LOUISVILLE Unfortunately in the field of pain management, there are still many misconceptions among both patients and healthcare providers. But, that is slowly changing with the efforts of specialists such as Kristal Wilson, MD, pain management physician with the Baptist Center for Pain Control at Baptist Eastpoint in Louisville.
According to Wilson, two of the biggest misconceptions in the field are that pain clinics only provide chronic narcotic therapy, and that when narcotic therapy is ineffective, escalating the dose is the answer.
At the Baptist Center for Pain Control, Wilson and her colleagues – Darel Barnett, MD, Brigid Buckman, APRN, and Jacqueline Dennis, APRN – do manage chronic narcotic therapy, but their main focus is on a “multimodal analgesic plan with conservative therapy, physical therapy, psychological therapy, moving all the way into interventional or surgical options,” says Wilson.
The Double Board-Certified Pain Physician
For Wilson, dispelling the myth of pain clinics as narcotic dispensaries begins with the qualifications of its physicians. “In my opinion, one thing that sets pain management physicians apart is that we complete a fellowship and are double board-certified in both anesthesiology and chronic pain management,” she says. “This gives us more options to offer to patients, with more opportunities to help them.” Wilson completed medical school and residency in anesthesiology at the University of Louisville and took her fellowship in interventional chronic pain management at the University of Cincinnati. She joined Baptist Health in August 2016.
“The thing I like about pain management is that there is such a need for it. It is a very challenging but gratifying field, especially end of life palliative care, cancer care, and people with chronic conditions who think they have no hope or any other options,” says Wilson.
Multimodality Treatment Options
The top complaint in Wilson’s office is back pain, closely followed by neck pain, knee pain, shoulder pain, and migraines. Many of their patients suffer from chronic pain post-surgery.
Conservative therapy is always the first line of defense, including things like physical therapy, weight loss, and behavior modifications. If those fail, there are a variety of new technologies, interventions, and surgical options available, including steroid injection, radiofrequency ablation, and neurostimulation.
Classic epidural steroid injections are appropriate for back or neck pain with radiculopathy symptoms (nerve compression or irritation in the spine).
Radiofrequency ablation can be used on nerves from the head to the knees. Electrical currents are used to heat nerve tissue and decrease pain signals from that area for six months to a year, providing longer lasting pain relief.
Neuromodulation treatment involves the implantation of a neurostimulator, much like a pacemaker, that stimulates the spinal cord or peripheral nerves to disrupt pain signals to the brain. Because the device is implanted, it must be trialed first in the patient, but Wilson says, “It has been very successful, especially in post-surgical patients.”
If medications are a part of a patient’s treatment plan, Wilson never recommends narcotics first or on their own, opting for a multimodal analgesic plan.
In addition to the array of medical, interventional, and surgical options, Wilson contends working closely with a pain psychologist is an important aspect of the program because of the anxiety, depression, and psychological issues that accompany chronic pain.
Education, Education, Education
A large part of Wilson’s job is educating her audiences, both patients and physicians, as to what pain management is and what it can do. “A lot of patients don’t know these options are available. What they’re familiar with is they hurt and there is a medication or pill they can take and feel better. So, they just think the more medication or pills they take, the better they will feel,” says Wilson. The problem is that’s not the case. “With narcotic therapy, continuing to escalate the dose when it’s not effective is not going to make it more effective. I tell patients, ‘If three Percocets don’t work, four is not the magic number,’” she says.
For physicians and healthcare providers, particularly those who do not regularly work closely with pain management physicians, new recommendations have been slow to circulate. “Older training in the specialty leaned towards high dose narcotics with no ceiling. The field has changed in the last 20 years. It has been proven that high dose narcotics are 1) not effective and 2) do come with harmful side effects. Now we’re dealing with addiction, tolerance, dependence, misuse, and abuse in the community. It’s a complete shift in the pain management field,” says Wilson.
Her goal is to reach primary care physicians who “are the first line patients go to when they hurt.” It is those primary care physicians who are managing much of the chronic pain and chronic narcotic therapy. Wilson recommends that physicians start conservative therapy with their patients as they normally would but schedule a consult with a pain physician as they are trying those therapies to see what other options are available. “On average we see people with chronic pain very late, later than we would like to. If we treat their pain sooner rather than later, patients will have better outcomes. A lot of our patient referrals we’re not seeing until they have chronic pain well over a year or a couple years, and they come to us as a last resort,” she says.
Another advantage of sending patients to a pain clinic is they have the staff and resources to very closely monitor patients who are on narcotic therapy. They do so with urine drug screens, pill counts, KASPER reports, and frequent visits. “We’re not here to promote narcotic use in the community. If anything, we’re trying to decrease it and make sure these patients are highly regulated and monitored to decrease misuse in the community, to try to help control the narcotic epidemic that’s increased over the last 10 years,” concludes Wilson.
On average we see people with chronic pain very late. If we treat their pain sooner rather than later, patients will have better outcomes.— Dr. Kristal Wilson
We’re not here to promote narcotic use in the community. If anything, we’re trying to decrease it and make sure these patients are highly regulated and monitored to decrease misuse in the community.– Dr. Kristal Wilson