Pain Management: trends in the field

Dr. Camden Kneeland at the Montana Center 

By DAVID REESE, Montana Health Journal

 “Take two aspirin and call me in the morning.”

While those words may have been the oft-quoted statement used by physicians in the 1950s or on shows like Marcus Welby M.D., pain management these days is not what it used to be. And that’s a good thing.

The entire field of pain management has changed in the last 10 years as evidence has mounted that the heavy use of opioid prescription medications like Lortab, Vicodin or morphine are not effective on most types of pain and — perhaps more importantly — new techniques have evolved for pain management.

Dr. Camden Kneeland (photo by David Reese)

At the Montana Center for Wellness and Pain Management in Kalispell, a multi-disciplinary approach has been adopted that incorporates modalities such as acupuncture, chiropractic, massage therapy, mental health counseling and yes, sometimes medications. There are eight specialties that the center uses to help patients with chronic pain.

The management of chronic (non-cancerous) pain is complex and requires a complex, diversified approach, says Dr. Camden Kneeland, a physician and pain specialist who helped develop the multi-disciplinary approach at the Montana Center. Gone are the days when a patient would hear “take two aspirin and call me in the morning.”

For many types of severe, chronic pain, physicians would prescribe the use of opioid medications like Oxycontin or benzodiazapene medications like Valium or Xanax.

That seems to have changed, with the advent of pain management centers like the one in Kalispell. “In the past there has been a school of thought that relied heavily on these two,” Kneeland, the director of the Montana Center, said. “As we’ve studied pain more we have found that there is little to no evidence to support the use of these medications to treat non-cancer pain. When we have a long followup for people without a terminal diagnosis these medications typically cause a lot more problems than they solve.”

Kneeland has seen the longterm effects of prescription pain medications.

“They can destroy families and friends just as easily as chronic pain can,” he said. “The fact that they do not, in the vast majority of cases, improve quality of life for long periods of time is something that needs to be understood by patients and healthcare providers.”

The trend in pain management is to reduce the use of these medications and incorporate other modalities like chiropractic — or even mental health counseling — that were once far outside the mindset of physicians.

There are as many as eight disciplines of pain management practiced at the Montana Center, from acupuncture to massage therapy. Regardless of the proper method chosen to help a particular patient, Kneeland said the provider and the patient need to come to an understanding of what pain management can accomplish — and how to get there.

“We are always trying to treat the underlying source of the pain. Now an we cure that? Most of the time we can’t,” he said. “There are some examples where the underlying sources can be cured … but in the vast majority of patients we see, the best we can hope for is to significantly reduce the amount of pain that they experience while improving the quality of their lives.”

And that’s what makes chronic pain management a field unto itself. It’s not an attempt to cure the patient, but with a varied approach and a strong team, people have a chance to reduce the amount of pain they experience, the way they cope with that pain and a greater ability to enjoy life.

“That is something that has to be understood initially by the patient,” Kneeland said. “The expectations of reaching 100 percent pain relief for most people with chronic pain are not reasonable. The provider and the patient have to understand that the goal is to significantly reduce the pain but probably not completely eliminate it.”

The combination of the approaches is new to the Flathead Valley, but has been successful and is even being used by state government in some of its workers’ compensation treatment guidelines, according to Kneeland.

State agencies like work comp are seeing that the long-term effects of prescription drug use are not effective in getting someone back to work, and they are very expensive over the long haul. With a multi-disciplinary approach like the one that Kneeland advocates, costs may be higher initially, but the success rates are greater, he said.

And cost is what has helped drive the creation of pain-management centers. In decades past, insurers were not eager to compensate physicians or other healthcare providers for certain types of pain management. But as a larger body of evidence and study has been gathered using these varied techniques, insurers have started to pay attention.

Society changes 

Now that society has seen what the long-term use of some prescription pain killers can do to a person, one of the evolving practices in pain management is the use of medications that were once only used for other medical diagnoses, such as depression. Research has shown that seritonin levels vary significantly in pain patients, just as they do in patients being treated for depression. So, medications that had been used for anxiety or depression are now showing effectiveness in treating pain without the issues of opioids or benzodiazepenes, Kneeland said. This means there are safer medications to treat pain on the level of the central nervous system without the “potentially disastrous effects of traditional pain medications,” Kneeland said.

He has worked to reverse the over-prescribing of opioid pain medications. “The philosophy of how to treat chronic pain here is 180 degrees different than it was five years ago,” Kneeland said. “It’s been very challenging but very rewarding to see that perception change.”

Obviously it was time for something new in the pain-management field. “It had to change … for the patients. You can’t treat patients that way and expect good outcomes,” Kneeland said. “Prescription pain medications work less effectively month to month and by the time they arrive here (at his office), they’ve been dependent on those pain medications for, sometimes, years.”

Every patient with chronic pain has a different measurement or perception of pain. That can make it very difficult to measure the source of the pain.

“An important part of what I do is finding the source of the pain as well as I can,” he said. “There are many patients where a specific anatomical source of the pain cannot be found, such as headaches, abdominal pain or pelvic pain. Those particular problems present a lot of diagnostic and therapeutic challenges”

“It’s virtually impossible to precisely identify the source of pain in every patient, because it is experienced completely within the brain,” Kneeland said. “The complexities of determining the source of pain can be difficult.”

Inaccurate diagnoses of the pain source therefore affects the longterm success of treating that pain.

That can sometimes lead to inaccurate diagnoses of the source of pain. “That is something that is absolutely crucial in treating chronic pain,” Kneeland said. “For instance, if someone comes in with low back pain … that doesn’t tell us anything about where that pain is coming from.”

Radiofrequency ablation of nerves is a procedure that may be used to reduce certain kinds of chronic pain by preventing transmission of pain signals. In this procedure a portion of nerve tissue is heated to cause an interruption in pain signals and reduce pain in that area. The period of pain relief varies in each patient, but can last from six months to 10 years, Kneeland said.

 PAIN TREATMENT

FOR SOMEONE who experiences ongoing pain on a regular basis, Kneeland said, 80 percent or more of those patients will develop depression or anxiety “and a multitude of other mental health problems that arise from their chronic pain.” Kneeland said it’s important that nontraditional pain management addresses the psychological effects of pain.

Another area that the Montana Center explores is something that’s been around for hundreds of years: acupuncture. While there might not be specific “peer reviewed scientific evidence” of the effects of acupuncture, Kneeland said “The risk is so low and the potential benefits so high, that we often recommend that to our patients.”

“We have seen amazing results” especially with abdominal pain or facial pain, Kneeland said.

Acupuncture also helps with smoking cessation — something that is vital in helping someone reduce pain.

The effects of smoking on chronic pain are much more definitive. The centers in the brain that are activated during smoking are identical to the centers that are active in chronic pain, so chronic pain treatment in people who smoke is much less successful than in those patients who don’t smoke, Kneeland said.

Also, the metabolism of some pain medications is increased when patients smoke, so the medications are less effective. “In facial pain, smoking cessation is very important,” he said.

Since smoking has such detrimental effects on pain management, Kneeland said in certain cases he’s seen he has recommended hypnosis, acupuncture or mental counseling to help get someone to stop smoking.

The Montana Center also employs massage therapy as one of its remedies for pain, especially facial pain. That’s why they have a massage therapist specifically trained in facial massage.

This interdisciplinary approach to pain is not new and in the 1980s many centers were developed around this approach. However, at that time there were two problems with this model: gathering the right types of people to work in the setting and work well together.

The second challenge was financial. The complementary therapies at that time were difficult to sustain financially because insurance did not reimburse for them. “What we’re seeing now, as an increasing body of knowledge of interdisciplinary pain management comes out and success stories come out, insurers are starting to see that utilizing different modalities, especially early in the process, saves money over time,” Kneeland said.

And patients are happy that physicians are incorporating these other, formerly maligned, therapies into their own treatments. “I get patients that say ‘it’s about time,’” Kneeland said. “For a physician to say there other modalities that are effective is something that patients are happy they recognize”

For instance, the relationship between osteopathic and chiropractic care providers has not been good, but that seems to be changing also.

When quantifying someone’s pain tolerance, Kneeland said he tries to measure patients’ functional abilities and quality of life, instead of using numbers on a pain scale of one to 10.

For instance, can you stand for only 10 minutes or can walk for only 100 yards? Or, maybe a person simply wants to be able to “dance again,” Kneeland said. “Many examples of patients who come in and say I want to dance again, ski again, or golf again … sometimes they don’t get there, but that’s why it’s so important to see how they’re doing with their quality of life.” Using those parameters they can then work improve a patient’s quality of life.

Kneeland said he helped develop a set of guidelines for the Montana workers compensation system that relies more on an upfront, interdisciplinary treatment of pain without the heavy use of narcotics.

“The scope of treatment that state comp is now recognizing and recommending is much broader than it was in the past, and that is encouraging,” he said. Kneeland thinks this progressive approach to treating pain can help primary-care or family physicians.

“It’s a significant benefit to primary care physicians here because they now have a place they can send their chronic-pain patients and have a greater level of comfort that the right type of treatment is being provided to those patients,” Kneeland said.

Of the many types of addressing chronic pain, neuromodulation is a technique that is showing promise. In this procedure a doctor uses spinal cord stimulation to change the way the body perceives pain.

An electronic medical device is inserted into the epidural space of the spinal cord, replacing the pain with a different sensation. If a person sees positive results in a week, a permanent implant can be made with a minor operation.

Chronic pain isn’t just something that hurts a specific area on one person. “Chronic pain is a multifaceted problem that affects virtually every part of a patients’ life — family, spiritually, friends, relationships,” Kneeland said. “As such it has to be treated with a multidisciplinary approach.”

Families play a large role in pain management. Kneeland said it’s common for families to not only cause someone’s pain to get worse by not changing their lives, but families sometimes enable pain sufferers by over-helping.

“What’s often overlooked is the patient’s ownership of their care plan,” he said. “They need to be heavily involved in taking ownership of their wellness and the patient has to participate in the care plan.”

Many patients’ care plans involved taking a pill “or a lot of pills,” Kneeland said, “so when a patient is told they are the most important part of the care plan, it’s very surprising to them and something that takes a lot of adjustment for them.”

For families and friends around people using prescription pain medications, it’s important to watch for signs of abuse. This might be missing work or school or unusual behaviors.

Chronic pain can be defined as pain that lasts longer than six months. But it’s more than just the amount of time that the pain lasts that defines it as chronic. It is the longterm stress and burden of constant pain on your life. This is very different from acute pain, which arises from surgery or an injury.

By treating the entire person using an interdisciplinary approach, healthcare providers can have greater success over the longterm, Kneeland said. “It’s rewarding to see their relief,” he said. “That’s probably the most rewarding part of my practice is improving the quality of life in the setting of hopelessness.”