Anesthesia Alert: Cornerstones of Chronic Pain Management

A patient of mine who had undergone previous spine surgeries came to me complaining of hip and back pain. He wasn’t in a position to have another surgery on his back any time soon, so I focused on treating the discomfort in his hip. I placed three sets of epidural steroid injections into the joint over the course of five months, and that took care of the pain in that area. The injections also alleviated some of his back pain.

Before the injections, this patient was living in a state of functional disability. He was in so much pain that he was basically sedentary. He wasn’t ambulating enough to get the cardiovascular exercise that helps with cortisol and stress levels — and his hip muscles were becoming quite tense. Once his hip started feeling better, however, he was able to do physical therapy, strengthen his back and hip muscles, and improve his entire posture.

The improvement of this patient’s condition highlights the effectiveness of a chronic pain management program that focuses on treating the overall person and understanding the correlations between seemingly separate symptoms. Increasingly, outpatient facilities are adding chronic pain management service lines to their offerings. If you’re interested in starting a program, here’s how to establish a foundation for success.

• Specialized providers. Have at least one board-certified pain physician on staff — and ideally more. Certified pain specialists have a holistic knowledge of pain and use the complete patient story — a detailed health history combined with a clear understanding of the patient’s imaging (X-rays, MRIs, etc.) — to develop a well-rounded treatment plan, which might include medications (NSAIDs, muscle relaxers and even a short course of opioids) and often centers around non-surgical interventions. My dual work in anesthesia and pain management allows me to treat pain from the acute and chronic perspectives, which is key because the two go hand in hand.

In a broad sense, most of the procedures I perform are nerve blocks and ablations, epidurals and pain injections. However, each patient’s treatment plan is an individualized approach based on their symptoms, the level and location of their pain, and their unique medical history. Interventions are targeted at the root cause of their discomfort. 

For instance, if a patient has a herniated disc in the lower lumbar level (L5-S1 region), a common issue, I place an epidural in that location to decrease the inflammation of the disc herniation. Another example of a common issue my patients face is sciatica, which is pain stemming from the compression of a nerve root in the lumbar spine. Again, an injection that numbs and decreases inflammation around that nerve root level is generally the best treatment for this condition.

Of course, patients will sometimes have residual pain, and that’s why medication management remains a viable option. Board-certified pain physicians have the training, experience and tools to handle these situations on a case-by-case basis.

• Multidisciplinary collaboration. Pain is a dynamic and ever-changing phenomenon that requires multiple providers working closely together to best serve the patient. Leaders of pain management programs must regularly communicate with the patient’s referring provider, who is usually the primary care doctor. In my role, I collaborate with spine surgeons at our facility, from whom many of my referrals come. It’s a great set-up because multiple providers share the same patient and can team up to determine the best course of treatment.

There’s still a common misconception that chronic pain management often involves the use of opioids.

Often, I will conduct a trial of injections for patients before they commit to surgery. For instance, if a patient’s sciatica-related pain decreases significantly after three epidurals, it’s possible they can avoid a surgical intervention all together. Pain specialists may also enter the patient care equation following procedures such as spine fusion surgeries. While the procedure results in a healthier overall spine, patients often experience some residual pain due to arthritis. In this case, pain injections can greatly improve their post-op quality of life.

• Clear expectations. A major component of any successful pain management program is the ability to set clear expectation for patients. My patients range from military veterans to professional athletes. I need to understand the individual goals of each and create a tailored plan to achieve it. Older patients might simply want to walk up a flight of stairs again, whereas a young athlete might expect to get back to running marathons.

There’s still a common misconception that chronic pain management often involves the use of opioids. That’s simply not the case. Yes, opioids can be part of the care equation, but effective treatment regimens also include injections of non-opioid medications, psychological coping mechanisms, exercise, stretching and physical therapy.

Successful pain programs raise awareness among patients about the true nature of their discomfort. That consists of a multidisciplinary approach to combating and treating their pain in a multimodal manner with the goal of providing lasting, long-term relief. OSM