Q: What do you think is most important for people to learn about chronic pain?
A: Pain was designated the “fifth vital sign” by the American Pain Society in 1995 and in 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced new pain management standards. In those subsequent decades, there was a lot of focus on pain and symptom management. In theory, this was a wonderful step for patients as pain had been ignored for quite a while. However, one of the challenges I think we’ve all run into in the past 10-15 years is that chronic pain is harder to treat than most people realize. I think everybody had hoped that there would be a magic pill or procedure that would cure chronic pain. The reality is that a simple approach is often insufficient. What you’re seeing with our pain program at Duke is the realization that it’s as much the system of care we build around the patient as it is the actual medication we prescribe.
Q: Can pain be genetic?
A: There are clearly some genetic predisposing factors. Markers of risk have been identified for conditions such as temporomandibular disorder (TMD) and erythromelalgia, a rare pain disorder linked to a dysfunctional sodium channel. However, the genetic story doesn’t appear to explain the entire effect, and there are important environmental factors that affect gene expression, so-called epigenetic factors. I think that this interplay between genetic and environmental factors needs to be explored in much greater depth to give us a true picture of risks and options for personalized therapies.
Q: How does someone know when it’s time to see a doctor for chronic pain?
A: I would suggest a three-month cutoff; if someone has been having symptoms for three months and it’s not getting better, and simple medications are not improving it, I would consider referral. Also, we would prefer to see patients before they are put on narcotic medications because once patients are taking those, sometimes it’s hard to get them off. There may be other therapies that can be offered, outside of narcotic medicines.
Q: What is the goal of Duke Anesthesiology’s Pain Program? What makes this program unique?
A: Our goal is comprehensive management and management of the system of care, coordinating with primary care practitioners and specialists. To achieve this care coordination, we offer both interventional services, led by Dr. Richard Boortz-Marx, and medical services led by Dr. Steve Prakken, a pain specialist with a psychiatry background who manages higher risk patients and the risk cohorts. Programs that we’ve built with Dr. Prakken include management of high-risk cohorts in hematology, hospital medicine and the emergency department. We’re now extending that care paradigm into the spine arena, trying to find ways to optimize perioperative spine care, so patients can get through the process a little more smoothly.
Not only do we want to manage the individual patient but we also want to treat the system to optimize perioperative outcomes and minimize unnecessary use of emergency rooms or hospital admissions. If you ask me, “What is the unique part of the program?” I would say the unique part is that we have a foot firmly planted in traditional, interventional and diagnostically-based pain medicine. And, we also have a foot planted firmly in population health modeling and management of high-risk cohorts. That right there is ultimately what makes this program unique.
Q: What are some recent innovations within Duke’s Pain Program?
A: We have built a close collaboration between the Pain Medicine and Pain Research divisions at Duke with a goal of optimizing translational scientific solutions and the development of novel therapies. In particular, Dr. Ru-Rong Ji’s work is very exciting. As the chief of Duke Pain Research, he has done quite a bit of work to understand some of the mechanisms of pain chronification and ways to resolve that neuroinflammation with compounds such as resolvins and protectins. The theory is really very elegant; that everyone has an inflammatory process after injury. Whether you break a bone, have surgery, or cut your skin, there is an inflammation that has to occur for the healing process to take place. One of the theories he is working off of is that in chronic pain there may be a problem with turning off that inflammatory process. You need the inflammation, you need the immune response to heal, but at some point your body has to turn off that immune and inflammatory response. I think that’s an area of intense interest, both clinically and scientifically. Can we alter that healing process to make sure that the patient can get back to their normal lives? This is currently being studied here at Duke. Interestingly, we are also finding strong inflammatory signals in our amputation injury cohort and significant differences in those with and without chronic pain after a nerve injury.
Q: What is your long-term vision for Duke’s Pain Program?
A: We need to build systems of care, not just look at treating the patients who come into the clinic but to work with the primary care clinics and surgical teams to optimize their efforts. For instance, training people in primary care so they can identify patients of high-risk or manage some of the more moderate-risk patients and we can be an outlet for resources for more challenging cases. Another concrete vision of our program is to build translational science solutions. We know that opioid medications are not going to cure chronic pain and there are probably some solutions and options for treatment that we haven’t yet discovered or explored. One of the things we are doing with our translational research is looking at patients who have nerve injury and one of the models we are using is amputation injury. If you take 100 patients who have a nerve injury surgery and ask a simple question of, “Why is one person hurt and the other person, who had the same surgical procedure, not hurt?” Try to look at it from a systems biology perspective to find out what is different about that individual and what can we change about the care of that individual to either better treat or potentially prevent some of the chronic pain issues that can arise.
Q: What are some of the key messages you want consumers to know about pain?
A: Diagnosis is critical. You don’t treat all pains the same. You want to personalize therapies because an opioid may not be appropriate for everyone. The more we do to improve our diagnostic process, the more we’ll be able to improve outcomes long-term. And that’s something we’ve done practically as well. You can do that with ultrasound, examination of peripheral nerves, granular questionnaires after a nerve injury surgery to find out if it’s neuropathic pain, and if so, what kind of neuropathic pain. But increasingly, the diagnosis needs to drive the therapy.
I would also add that there appears to be a strong inflammatory component with neuropathic pain syndromes. That is increasingly obvious as we look at some translational science results and nerve injury patients. It’s obvious in new literature coming out, and I think as we understand the inflammatory mechanisms that occur and the lack of resolution of that inflammation, we will be able to tailor therapies much better.
We recommend to patients, that if you are seeking a specialist for pain management or procedural intervention, we recommend you look for a doctor who is board certified. If you are seeking a procedure or intervention, we recommend that the proceduralist have formal fellowship training to learn those techniques.
Q: How can people prevent chronic pain?
A: Well, that is the $10 million question. There are a lot of multi-modal therapies that Brian Ginsberg, MB BCh, the acute pain service, and the Duke Regional Anesthesia Division are doing right now. Patients don’t just get traditional pain medications; they will get a regional anesthesia catheter, they will get gabapentin or pregabalin, they will get ketamine if need be, they will get steroids, and they will get a multi-modal regimen that has shown to most likely decrease some the incidence of the chronic pain. It depends on the surgery people are having but it certainly helps acutely and there’s an increasing signal, especially if those therapies are carried out beyond two to three days, that they can prevent chronic pain. It may also take new medication/drug therapies to be able to do that effectively.
Q: What is the most effective way to treat chronic pain?
A: We’re probably better off going upstream rather than trying to treat the post-thoracotomy or post-mastectomy neuropathic pain that patients have after surgery. We need to try and start asking the questions or things that we can do at the time of the surgery, or immediately after surgery, that prevents one of those neuropathic pain conditions from arising.
When it comes to the use of opioids, I think our philosophy is that conscientious, appropriate prescribing is suitable for many but not all patients. We know we’re not going to cure chronic pain with opioids prescribing. At the same time, there are some people who believe that chronic opioids are only appropriate for patients dying of an end-stage disease or condition. I believe the answer is somewhere in the middle: opioids aren’t appropriate for everyone but they can be appropriate for many patients, done conscientiously and in moderation. What we’re trying to build at Duke is a pain program that is both comprehensive and personalized, not a one-pill-fits-all kind of therapy.
Q: Why should a patient come to Duke to be treated for chronic pain?
A: There are a lot of places you can get a single injection done but we know that doesn’t cure most patients. Typically, they need more comprehensive therapy. Duke is a great place for a personalized therapy that includes diagnostic work-up, procedural intervention and comprehensive management. I think we do a great job at that. We have a full multidisciplinary clinic that includes physicians and practitioners from anesthesiology, psychiatry, physical therapy, medical physiology, and maintain a close tie to other Duke physicians and surgeons. I think it’s the comprehensive care that sets us apart.
Q: Is there anything about Duke’s Pain Program that people may not know?
A: We have a busy diagnostic and interventional section, and the diagnostic part is continually improving. We also have a very busy interventional program that includes spinal cord stimulation, radiofrequency lesioning, and all types of spine injections. Additionally, all of the physicians in clinic are board certified, and all of the proceduralists have had formal interventional training in their fellowship.
Q: Do you believe this chronic pain issue in America will get better?
A: I think it will get better. The reason why it’s going to get better is because our diagnostic capabilities continue to improve, our systems of care are improving, and we’re in the process of developing translational medicine solutions to treat, and hopefully prevent the development of chronic pain, especially after nerve injury. In the next decade, I think we will also start to see disease-modifying agents for neuropathic pain with mechanisms of action that we don’t currently use. I’m also optimistic that we can make significant strides as we continue to develop the systems of care around the patient in an individualized medicine paradigm.