Lest you be mistaken into thinking that pain management centers exist only to dole out prescriptions of addictive narcotics, Dr. David Bosomworth of Bluegrass Pain Management is quick to dispel such notions. I met with him to discuss the types of treatments offered and some of the problems faced when dealing with pain medications.
Dr. Bosomworth sees two different types of pain patients – chronic and neuropathic – and the type of pain will determine the goal and method of treatment. He estimates that some 65% of his patients are suffering from chronic neck and back pain, a number that has remained fairly steady throughout his career. Another 7% are workers comp related chronic pain cases. For these patients, Dr. Bosomworth sees his primary goal as one of function over comfort, saying “I want the patient to take them because it enables them to function at a near normal level, not so they can go to sleep on the couch all day and not be productive.”
For chronic patients, a pain profile will help to determine whether a sustained released opioid such as methadone be prescribed (used for chronic benign pain), or a shorter-lasting medication such as hydrocodone (used for activity related pain). Doses of both are carefully managed to avoid building up a tolerance. Under no circumstances will Dr. Bosomworth prescribe a dose higher than 40 mg a day, and if a patient does develop a tolerance, he recommends a month with no pain medication, allowing the body to reset itself so that they can then start again with a low but effective dose. “Otherwise,” he says, “you’ve got a little pill running your life.” When asked about Kentucky’s House Bill 1, he responds that although it has created something of an administrative burden, he believes the bill has good intentions and should help in minimizing the prescription of pain narcotics for illegitimate purposes.
For neuropathic pain, including that suffered by the oncology patients who make up roughly 5% of B.P.M.’s clientele, as well as those patients with Reflex Sympathetic Dystrophy (RSD), Complex Regional Pain Syndrome, or diabetic neuropathy, the goal is different: comfort over function. Therefore the type of treatment typically used will differ from that used for chronic pain and the doses of oral pain medication may be increased. Forms of treatment include:
- Spinal cord stimulation – electrodes are inserted into the spinal cord sending electrical impulses through the nervous system to provide immediate relief.
- Pain pumps – a small catheter is inserted into the spinal fluid allowing much smaller doses of pain medication to be released but with much more effect.
- Radiofrequency Ablation – a probe allows the physician to give a controlled burn to deaden the sensory nerve causing the pain.
Spinal cord stimulation and pain pumps are both controlled by the patient, allowing them greater management of their pain, as needed. Both are particularly effective in oncology and end of life patients. Pain pumps are also useful in spasticity disorders such as multiple sclerosis and cerebral palsy. The effects of radiofrequency ablation can last anywhere from three to twelve months before the nerve regenerates; the procedure is typically used on those with degenerative or arthritic disorders.
What does the future hold for pain management? Dr. Bosomworth reports that there are very few oral medications in development now. Instead, he sees advances in spinal cord stimulation as eventually paving the way for direct deep brain stimulation. As equipment becomes more digitized and allows for an even more specific focus, it is possible that physicians may be able to treat the brain and therefore the source of pain directly.
By Fiona Young-Brown