Q: What are the biggest concerns regarding quality in pain management right now?
Dr. Ira Fox: The big buzz in the pain management industry has revolved around finding uniformity among pain physicians on how we can practice in a cost-effective manner. I think there is good news and bad news to that. First of all, pain management practice guidelines attempt to be based on evidence-based medicine. The issue with that is the procedures we do are very technique-dependent.
For instance, a 23-year-old woman can come into a physician’s office with herniated disc pain in her back that goes down her leg. It’s a basic problem and a typical presentation of pain at that age when individuals are generally very active. It’s very common for that type of situation to be treated with epidural injections and medication to reduce inflammation around the herniated disc and allow it to heal. It’s also not unusual to see a patient who received injections that didn’t help. When those patients come into my office, I offer the patient just one repeat epidural. Lo and behold, the patient feels much better. Does that mean epidurals don’t work for that patient? Of course not. It means procedures are very technique-dependent.
This is where evidence-based medicine is problematic because the evidence generated on outcomes of pain management procedures is dependent on those who do the procedures. Although medical literature and professional societies, including the American Society of Interventional Pain Physicians, are trying to formulate guidelines, pain management physicians should look at each patient individually.
Q: How has quality in pain management improved over the years?
IF: To some degree, the newer technologies are elaborating on previous techniques and technologies. So spinal cord stimulation companies have come out with newer stimulation products, and they all have made marked improvements in the quality of their products. By comparison, current stimulation leads compared to leads from past decades is like driving a 2011 car versus a 1996 car. The key word is coverage. Spinal cord stimulation technologies have been around for more than 20 years, but it wasn’t always as effective because the coverage of the leads weren’t as good. Now, they are much more refined and improved.
Other technological advances are more geared toward intradiscal treatments, which are minimally invasive surgical techniques. The trend will continue along that regard to be very important. The intent of many injections for intradiscal treatments is to identify where the pain is coming from and heal that pain or eliminate pain fibers in that area. Lately, there has been a lot of interest in fixing sources of pain in a minimally invasive fashion.
There are some additional advances in the field of radiofrequency lesioning, which is utilized to eliminate pain fibers or burn nerves that are sources of pain. Advances in that area of technology allow larger lesions to be made to make the burn or elimination of pain more dramatic, leading to longer or better results.
Q: What are your thoughts on the perception of pain management in light of the negative coverage of “pill mills”?
IF: I think that all the advances in pain management technology spell opportunity for pain management physicians. In terms of treating patients who really have pain, with interventional techniques like the ones I just described, they usually don’t have to be on narcotic medication. Also, one point I try to make very clear is that “pill mills” are not pain management. People who really practice pain medicine should not be associated with that. There are great means and methods available to treat people with pain, and those means and methods don’t entail giving patients bottles of pills that they can become addicted to.
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