekers.
For those who are drug seeking there are other potential consequences to keep an eye out for:
- Potential for increased incidences of “doctor shopping” in neighboring states
- Potential increased theft of medications and break-ins,
- Increase in use of heroin and alternative drugs as opioids become more difficult to obtain.
The three-day rule is certainly a conversation to be had, but perhaps equally as relevant is exploring alternative pain treatments.
Are we taking the right approach?
Many people do not realize that pain management is a specialty itself and is offered as a separate board-certification.
Unfortunately, most people seek specialist pain management care after having suffered with chronic pain for a long time and seeing physicians whose therapies are limited to pain medications.
Chronic pain along with prolonged use of narcotics causes multiple changes in the body such as changes in normal levels of circulating hormones and sleep cycles. These chronic physiologic changes can cause mood changes along with changes to how our bodies perceive pain.
The good news is that there are many alternative pain treatments available. In most cases successful pain management utilizes an integrated approach that encompasses a combination of treatments.
As physicians we recognize that the opioid epidemic is a very real and serious situation. As board-certified interventional pain specialists we also recognize there is a need to treat genuine pain responsibly.
We therefore recommend;
- Using non-surgical, interventional procedures to immediately and effectively reduce pain levels.
- In cases where medication management is necessary; reduce reliance on pharmacologic substances, maintain low doses and do not limit “pain medicine” to strong opioids & narcotics,
- Outline a detailed and carefully designed treatment plan that takes a multi-modal approach to include: weight-loss, chiropractic, physical therapy and/or counselling.
Interventional pain management procedures often enable patients to participate in and get the most out of other alternative treatments such as exercise, physical therapy or chiropractic manipulation.
These therapeutic interventions (procedures) work extremely well at the onset of pain when other physiologic changes have not yet occurred in the body and there is less damage to reverse.
Therefore, the earlier a patient seeks specialist care for their pain the less likely that patient is to be placed on a long-term medication schedule.
Pain is often misleading. It can radiate and travel throughout the body leaving a patient unsure of the actual source of pain or injury this is the case with cervical radiculopathy.
Impingement of a nerve in the cervical spine (neck) can often cause cervical radiculopathy or cervical radiculitis.
This type of pain is particularly deceiving as it may present as shooting pain, tingling, numbness and muscle weakness and may be felt in the neck, upper back, shoulders, arms, hands and/or fingers.
Cervical radiculitis usually occurs as a result of some underlying condition affecting the cervical discs or vertebrae. Such conditions may be; herniated disc in the neck, spondylolisthesis, or a buldging disc for example. In some cases the cause of these conditions is due to an injury or trauma of some kind, however, very often cervical pain is due to degeneration in the spine. Age, poor body mechanics, smoking, and genetics are all factors that contribute to neck pain.
Treatment of cervical radiculopathy
Radiating pain can mask the underlying cause or source of pain which could lead to an inaccurate diagnosis and mistreatment of the pain.
Therefore it is imperative that patients seek the medical attention of a qualified pain specialist who can perform appropriate diagnostic tests and order MRIs or XRAYs to pinpoint the true source of their pain.
The conservative, non-surgical and minimally invasive treatments offered by interventional pain specialists often solve the pain associated with cervical radiculitis at the source of the problem.
Interventional pain management offers advanced injection based procedures that reduce the need for medications, provide longer term pain relief and reduce the likelihood of expensive surgeries with long recovery times.
Procedures designed specifically for the cervical spine include:
The Surgeon General, Vivek H. Murthy, M.D., M.B.A. recently sent out a letter to all American physicians urging us to do everything in our power to address the opioid epidemic.
The opioid epidemic is a very real and serious situation, so too is the need to treat pain responsibly.
Newbridge Spine & Pain Center is one of the Greater Washington area’s premier interventional pain management facilities dedicated to treating pain. Our physicians are Anesthesiologists with sub-specialty training in pain management.
There are many misconceptions about the ‘pain management’ specialty resulting from the mismanagement and over-prescribing of addictive painkillers. However, our specialization, interventional pain management, addresses both the rising opioid epidemic and the need to treat pain.
Treating pain in a conservative, responsible manner is our daily commitment.
We do this by:
- Utilizing non-surgical, interventional pain procedures to quickly and effectively reduce pain levels.
- In cases where medication management is unavoidable, we aim to reduce reliance on pharmacologic substances, opioids & narcotics by maintaining low doses and outlining treatment plans that take a multidisciplinary approach to include; weight-loss, physical therapy and/or counseling for example.
The Newbridge team spends a significant amount of energy encouraging our fellow healthcare providers to refer to interventional pain management before prescribing or laying out a treatment plan. This is because our therapeutic procedures work at the onset of pain as well as for chronic pain conditions.
We firmly believe that the sooner a patient can be treated by a pain specialist using interventional methods the less likely that patient is to be prescribed a long-term medication schedule.
Most pain complaints relate to pain originating throughout the spine, however, an interventional pain doctor can treat acute and chronic pain all throughout the body to include the limbs and joints in the peripheral body.
September is Pain Awareness month!
Sports injuries are common and no doubt you’ve heard the saying in competitive sports, “no pain, no gain”. As pain specialists, however, we wouldn’t recommend subscribing to this theory.
As with any pain there are acute and chronic injuries. According to the National Institute of Health [NIH.gov] signs of an acute injury may include:
- Sudden, severe pain
- Not being able to place weight on a leg, knee, ankle, or foot
- An arm, elbow, wrist, hand, or finger that is very tender
- Not being able to move a joint as normal
- Extreme leg or arm weakness
- A bone or joint that is visibly out of place.
Many acute injuries can easily be treated using home remedies beginning with the RICE method (Rest, Ice, Compression, and Elevation). But, if pain symptoms get worse or do not improve you could be at risk of developing a chronic injury.
Chronic injuries will continue to cause pain after you’ve played a sport or participated in exercise for a long time. The signs of a chronic injury may include:
- Pain when you play
- Pain when you exercise
- A dull ache when you rest
Interventional procedures are well suited to aide recovery from many chronic and acute sports injuries. Since they are outpatient procedures they require little recovery time and often result in immediate pain relief or at the least moderation of pain.
Procedures range to treat shoulder injuries, tennis elbow (bursitis), knee pain, back injuries and neck injuries. The best course of treatment for sports injuries is often a multi-disciplinary approach.
Interventional procedures coupled with rehabilitation exercises, such as physical therapy will help patients recover faster, regain range of motion and strength.
A few of the procedures commonly used to treat sport related injuries include:
Post traumatic stress disorder (PTSD) is often known to occur in military veterans and those who have suffered traumatic events involving either physical harm or the threat of physical harm [ Source: www.nimh.nih.gov]. PTSD is defined as having at least 1 month of re-experiencing trauma symptoms, 3 avoidance symptoms and/or two or more hyperarousal symptoms.
Symptoms of PTSD make it difficult for patients to function throughout their regular daily lives and is often found to co-occur with chronic pain. A recent study published in the Journal of Pain [Vol. 16, No. 10, Oct 2015) found that the two conditions exacerbate each other. Chronic pain intensity was associated with anxiety and anxiety sensitivity, a symptom of PTSD.
We have long known that depression and chronic pain have a similar co-occurrence. However, the study showed that PTSD had a unique profile for hyper-responsiveness and hypersensitivity to pain.
Chronic pain was reported to be 2-5 times more likely to affect PTSD patients than the general population. Conversely chronic pain patients were 2-4 times more likely to exhibit PTSD symptoms than the general population.
PTSD is not the only type of stress that has been linked with pain. Psychological factors of stress have been long known to impact the central nervous system feeding into the stress cycle and exacerbating chronic pain.
The journal of pain article indicates that a reduction in stressful episodes may lead to a reduction in pain over time.
The US Department of Veteran’s affairs suggests that patients experiencing PTSD may benefit from therapy sessions and provide several resources, including the Veteran Combat Center 1-877-WAR-VETS for 24/7 support and the Vet Center for military vets transitioning into civilian life.
There are many other stress reduction techniques including; meditation, yoga, and exercise. For those in severe immediate pain interventional pain management can help improve mobility and the ability to participate in some of the above stress reduction techniques.
Neck pain is the second most common complaint among our patients second only to lower back pain of course.
There are myriad reasons that pain in the neck can occur. Sometimes the cause is obvious, a patient has had an accident or injury resulting a physical trauma that causes pain in the neck or cervical region. However, other times you may not be able to pin point a specific incident or don’t understand what happened to actually cause the pain you are experiencing. In medical terms this is called idiopathic pain which can be more difficult to treat.
Your neck is made up of ligaments muscles and bones. The cervical spine (the upper vertebrae of the spine) goes from the skull to the torso between each vertebrae are discs that act as shock absorbers between the bones.
Injury, inflammation and a range of abnormalities to any of the above can cause neck pain and stiffness.
Types of neck pain and possible causes
Pain going down your neck through your shoulders or arms is called radiating neck pain or cervical radiculopathy. If you experience this you may be suffering from either a cervical herniated disc spinal spinal stenosis or degenerative disc disease.
Cervical radiculopathy is commonly associated with an injury near the nerve root and is often called a “pinched nerve”. Radiating pain may be accompanied by numbness or tingling down the arm.
Spinal stenosis is the narrowing of the spinal canal. As the spinal canal narrows it puts pressure on the nerves which in turn may cause pain. Foraminal stenosis is the narrowing the cervical disc space due to the enlargement of a joint in the spinal canal. In some cases this condition may require surgery.
Degeneration of the disc, where the space between the individual vertebrae becomes smaller and the disc becomes less spongy and therefore less capable of absorbing shock, is also a very common cause for neck pain.
In some case muscle stiffness may be the cause of neck pain. In these cases trigger point injections can help by encouraging blood flow to the region by igniting the body’s inclination to self heal.
If you are experiencing neck pain that persists your pain management specialist can order Xrays and MRIs to discover the root cause of this pain and develop a multi-modal treatment plan to combat pain and help you regain your quality of life.
5 misconceptions about Pain Management
We asked our Doctors to set the record straight and clarify 5 common misconceptions about Pain Management, pain medicine and what we do. Here’s what they had to say:
1) It just entails a doctor writing for pain medications:
Most people have the misconception that pain management specialists primarily and solely write for pain medications as their means of treating acute/chronic pain. This couldn’t be farther from the truth. In fact, it is our goal to keep people from requiring chronic dosing of pain medications as this in itself has long term side effects and changes how our bodies work.
Our intention is to start with an accurate diagnosis of the cause of a patient’s main source of pain and to then implement interventional procedures that can either treat or moderate a patient’s pain. The idea is to either resolve or, at the least, temporize a patients level of chronic pain so that they have more tolerance to physical therapy and require less daily pain medication in the future.
Another common misconception is that a Pain Physician’s use of the term “pain medication” refers to controlled narcotic substances. It is always our initiative to use a combination of different types of medications which are not necessarily narcotics.
As Pain Physicians we avoid the initiation of these pain medications as narcotics carry inherent risks and can become a long term burden on the patient.
There are certain cases where patients have causes of pain that cannot be treated with interventional procedures, and in these few cases we then explore different types and combinations of medications.
We reserve the use of narcotics, for a short time, for cases where procedures do not provide adequate relief, however, hoping not to introduce controlled substances on a long term basis.
2) It’s only for people with neck and back problems:
When people think of pain management, they usually first think of neck and low back pain limited to the spine. Although this can describe a majority of our patients, we also treat many other sites and sources of pain such as chronic headaches, knee, shoulder, abdominal, pelvic pain and facial pain.
We can also treat peripheral neuropathic pain such as that caused by diabetes and chemotherapy or postherpetic neuralgia as a result of having had shingles.
3) It’s a last resort:
Unfortunately, most people come to pain management after having dealt with chronic pain for a long time and seeing physicians whose therapies might be limited to pain medications. Chronic pain along with prolonged use of narcotics causes multiple changes in the body such as changes in normal levels of circulating hormones and sleep cycles. Therapeautic interventions work best the sooner we see a patient as these other physiologic changes have not yet occurred and there is less to reverse.
These chronic physiologic changes can cause mood changes along with how our bodies perceive pain, sometimes making us more sensitive to painful sensations. In short, seeking a consult with a pain specialist as soon as pain persists is the best way to manage your pain in the long term.
4) Pain procedures are only a short term fix and only mask the pain until it returns:
In many cases this statement is actually true. Our goal in interventional pain management is to alleviate or minimize the pain that a patient feels on a daily basis so that they can be more functional and participate in modalities such as physical therapy. Our purpose in pain management is to prepare a patient’s body for building strength so that there are less acute and severe painful episodes.
Although sometimes we are unable to relieve pain completely, we can provide intermittent episodes of relief and eliminate the need for surgery if the patient is a poor surgical candidate or chooses not to undergo surgery.
The longevity of the pain relief a patient experiences depends on the cause of their pain and available therapies that can be offered to the patient. Although some of our therapies do not give prolonged relief, some do.
It is all on a case by case basis, and depends on the age and pathology of a patient’s pain. It is important that patients get assessed by an interventional pain physician to determine if there is a long term relief option for their source of pain.
In many cases, the earlier a patient seeks treatment for their pain the longer their pain relief experience may be.
5) All pain management specialists are the same, if you’ve tried one, there is no use exploring your options with another:
As with any specialty, outcomes are based on a physician’s individual skill and training. Because pain management is an evolving specialty, there are many new procedures that could be introduced to patient’s treatment plan.
Sometimes patients have a failed procedure or had a bad experience and assume that any future interventions will continue to be unfruitful. This is not usually the case. Therefore, it is important to do your research.
Seeking a more interventional driven pain physician who might have more skill or experience in different therapies may be an option to better treat your pain.
We’ve been getting a number of questions regarding pain treatment for scoliosis lately. We thought we’d elaborate a little on what scoliosis is and what we can do to help manage pain associated with this condition.
What is Scoliosis?
Scoliosis is an abnormal (usually sideways) curving of the spine. The spine might look like the letter “C” or “S.” An inward curving of the spine is called lordosis.
What causes pain in Scoliosis patients?
As the spine twists it effects the supporting musculature and can affect heart and lung function if severe enough. The imbalance of the spine causes trouble with posture and puts stress on joints that wouldn’t otherwise see so much weight.
How can a pain management specialist help scoliosis patients?
In the setting of scoliosis our pain specialists would make sure the scoliosis is not severe enough to require surgery. If the scoliosis is not severe we can deal with the stress of the curved spine on the joints of the spine and the pain due to pinch nerves where the spine bends and puts strain on the supporting muscles on each side.
Treatment includes facet blocks, epidurals, trigger points for myofascial pain, muscle relaxants, nerve pain medications, gait supporting accents such as canes and foot insoles.
In cases where surgery is required our pain management physicians will refer the patient to an Orthopedic spine surgeon. Following surgery and orthopedic treatment a pain specialist can continue to help manage pain associated with scoliosis and would do so in coordination with a patient’s Orthopedic specialist.