Chronic pain treatment options

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. People who live with chronic pain know how debilitating it can be. Today I'm talking about management of chronic pain with Dr. Vandana Sharma. She's an associate professor of anesthesiology and the director of pain medicine services at Upstate. Welcome to "The Informed Patient", Dr. Sharma.

Vandana Sharma, MD: Thank you, Amber.

Host Amber Smith: Let's start with a definition of what chronic pain is. Does pain have to exist for a certain amount of time before it's considered chronic?

Vandana Sharma, MD: Amber, let me start with what is pain, and then we'll move on to chronic pain. So pain is an unpleasant sensory and emotional experience that may or may not be associated with tissue injury. So, I emphasize three things in this, when I talk about pain. It's unpleasant, it's sensory, and it's emotional. So it's not "or." It's "and" emotional. And it's an experience. So the parts of it are, most people do not like the feeling of pain. It has these two components that is sensory and emotional, and sometimes tissue injury is involved, and sometimes it's not. And this is especially true for chronic pain.

So when we say chronic pain, it has gone longer than 90 days, or 12 weeks of time. When acute pain persists for this much of duration, that's when we classify it as chronic pain. Now the majority of the times with acute pain, there is usually a preceding injury. But when it comes to chronic pain, a lot of times the preceeding injury might have healed by that time, but the patients may still be reporting pain. It's not like they're just reporting, they're actually feeling pain. They're experiencing that unpleasant feeling that is debilitating, sometimes to the extent that it inhibits them from doing their routine work or their work-life balance and all those things. So, just to emphasize the fact, again, that tissue injury may or may not be needed for pain to occur.

Host Amber Smith: So if there's not a tissue injury, is pain sometimes tied to illnesses?

Vandana Sharma, MD: A very good question, actually. So when I talked about pain not being associated with tissue injury, in medical terms we call it central sensitization, or wind-up phenomenon. What happens is that pain pathways are not very simple. Like, there are several associations. A very simplistic definition of the pain pathway would be that you get injured in the periphery, and then the pain travels from the periphery to the spinal cord, from spinal cord to the brain. And this is the very simple form of the pain pathway.

What people do not understand is that over a period of time -- and this time, what I'm talking about of 90 days or 12 weeks -- is when several other processes actually come into play, which modulate pain, or which may sometimes increase the pain and sometimes decrease the pain. These pathways happen in the periphery, what we call peripheral sensitization, or they could happen at the spinal cord level, what we call central sensitization, or in the brain. Again, central sensitization. The role of these is to modulate and make the person feel or adapt to the pain. But sometimes, this amplifies pain. So the brain may be erroneously sent signals that I'm still feeling pain even though the injury has subsided. But these erroneous pathways that have developed keep sending signals of continued pain to the brain.

Host Amber Smith: So some chronic pain is not the result of a physical cause?

Vandana Sharma, MD: Or you can also say that the physical cause cannot be ascertained. For example, a person had a sprain that they did not pay attention to at that point. Like, sometimes, minor injuries happen that may just escape your attention. But then over a period of time, the same person may continue to have pain in the foot that may be associated with some other signs like redness or swelling or color changes or temperature changes, or something that we call sympathetic involvement, sympathetic pain involvement, which may, in unfortunate circumstances, it may progress to become a condition called complex regional pain syndrome, where when you ask the patient going back into the history, how did it happen? And they may not be able to give you a succinct answer. "I don't know. All of a sudden I had this foot pain. I can just tell you maybe 4, 5, 6 months ago as I was playing, I don't remember if I hurt myself or if I injured a nerve or anything. But since then, the whole foot hurts. And now this is expanding to involve the leg or the knee, and I'm in constant pain."

So those are some of those examples when they may not remember that there could be a tissue injury. Or sometimes, as I said earlier, that tissue injury may have happened. It may have completely healed. But the pain continues to happen. And one such example would be post-surgical pain. When surgeons did their best to treat the cause of pain, whether it was abdominal pain or it was spinal related pain, the cause of pain, like compression of the nerve or pressure on the spinal cord has been relieved. But the patients may continue to be in even more severe pain than than the first place that they went for surgery. So how do we explain pain like that? And that's why when I said that pain is not a black and white area, it's a gray zone where there are a lot of associations with the peripheral organs as well as with intricate neural connections that develop over a period of time in the periphery, in the spinal cord, or even in the brain.

To elaborate this a little bit further, I would say that even in the brain, there are several areas, like thalamus is one of the areas that is involved with sensing pain or is the antenna for pain in the brain, for pain signals in the brain. It has connections with several other areas like prefrontal cortex or the cingulate cortex, which are also involved with emotional pain.

So in a very interesting study, functional MRIs (magnetic resonance imaging) were done on people who didn't have any physical pain, just emotional pain, like separation, like any kind of emotional stressors that happened during the life. And the same areas that actually lighten up the areas of brain causing pain are also the areas that are lighted up with emotional pain. So that tells you that physical pain and emotional pain are so commonly intricately related. And that's why this biocycles physical model of pain, where not just are the biological markers, like the tissue injury, that plays a role in pain, but also there are the psychological markers and the social markers that affect pain.

Some of these that I would like to highlight are preexisting stress, or psychological conditions or psychiatric conditions like anxiety and depression. They may or may not be predecessors of pain, but they are so closely related to pain that it's hard to dissociate them after a period of time. Closely associated also -- sleep deprivation, or fatigue. When people who are sleep deprived, they all of a sudden feel way more pain than on the days when they're more relaxed or had a restful night. So it has it's like a vice versa, like a two-way phenomena that happens with sleep and pain. Similarly with emotional situations that I described earlier and pain, what leads to what is hard to say, but they are so closely intricately related to pain that you need to treat the whole thing rather than just treat the biological cause of pain. Otherwise you will be massively unsuccessful.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. My guest, Dr. Vandana Sharma, has been telling us about treatment options for chronic pain. She's an associate professor of anesthesiology and the director of pain medicine services at Upstate.

I wanted to ask you about the pain medicine services and have you kind of elaborate on what's involved in that. I know your training is in anesthesiology. Are there medical providers from other types of medical backgrounds who work with you in pain medicine?

Vandana Sharma, MD: Absolutely. So let me start with Upstate's pain medicine services. Under the umbrella of department of anesthesiology, we cover acute pain service and chronic pain service. And I believe, Amber, you are more interested in talking about chronic pain services here. But just to give you an introduction of acute as well. This is an inpatient consult service which is more catering to the needs of patients who get admitted with certain acute pain or acute exacerbation of chronic pain that brings them to the hospital where they require admission, or sometimes simple postoperative pain that cannot be just treated with simple maneuvers. And that's why acute pain service is needed there. So we are a 24-hour consult service that provides consultation treatment options for all these conditions.

Now, moving on to the chronic pain service, which is also covered by the same physicians who cover acute pain service also cover chronic pain, but this is for outpatient service needs. We have a comprehensive pain clinic at 6620 Fly Road, at Upstate Bone and Joint Center, where we see patients who have been referred from acute pain service after 90 days. So if the acute pain does not subside after 90 days, that's when they come to see us in the chronic pain clinic. In addition, we get referrals from orthopedic spine surgery, neurosurgery, spine surgery, again, from physical medicine and rehab, and from neurology. So these are not just the centers who send us referrals, but this is a two-way approach where we see their patients. And because pain is such a multidisciplinary service, and we are proud to call us one of the very few multidisciplinary pain centers in the whole country. We have developed a network of all these services where we could have a very smooth transition or referral base, where the patients can be seen among these services, depending upon what is etiology of pain.

And sometimes we feel only one physician is not enough to control the etiology and the whole spectrum of pain. And that's why we need help from psychiatrists, from addiction pain medicine and from physical therapy services, from physical medicine and rehab services, from neurologists. So, we provide a holistic approach to pain management to our patients where most of their care can be consolidated within Upstate, but using many different services.

Host Amber Smith: Does medical management work for some people with chronic pain?

Vandana Sharma, MD: Absolutely. When I see patients, I tell them I'm going to offer you three treatment pillars. The most important one of them is physical management, which is treating your biomechanics of pain using physical therapy, using chiropractor care, using acupuncture, TENS unit (Transcutaneous Electrical Nerve Stimulation,) like, many different alternative techniques. Second is the medication, which is as important as physical therapy is. And third is the spine injections.

So moving on to your question about medication part, we involve several different kind of medications to treat pain. As more and more research is growing into pain, pain medicines that help treat pain, we see that there is a wide role of medications like anticonvulsants, which are primarily used to treat seizure disorders. But they also have a great role in treatment of nerve-related pain, such as gabapentin and pregabalin. We also use other pain medications such as antidepressants. So a lot of times patients have questions: "isn't this a drug for depression?" But the doses that are used for pain management are much different from the ones that are used for depression doses. And they have, actually, the widest variety of evidence for these medications that they have a significant role in treatment of pain. These drugs include tricyclic antidepressants such as amitriptyline or nortriptyline, some selective serotonin reuptake inhibitors, SSRIs, what we call like Cymbalta and SNRIs. So these drugs are commonly used for treatment of pain, in addition to over-the-counter drugs like NSAIDs, like ibuprofen and Advil or a widely, commonly used household medication, acetaminophen. All these drugs in combination have a role in modulating pain at several levels, for example, by reducing the inflammation or by reducing the neuro transmission of pain from periphery to the brain as anticonvulsants and antidepressants do. They also help with the negative feedback loop of pain like the descending inhibition of pain. And the most important ones among these are the anticonvulsants because they work in your mid-brain level as well as they stop the processes of association of pain with other parts of the brain, such as mid-brain and higher up. So, they work by this modulating the descending inhibition of pain.

Host Amber Smith: So it sounds like there's many alternatives to opioids.

Vandana Sharma, MD: Absolutely. Yes. I forgot to talk about opioids because our clinic tries not to go to that option right away, and that's why. It's not used as a first line, ever, especially in non-malignant pain. Sometimes -- as I just forgot it here -- I forget it in most of my patients when it comes to non-malignant pain because it's not something I would like to offer as first line, second line or even third line, sometimes, for chronic non-malignant musculoskeletal spine pain or limb pain and all that. As we have more and more research coming up regarding the mechanisms of opioids, how they work and how they modulate pain and their longer lasting effects on pain management. Our patients who are treated with these drugs for a very long time, we see that the harms that are caused by these drugs are way more than the benefits.

With that said, these drugs are an important tool in a pain medicine physicians' wide plethora of medications that they could use for these patients and should never be not given when they're actually indicated because they are one of the strongest pain medications that we have available moreso to treat acute pain for cancer pain-related problems, as well as for chronic pain that is not being controlled by everything else and significantly impacts the quality of life of the patients. And when I say these things, these are the things that we actually used to monitor the use of opioids, as well, over a period of time. For example, if a patient where I have tried everything else, the three pillars that I talked about, I've used all of them, and nothing has really worked, and it's just short of surgery, or sometimes surgery has already been done, or an 80-year-old who's not a candidate for surgery, but their quality of life is so much impacted by pain that you would actually want to start a monitored opioid regimen in them.

And by monitored, I mean we like to make sure that there's a pain agreement where patients understand what are the risks of starting these medications, not even continuing. Like, what are the risks that you could be exposed to? A lot of education on opioids unfortunately comes from friends and relatives in these patients, where people may be like, "Oh, my doctor gave me this hydrocodone, and it worked great. Why don't you ask your physicianfor that?" without understanding that taking this medication even sometimes for longer than few days, could put you at higher risk for grave problems such as addiction, dependence, tolerance and something we call opioid induced hyperalgesia, where your body may respond very differently, to acute pain if at any point, if you're subjected to that. And it may be very difficult to control acute pain at that point if you have been chronically subjected to opioids for a period of time.

So all these things need to be discussed with the patients before we even start them on opioids. Make sure that they actually understand that there are risks, and I am actually inducing changes in my receptors, in my pain receptors in the body, in my spinal cord, in my brain, and my coping mechanisms that could be affected by these medications. Once we realize that the risks are actually lesser and the benefits are more, that's when opioid medications can be initiated -- under a very strict monitoring regimen, which includes regular urine drug tests, discussions about how the quality of life has changed, whether there are certain things that couldn't be done before starting these medications that now can be done, and making sure that patients are taking these medications in the best possible way, that does not include a harm to them or their family members.

Host Amber Smith: Can you tell us more about the spinal injection option?

Vandana Sharma, MD: Absolutely. So spinal injections, most of the times we restrict these to when the etiology of pain is coming from the spine. And by spine I mean the common ones are the chronic back pain or chronic lumbar pain and cervical pain, which is neck pain. Let me talk more about the lumbar pain first. So, there are several sources of pain, and these injections are actually targeted to treat the source of pain. And the sources of this pain could be coming from the pinched nerve or pressure on a neural element in the spinal canal, whether it's in the neural foramina where we call spinal nerve root, or in the center of the spine, what we call spinal stenosis, whether it's central or neural foraminal stenosis. Sometimes the pain that is mediated by facet joints in the back, or a sacroiliac joint. All these etiologies of pain can be treated by targeted injections at these levels. For example, epidural steroid injections that can be placed targeted in the area of pain for conditions such as spinal stenosis or herniated discs, or chronic degenerative changes in the central spine.

They can also be used in a more targeted way that is using a transforaminal epidural steroid, where we put that along the nerve foramen where the nerve roots are emerging from the spinal cord, if we know that that particular nerve root is the cause of the pain. So we deposit the steroid, under X-ray guidance, very closer to the area from where the nerve root emerges, what we call neural foramen. These are called trans foraminal epidural steroid injections.

The other things, as I mentioned, facet interventions, done to treat facet joint related pain, or sacro iliac joint related pain. These are also steroid injections that are used in this area. These can further be followed by more advanced techniques like radiofrequency ablation of these nerves, where the smaller nerves, not the nerve roots but the smaller nerves targeting the joints can be -- the term I commonly use with the patients is we don't burn the nerves. We actually cause changes using heat around these nerves so that the nerves are deactivated for a period of time, which is usually between four to six months. In some patients, it may last longer than six months, up to nine to 10 months, and gives them pain relief for that period of time.

Host Amber Smith: So, the injection is not necessarily meant to be a permanent fix, but it could last several months?

Vandana Sharma, MD: Yes. the injection is not a permanent fix. It's basically using the steroid for its antiinflammatory activity. Pain is, usually the cause is inflammation. So when there is inflammation in an area of body, that's what creates or causes pain. Here we are talking about tissue injury, not the causes of pain where tissue injury is not involved, but where we know that the disc is the cause of pain, or pressure on the nerve is the cause of pain, or arthritis in the joint is the cause of pain. And all these are inflammatory conditions. And steroids, from their inherent effect on those inflammation areas, can help subside the inflammation and relieve the cause of pain. But inflammation happens again because steroids only work for a period that could be variable from six weeks to 12 weeks. And after that, in a smaller subset of patients, we see that the pain control may linger on for longer.

It also depends how the patients utilize this time. And that's what I tell the patients, that this is the bonus period that you're getting for six to 12 weeks where you could modify your activity levels, where you could use everything else that can be used to treat pain. For example, people who are not able to do physical activity or cannot go to physical therapy or could not do chiropractor therapies, this is your golden period where your pain is lessened to some extent, and you could perform in physical therapy better. Because in the end, it's the muscle deconditioning and your postural changes that are major contributors to your pain. So anything that helps you to correct those problems, just for a period of time, would help you perform better in physical therapy, would help with muscle strengthening. And maybe you don't need the second injection again, because now you're used to the lifestyle changes. That can be done. Or occasionally you need them once or twice a year -- again, when the pain goes out of control -- to help you assist with these training programs for your biomechanics of the spine.

Host Amber Smith: When would surgery be an option for chronic pain?

Vandana Sharma, MD: Unfortunately, surgery is an option sometimes. Usually I tell my patients when all the other non-surgical options that we are trying for pain have failed, then I send them for a referral to the orthopedic spine or neurosurgical spine and see whether they think that this patient would benefit from surgery at that point. That's when we do that. And again, most of the times it's like a consultation between the two services that goes back and forth, where it's like, "Are there any injections, any other injections you could do?" or, "These are the commonest things that are expected after surgery," or "Surgery may not be just a simple thing like a discectomy or a microdisectomy. It may involve a much bigger surgery."

And the surgeons are pretty open to all those suggestions at that point, where they may be like, "probably go on with the injections for a little longer, probably continue with physical therapy for a little longer, because the surgery may be more extensive than we think," and gives another extra option to the patients what they would want to do at that point, or opens up their knowledge about their pain condition, what is causing that and what are the things that could be used, whether they want to come back to the injections, if they were helping to some extent, in combination with physical therapy, or they would want to just go ahead with the surgery where the root cause can be fixed, or at least tried to be fixed.

There are no guarantees, though, with surgery. And sometimes, patients may have to wait for several months for the healing process from surgery to happen before they can actually see the response. In certain situations like cauda equina (in which roots of the lumbar and sacral spinal nerves form a bundle in the lowest part of the spine) or sudden pressure on the spinal cord or spinal canal, where the pressure needs to be relieved, like decompressive surgeries. Absolutely they're needed as emergent procedures. However, in chronic pain conditions, what we see routinely in the pain clinic, where surgical consultation actually just opens up another source where the patients can be sent to see, like, this is when I would need surgery. Until then I'm going to continue with my injections or continue with my medications and physical therapy.

Host Amber Smith: What can you tell us about neuromodulation?

Vandana Sharma, MD: Neuromodulation is a relatively newer field. By newer, I mean it's at least 15, 20 years old, when it's being used more proactively in the United States and in the entire world. When we talked about the pain pathway, as I loosely said, the pain can be processed from the periphery to the spinal cord, and from spinal cord to the brain. These are actually the targets of neuromodulation as well, because these are the hubs of processing of pain by our body. And based on where we modulate pain using these low current signals, that is the neuromodulation that we offer the patients.

For example, it can be peripheral nerve modulation, peripheral nerve stimulation where we treat peripheral nerve diseases -- for example, limb neuropathy or mononeuropathies or traumatic nerve injuries that can be treated with neuromodulation using peripheral nerve stimulators.

More commonly used is a spinal cord stimulation because now we know that two areas in the spinal cord -- the dorsal horn and the dorsal root ganglion -- are the two hubs of pain modulation where the body decides whether I need to send the signal over to the brain, or do I need to stop this signal, this pain signal, over here. So these are also the areas where the signals from the brain are coming back, the descending modulation of pain. So obviously it's a very active hub of pain processing and modulation. So that's why spinal cord stimulators, they have been actually in use for several, several decades now, and have been successfully treating pain in these selected situations where nerve neuropathic pain conditions can be treated by them.

Host Amber Smith: So this does involve a surgical procedure to place the device, right?

Vandana Sharma, MD: Yes, absolutely. But it's a, it can be done in several ways. There are two kinds of spinal cord stimulator leads. One is a percutaneous lead, which involves almost like getting an epidural, using a slightly bigger gauge needle through which the electrode can be actually passed. So it's an outpatient, ambulatory surgery center kind of a procedure, which lasts less than an hour, where we use the epidural needle, slightly bigger gauge through which the electrodes can be passed in the epidural space and kept there for a period of five to seven days. This is called The trial period. And they are externally connected to a programmer and a pulse generator. And the company reps actually educate the patients at that point what programming settings they need to use for that time period, to treat their pain. And the patients could utilize all those programming settings available and modulate their pain themselves. At the end of seven days, if they feel that it made a significant difference in their pain and their quality of life, that's when we remove these leads and permanently implant that.

Now permanent implantation actually means having two incisions, one at the site of where the previous percutaneous trial was done, one incision there, and another incision to now put this programmer device, actually internalize it into the body. So this is what we call IPG, (Implantable Pulse Generator.) Now with more research and the advent of the newer companies and newer devices that are coming in, these IPG devices are smaller and smaller and sleek. So they could be implanted right under the skin, just a few, not even a centimeter, like less than that, deep under the skin. It's a small incision, about two inches, at the most two inches, that is placed on your back. And you get to decide, depending upon what side you sleep on or where you tie your belt, and that's where it is implanted after a thorough discussion with the patient.

And the healing process itself probably takes about seven to 10 days, and patients are not allowed to soak themselves or take a shower during this time. But after that, once The incision is healed, they're free to do whatever. They're also not allowed to bend, twist, or lift heavy weights during this time to avoid lead migration. But over a period of time, the leads are more accepted by the body, or they are actually held better by the scar tissue. And then the migration is much lesser after a few weeks. So after that, the patients are free to do what they do. Some of these devices have driving restrictions, and they would be advised not to drive with the lead turned on, just when they don't know, especially in the beginning when they do not know what to expect. So they're not allowed to drive or sometimes sleep with the device turned on. But then later on, as patients are used to it, it can safely be done. And again, under the guidance of the company reps and all that.

Host Amber Smith: We sometimes hear about patients whose chronic pain does not get better. Do you care for patients who are able to get back to their regular lives, living pain free? Does that happen?

Vandana Sharma, MD: It absolutely happens. And again, as I initially started with the emotional component of pain and how much there is a psychological dependence that is associated with pain. So, using a comprehensive, multi-modal, holistic approach to pain when we utilize physical therapy, when we utilize psychological the like cognitive behavioral therapies and biofeedback, optimizing the medications, optimizing the physical level, the deconditioning and the biomechanics of spine, and then utilizing injections judiciously when they're absolutely needed, and then sometimes going to more advanced technologies like neuromodulation can actually help these patients lead up, I wouldn't say a completely normal life, but at least a life that can be as close to normal as possible, where they could do the routine activities and all those things.

It also depends upon your approach as a patient as well, how much invested you are into your pain treatment, how much you want to get better. And obviously everybody wants to get better. Everybody wants to lead. as much of a normal life as possible. But then trying to incorporate all these different techniques to get the pain under control are helpful rather than just relying on one thing or the other.

One more thing I want to highlight is social support, presence of family members close by, if that is at all possible, plays a long role in the management of pain. Studies have shown that patients who have a strong social support network, whether it's through their own family or through the friends or even the online networks that are available to offer social support among the chronic pain patients, all these things go a long way in management of pain.

Host Amber Smith: Dr. Sharma, thank you so much for making time for this interview. Thank you.

Vandana Sharma, MD: Thank you for having me here, and it was a pleasure talking to you, Amber.

Host Amber Smith: My guest has been Dr. Vandana Sharma. She directs the pain medicine services at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listen.