Attacking Chronic Pain
The opioid crisis illuminated the problem of fighting pain with pills. So what are the alternatives? Researchers and clinicians at the University of Kansas Medical Center are offering solutions.
Five decades ago, Winston Pelfrey strode across the decks of a seafaring aircraft carrier. The young Marine managed the payroll of the other Marines on board and watched propeller planes and helicopters take off for search-and-rescue missions throughout Vietnam. He stood surefooted through ocean swells.
But in ensuing 50 years, the ground under Pelfrey’s feet proved more hazardous than that flight deck of his youth. He was diagnosed with painful diabetic neuropathy at age 71. Pain and numbness radiated from his knees to his toes, and he often needed a walker when in unfamiliar surroundings.
“It hurt just to walk around in your home,” Pelfrey said. “Lots of nights where, with the neuropathy, I would toss and turn, and my feet would constantly move because of the pain.”
The pain was so bad, Pelfrey rubbed his feet against the legs of his coffee table as he watched the 10 p.m. news. The counterpressure helped him find some semblance of relief.
Pelfrey, now 76, faced a future of limited mobility and constant, chronic pain until he found a solution through a clinical trial at the University of Kansas Medical Center. For him, relief came from a nerve-blocking device surgically implanted in his lower back.
For others in pain, help comes from a multitude of research projects that are seeking new ways of handling pain beyond medication. From team approaches to pain treatment to implanted devices to physical therapy and biofeedback, researchers are seeking out a better quality of life for those with chronic pain.
The extent of the pain problem
Pelfrey is one of an estimated 50 million Americans who live with chronic pain. According to a study published in 2019 by the Centers for Disease Control (CDC), 20.4% of all Americans have some form of chronic pain. For 7.4% of that group, the pain is so severe it limits life or work activities.
Andrea L. Chadwick, M.D., associate professor in the Department of Anesthesiology, Pain and Perioperative Medicine at the KU School of Medicine, has been studying pain for more than a decade. She said she’s seen a shift in pain management since she earned her medical degree from KU in 2005. Chadwick said there has definitely been a movement towards a focus on pain management as comprehensive care.
“Because, and I can’t stress this enough, pain is more than just a physical phenomenon. The definition of pain includes the experience of pain, which is both physical and psychological,” Chadwick said. “A lot of people overlook the psychological component and instead focus on the physical. But if you only address one of these problems ― the physical manifestation ― you may not be getting where you need to be for treatment to be successful.”
Chadwick added that for most patients with chronic pain, a downstream issue of that pain is that the symptoms affect their daily lives.
“It’s not just physical functioning. It may affect their work or their enjoyment of social activities, and in a broader picture, a person’s life and livelihood,” Chadwick said.
Sounding the alarm on opioids
The problem of chronic pain was illuminated by the opioid crisis, a term coined to reflect the dramatic increase in prescribing a specific class of pain killers from the 1990s to today. These drugs when naturally sourced are derived from the poppy plant and have a long history of misuse in the forms of opium and heroin.
In the 1990s, companies actively marketed new formulations of opioids with the promise that they weren’t addictive. Scientific testing and human experience showed that claim to be false, and the number of deaths due to drug overdoses tripled between 1999 and 2017.
In 2017, the U.S. Department of Health and Human Services declared a public health emergency because of the misuse of prescription and non-prescription opioids. The government issued a five-point plan to combat the crisis, including improved access to treatment for those already addicted, as well as support for cutting- edge research on addiction and pain. The last point on the list was an even loftier goal: to advance the practice of pain management.
A number of researchers and clinicians at KU Medical Center have been studying pain management for years and have come up with some possible solutions to help patients dealing with chronic pain.
SOLUTION 1:
Get a proper diagnosis.
One reason for the opioid crisis is the simplicity of medication to treat pain. Unlike other treatments, pills take little commitment other than monitoring when to take them. And they often work well enough to lessen or eliminate pain no matter what kind of pain you’re suffering.
Christopher Lam, M.D., assistant professor in the Department of Anesthesiology, Pain and Perioperative Medicine at the KU School of Medicine, said opioids ― and even over-the-counter medication such as Tylenol or Advil ― can work on pain before it’s diagnosed.
Nerve pain, muscle aches and even pain from a broken bone all respond to pain medicine, so doctors don’t have to pinpoint the cause of the problem before the medication grants some relief.
But in the long term, a proper diagnosis of the cause of the pain is necessary to pinpoint the most effective treatment. A problem arises, however, when doctors misdiagnose a pain problem and prescribe an ineffective treatment. Patients don’t want to try that treatment again, even if the pain is completely different.
“Many times, we see pain patients as a second, third or fourth opinion,” Lam said. “They were in a different timeline or chronology of their pain process, so maybe at that time, the medication didn’t work because it didn’t address the cause of their pain. But then the pain evolved over time, and the best medication may be the one they tried before, but they don’t want to take it because it didn’t work in the past.”
SOLUTION 2:
Monitor opioid prescriptions.
As chair of the opioid stewardship subcommittee for The University of Kansas Health System, Andrew Sack, M.D., is responsible for making sure opioids are being used safely. The committee was formed 2018 in response to the HHS public health emergency and the subsequent guidelines created by the CDC.
Sack, an assistant professor in the Department of Anesthesiology, Pain and Perioperative Medicine at the KU School of Medicine, said the committee recommended a best-practice alert to question doctors when they prescribed opioids.
“The alert is a pop-up box that opens automatically in the electronic health record when certain criteria are met,” Sack explained. “Prescribers cannot complete prescriptions until they acknowledge the warning, then they may proceed with or without changes to the prescription.”
In the research phase, only 1.8% of physicians changed their mind about a prescription after being asked “Are you sure?” But even with the low numbers, “any change has some significance,” Sack said.
“I don’t think we’re in the right place for opioid prescribing, but I think we’re a lot closer than were in the early 2000s. The CDC guidelines have raised awareness,” he said. “And I’m seeing patients who understand that opioids are not always the right answer. So I think we’re moving in the right direction.”
SOLUTION 3
Get physical therapy.
If opioids aren’t the answer, then how is chronic pain treated? According to the CDC guidelines for prescribing opioids, the No. 1 determinant states, “Opioids are not first-line therapy.”
“When the CDC guidelines came out, non-pharmacological interventions were emphasized for pain management,” said Neena Sharma, Ph.D., associate professor in the Department of Physical Therapy, Rehabilitation Science and Athletic Training at the KU School of Health Professions. “This was exciting news for physical therapists and for the public in general. Since then, we have seen a shift where physical therapy is considered one of the first-line intervention options.”
Physical therapists are mainstream health care providers who routinely provide nonpharmacological treatments, Sharma explained, including exercises, manual therapy and patient education among a host of other interventions.
Sharma said that recent research studies have shown that physical therapy early in the chronic pain management timeline shortens the time patients are taking opioids and lessens the amount of the drug needed to reach an acceptable pain threshold. This is especially true for management of back and knee pain.
Sharma’s own studies center on the underlying mechanisms and management of chronic back pain. In one study, she weighed the effects of manual therapy, where a therapist manually moves a problematic body part such as a joint or muscle in a specific direction or with a certain amount of quick force. The movement then triggers the nervous system in what experts call a neurophysiological response.
“When you experience pain, it changes the nervous system,” Sharma said. “Usually, the nervous system guides the muscles, so your muscles respond to the pain you’re experiencing.”
Pain is a major factor in how the muscles work, and if muscles are in pain, they stop working. With manual therapy, the function of those muscles can be restored. Sharma calls the process “increased activation of the muscles.”
"PAIN IS more than just physical symptoms.
The definition of chronic pain is the experience of pain, which is BOTH PHYSICAL AND PSYCHOLOGICAL."
A lot of people overlook the psychological component and instaed focus on the physical.
But IF YOU ONLY ADDRESS ONE OF THESE PROBLEMS - the physical manisfestation - YOU MAY NOT BE GETTING TO WHERE YOU NEED TO BE for treatment to be successful.- Andrea L. Chadwick, M.D., Associate professor, Dpeartment of Anesthesiology, Pain and Perioperative Medicine, KU School of Medicine
In another study, Sharma examined how physical activity affected patients after spine surgery. Chronic back pain is a problem for an estimated 16 million Americans, and there are two common surgeries offered to treat it. Each usually require a hospital stay of three to five days.
First is a laminectomy, also known as a decompression surgery, which removes the back part of the vertebra covering the spinal cord. This surgery is often a solution for patients with bone spurs on their spine or painful arthritis, compressing on nerve tissues. Second is the spinal fusion, where two or more vertebrae are connected using rods and screws. The surgery can treat spinal deformities, damaged disks and too much space or instability between disks or vertebrae due to arthritis or fracture.
Sharma’s research found that physical activity shortly after surgery can be beneficial to the patient. Patients who try some form of physical therapy improve their walking ability, and the ability to walk is a key factor to being released from the hospital.
In a different study, she found that patients who asked for more opioids for pain relief after spine surgery felt very little relief after an extra dose. In fact, the patients reported similar pain scores as those who receive a lesser dose.
“Since the pain intensity was the same, getting more medication doesn’t mean more pain relief,” Sharma said. But she does acknowledge that some pain medications may be needed to allow the patient to try to move and gain the effects of physical and manual therapy.
“Pain management should be viewed in terms of functional outcomes,” she said. “Health care providers need to determine what is the optimal level of opioids after surgery that not only improves pain but also results in improved function, and if those opioids are not helping with their functioning, such as getting out of bed, then they need to think of other strategies.”
MANY PEOPLE IN PAIN...
The prevalence of chronic pain among adults in the U.S. is increasing and affects more people than many other common diseases.
...BUT FEWER CENTRALIZED RESOURCES
Nonprofit associations support research, patient education and community outreach efforts for a particular disease or medical condition. These national organizations also fundraise under one known reputation, which leads to greater contributor trust and loyalty. The problem with pain is that it manifests in many different parts of the body, so it's not as easily covered by a single organization such as the American Heart Association's advocate role for cardiovascular disease research. These are the contributions and grants each overarching association collected:
SOLUTION 4:
See a psychologist.
One alternative process for dealing with chronic pain focuses more on the brain, where pain messages are encoded and decoded.
“There’s a great amount of research showing that psychological, emotional and attentional factors play a role in how pain is processed in the brain,” explained Lora Black, Ph.D., MPH, assistant professor in the Department of Psychiatry and Behavioral Science at the KU School of Medicine.
Black is part of the team at the spine care center at The University of Kansas Health System, and her specialty is pain psychology. She meets with patients of the center to address the hidden issues of pain.
“A large component of what I do is education about what chronic pain is and how addressing psychological factors can have an impact on quality of life with chronic pain,” Black said. “When I first meet a patient, I let them know that their pain is absolutely real, even if the chronic pain doesn’t show up in testing. Pain is a very subjective experience ― a broken bone or a herniated disk may show up on an X-ray, but I can’t see the pain on the X-ray.”
Black believes it is important to validate the pain because some patients believe that in her role as a psychologist, she’s there to tell them their pain is imagined.
“Research suggests that whenever someone is in pain, it activates the central nervous system. The central nervous system, among other things, is responsible for stress processing, danger processing and our fight-or-flight response,” Black said. “With chronic pain, the pain signals keep going and going, but they don’t get turned off properly on the back end.”
These pathways then get stuck open and become more sensitive to pain.
“What we see with chronic pain is a progression where the pain gets worse over time,” Black explained. “That does not inherently mean that more damage is being done to the body, It is just taking less input externally to create higher levels of pain.”
Black teaches pain patients to remodulate those pain pathways through stress reduction techniques, relaxation exercises and distraction.
“We also work on acceptance. It’s this idea that, ‘I accept my chronic pain to some degree and learn to live my life with it,’” Black said. “Some people find that once they’ve accepted that, their pain is lessened because they aren’t thinking about it all the time.”
SOLUTION 5:
Try cognitive behavioral therapy.
The idea of remodulating pain pathways is also known as cognitive behavioral therapy (CBT). This specific type of psychological therapy focuses on faulty or unhelpful ways of thinking, according to the American Psychological Association. With help from a CBT specialist, a patient can learn better ways to cope with problems and learn new patterns of thought and behavior.
CBT was a concept that Chadwick analyzed in an article about therapies for centralized pain syndromes. Examples of centralized pain syndromes include fibromyalgia, migraines and chronic fatigue syndrome.
With assistance from her colleagues from the KU Department of Anatomy and Cell Biology, Chadwick reviewed literature that included clinical trials of humans and rodents and their responses to therapeutic interventions to pain. In a study evaluating
CBT as a form of fibromyalgia treatment, a greater percentage of patients displayed improvement in physical functioning after CBT than those who received medication.
“It is hypothesized that the positive effects of CBT seen in the treatment of chronic pain are due to structural changes in the gray matter in regions of the brain associated with pain management and/or in the functional connectivity of these regions,” Chadwick and her colleagues wrote.
SOLUTION 6:
Consider interventional techniques.
For situations where physical therapy and CBT may fall short of managing pain, more invasive therapies could be the solution.
Dawood Sayed, M.D., professor in the Department of Anesthesiology, Pain and Perioperative Medicine, is a champion for interventional techniques that allow for decreased pain, increased mobility and a minimum amount of recuperation time.
He said such intervention could be as simple as a steroid shot to an arthritic knee or lower back. On the other end of the spectrum, Sayed is conducting clinical trials on an implanted device with artificial intelligence that can interrupt pain signals. The device is similar to the one Winston Pelfrey had implanted for his diabetic neuropathy, but this newest generation of implants will not need feedback from patient to decide when to activate. A small computer, inserted under the skin, will kick in when it senses pain signals. Such devices are called closed-loop stimulation.
“I think this is really going to be the future for spinal cord stimulation. By harnessing artificial intelligence, it actually kind of measures the variability in nerve signals in the spinal cord, and it autoregulates according to what the patient is doing at that time,” Sayed said.
Sayed explained that in traditional spinal-cord stimulation, a small device is implanted near the spine. It interrupts pain signals before they have a chance to get to the brain by releasing a small burst of energy at just the right time.
The main computer that decides when to emit that energy is outside the body. In Pelfrey’s case, it’s a blue square about the size of a mouse pad that he wears between his skin and his waistband. The battery that powers the unit clips onto his belt.
“I did not expect it to work as well as it does, but I’m sure glad it does,” Pelfrey said.
Since the device was implanted, Pelfrey has stopped using a walker and has improved sensation in his feet and lower legs.
“I had no feeling in the bottom of my feet and halfway up my legs, but right after the stimulator was put in, the doctors did little pinpricks at the bottom of my feet, and I was able to feel my feet again,” Pelfrey said.
Because the system is open-loop stimulation, a technician helped to find the right frequency and modulation to best handle Pelfrey’s pain using trial and error. At night, Pelfrey must charge the system by sitting next to an outlet, plugging in the pad and keeping it near the implanted device.
“While you’re charging, you have to stay very still, because if you don’t, the device will go to zero and you have to start all over again,” he said. For those 45 minutes, he reads a book.
Sayed said the new closed-loop system will be a functional improvement because of the artificial intelligence. Battery life hasn’t gotten to the level where charging time can be avoided, but Sayed has confidence that those issues will also improve with time.
“The silver lining to chronic pain and spinal disease is that the innovation in the field is unprecedented, especially interventional pain management,” Sayed said. “Implanting small electrodes near the spinal cord to control the body’s way to perceive pain isn’t new. These treatment modalities have been around for 25 years or more. But in the last few years, we’re seeing significant improvements in the technology.”
SOLUTION 7:
Investigate futuristic, cutting-edge treatments.
Sayed said he’s also intrigued by other pain management treatments that he said are just scratching the surface of what can be done to manage chronic pain.
“Some of the treatments are looking at stem-cell-type therapies to regenerate and restore disks in the spine, to get them back to how they looked when you were 35 instead of your current age of 55 or 65,” Sayed said. “Regenerative medicine looks very promising as potential solution for lower back pain, spinal disease and chronic pain.”
Chadwick’s futuristic research examines phenotypes, which are the observable traits of any organism. Or, from a genetic standpoint, a phenotype is the connection made between genetic material and the living environment. By documenting how different people react to pain and what pain management tools work best for them, Chadwick is hoping to draw conclusions on “This type of research is at the forefront of treatment,” Chadwick said. “If we can truly home in on a person’s exact makeup and see how genetics reacts with the environment, we can determine how all of this can play a role in how a person responds to pain treatment.”
"THE SILVER LINING to chroinic pain and spinal disease IS THAT THE INNOVATION IN THE FIELD IS UNPRECEDENTED. In the last few years, we're seeing significant improvements."- Dawood Sayed, M.D., Professor, Department of Anesthesiology, Pain and Perioperative Medicine, KU School of Medicine
In the October 2021 issue of the Journal of Pain Research, Chadwick and three of her colleagues from KU Medical Center looked at how psychological, physiological and genetic factors could be analyzed to offer a more personalized treatment for chronic pain.
“Precision pain medicine provides an opportunity to identify populations at risk, develop personalized treatment strategies and reduce side effects and cost through elimination of ineffective treatment strategies,” the authors concluded.
SOLUTION 8:
Consider all solutions.
So what is the best way to manage pain in a post-opioid-prescribing era? The answer, according to multiple experts from KU Medical Center, is a team approach where all of these solutions are considered.
Twenty years ago, Talal Khan, M.D., professor in the Department of Anesthesiology, Pain and Perioperative Medicine at the KU School of Medicine, published guidelines for constructing teams of caregivers that included the patient, the primary care physician, the pain specialist, the pain psychologist and other important members such as physical therapists, neurologists and surgeons as cases dictated.
Khan urged the medical community to break down the silos of their own medical practices to meet and discuss the patient’s treatment plan. That team approach has been adopted at the KU Spine Center and copied at pain centers across America, Chadwick said.
“When you look at the literature for the patients who do best with their treatments, it’s within these comprehensive and multidisciplinary groups,” she said.
Sayed likes the team approach because it allows different practitioners to work in concert. He said sometimes the best solution is to try many types of treatments, or modalities at once. That way, the pain problem is attacked as an all-out assault instead of a linear pathway of trying one treatment, then waiting to see if it works, before trying another.
“Patients recognize that multidisciplinary pain care is effective, and clinicians do too. But we’re having a lot of push back from insurance companies,” Sayed said. “Because, unfortunately, some of these multimodal treatments are more expensive, compared to just filling someone’s Percocet prescription.”
If you examine the costs in the long run, he cautioned, the cost of simultaneous therapies or more expensive interventional therapies could be cost-effective, especially when compared to the costs of opioid addiction or continued chronic pain.
“Payers are a bit short-sighted, and that’s a frustration we’re dealing with now,” Sayed said. “But it is critical that we all recognize that chronic pain is a big problem, and opioids are not the solution.” what treatment would be most effective for people in a certain phenotype.
This mix of precision medicine ― where genetics dictates the way a person is medically treated ― and environmental factors is the next frontier of pain management.