Chronic Pain in the Era of the Opioid Crisis

Pain Management

By: Jared Bilski

Published: 12/19/2019

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Image-guided interventions like epidural steroid injections, radiofrequency ablation and spinal cord stimulators are in high demand.


In the absence of antibiotic alternatives, physicians in the early 1900s had no choice but to treat every infection with penicillin. Chronic pain went through a similar "penicillin phase." No matter the type of back pain — radicular, axial or arthritic — patients got an epidural steroid injection (and perhaps a recurring script for opioid painkillers). But with the advent of treatments like radiofrequency ablation and spinal cord stimulators, pain management is shedding its penicillin phase.

"Pain management is just starting to come out of that one-size-fits-all approach to treating patients," says neurologist Vladimir N. Kramskiy, MD, the director of the Ambulatory Recuperative Pain Medicine Program at the Hospital for Special Surgery in New York City.

With facilities pressed to find opioid-free ways to manage chronic pain, the timing of these promising interventions couldn't be better.

1. Epidural steroid injections. Steroid injections in the epidural space around the spinal cord to reduce the inflammation of a problematic nerve root remains chronic pain medicine's bread-and-butter procedure. It's quick and effective (for the right patients). Roughly half of the 5,000 injections administered each year at the Montefiore Multidisciplinary Pain Program are epidurals, says Naum Shaparin, MD, the program's director at the Montefiore Medical Center in the Bronx, N.Y.

"Even in an academic environment, we could still do 14 to 16 injections per day, per room," says Dr. Shaparin. "In a private practice environment, you can double or triple that amount."

Who's best suited for epidural steroid injections? "People with clear radicular pain respond best," says Steven P. Cohen, MD, chief of pain medicine at Johns Hopkins Medicine in Baltimore, Md. "A herniated disc responds better than spinal stenosis, but spinal stenosis responds, too."

Epidurals are less effective for longtime opioid users who've had many failed procedures, including back surgery, adds Dr. Cohen, who also serves as the director of pain research at Walter Reed National Military Center in Bethesda, Md.

For the most part, steroid injections are cost-effective. The supplies are minimal, and for an ASC, the facility fee is around $400 depending on your location, says Dr. Cohen. But the problem is the relief is temporary — on average, the injections last 3 to 6 months — and highly variable.

2. Radiofrequency ablation. A more involved, albeit costly, intervention is the thermal ablation of the nerve. Radiofrequency ablation is a multi-step procedure for chronic pain treatment that uses an electrical current produced by a radio wave to burn an area of the nerve that causes pain and thus decrease the pain signals coming from that area. The first step is a medial branch block, an injection to determine if the medial branch nerves surrounding the facet joints — small joints between the vertebrae at the back of the spine — are the source of the patient's pain.

GAME CHANGER Spinal cord stimulators have proven effective at relieving the chronic pain of patients who have been suffering the adverse effects of failed back surgery syndrome for years.

"The medial branch block is a diagnostic test to see if the nerve that innervates the joint is the cause of the pain," says Dr. Shaparin. Generally, the procedure or "test" is done twice, and if that test is positive, you proceed with an ablation. "Ablation gives the patient months if not years of relief. But it's not forever because the nerves do grow back," says Dr. Shaparin, adding that ideal candidates are patients who suffer from serious joint pain, whether it's from the facet joints in the back of the neck or the sacroiliac joint.

From a cost perspective, there's some heavy upfront investment, says Dr. Cohen. The radiofrequency generator needed for the procedure can run you more than $30,000. Plus, the time for the radiology tech is costly.

"They're very expensive. They bill at over $20 a minute," says Dr. Cohen. But again, there's the effectiveness factor. "Some patients see a tremendous response to this intervention," says Dr. Shaparin. "I've had patients who've seen relief for more than 2 years."

3. Spinal cord stimulators. The most intensive intervention on this list, spinal cord stimulators (SCSs) — also known as dorsal column stimulators (DCSs) — are for patients who haven't found relief from major surgery or who have undergone multiple back surgeries, have a diagnosis of failed back surgery syndrome or have a major dependence on opioids for their chronic pain. The SCS intervention involves placing an implantable neuromodulation device into the patient that sends mild electrical signals to select areas of the spinal cord to reduce pain.

Like radiofrequency ablation, SCSs involve a 2-step process. The first step is a trial where the surgeon places the lead wire into the epidural space in the spinal column and sends the patient home for a week to see if they get relief from the intervention, says Dr. Shaparin. When the week is over, the implant comes out regardless of the outcome. The trial period is key because the patient can adjust the stimulation in real time.

"Let's say the patient is home, and the SCS is not stimulating the exact right area enough," says Dr. Shaparin. "A lot of times, the device rep can change the stimulation over the phone or over the internet." If there's adequate relief, a permanent SCS is implanted in the epidural space, and the battery goes around the buttocks area, below the beltline, with a remote control for the patient to adjust as needed.

As you can imagine, between the trial and the implantable device, this intervention is costly. The stimulator implant alone costs upwards of $25,000. Plus, from a staffing standpoint, at a minimum you're talking about needing a physician, at least 2 OR techs, and an X-ray tech or at least someone who's well-versed in fluoroscopy. The good news is CMS just began reimbursing for this procedure in 2018, and commercial insurers tend to pay around the Medicare rate for SCSs.

But the reimbursement process itself is more involved for SCSs. "Implantable devices require the use of a psychologist, because this intervention can lead to significant long-term implications," says Dr. Kramskiy. Due to those implications, insurers' response is to require some degree of additional screening, besides just relying on the physician's recommendation, before approving this treatment, he adds.

Still, there's some compelling reasons to consider this option. For one, it can be very effective. "There's quite a bit of evidence for the value of spinal cord stimulation in patients who have back pain and shooting leg pain after surgery," says Paul Christo, MD, the director of the multidisciplinary pain fellowship program at Johns Hopkins Medicine in Baltimore, Md. Plus, the upfront costs can be misleading. "Sure, the upfront costs of doing a spinal cord stimulator are going to be high," says Dr. Christo, "but over time, the break-even point might only be 21???2 years."

Worthwhile endeavor

Your facility can take advantage of the paradigm shift in how we treat chronic pain. Dr. Christo says the investment in procedural interventions for pain control is worth it for 2 reasons.

"These can make a big difference in someone's life. They can drastically improve the function of patients with chronic pain, so there's the public health aspect," he says. "Plus, most of these things are reimbursable."

With the push to reduce or eliminate opioid use among chronic pain patients getting stronger each day, you can imagine the reimbursement will only become more favorable moving forward. OSM

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