SEE YOU IN 8 WEEKS Chronic pain procedures offer what other surgical specialties can't: repeat business.

The crackdown on opioids has changed the way many pain physicians practice. Instead of reaching for their prescription pads, they're relying more heavily on interventional pain treatments: steroid injections, joint injections, fluid injections, nerve blocks, implantable pain devices and radio-frequency ablation.

"A decade ago, doctors misread their responsibility to treat chronic pain," says Robert Saenz, president of VIP Medical, a San Antonio, Texas-based consulting firm that advises pain management practices nationwide. "They believed they needed to prescribe painkillers, or risk being reported to their medical board. But what I teach people is that this is not the only way. More and more, physicians are open to embracing alternatives."

Pain medicine continues to gain in popularity, especially among patients who want to remain active, mobile and pain-free as they age. OR managers have recognized that adding pain procedures to their surgical services can be quite profitable, supplying a high-volume, low-cost source of revenue that offers what other specialties can't: repeat business. Most surgeries are single events at your facility, whereas most pain management patients require ongoing visits to your facility.

As a service line, pain management is a natural extension to specialties that frequently deal in chronic pain: the cervical and lower back pain of orthopedics and neurosurgery, the foot and leg pain of podiatry, even the pelvic and prosthetic pain of urology and gynecology. Surgeons practicing these specialties at your facility have a captive audience for pain management referrals.

The overhead is low, as the amount of equipment required is minimal. Capital equipment is limited to a C-arm or other intraoperative imaging system and a fluoroscopy table. In terms of OR personnel, you'll need someone to run the C-arm and a nurse to assist the surgeon. Basic pain management cases like lumbar epidurals, facet joint injections and lumbar facets — the patient's pain is diagnosed and located, an injection is administered — take about 15 minutes apiece. Here's a look at how our understanding of pain, and our strategies for managing it, have evolved.

FACET JOINT Along with the numbing medication, a facet joint injection also includes injecting a time-release steroid (cortisone) into the facet joint to reduce inflammation, which can sometimes provide longer-term pain relief.

Multifaceted management
A major impetus behind an evolving pain management arsenal is the country's opioid epidemic. While these drugs used to be the go-to defense, sobering statistics have disrupted American health care's love affair with opioids. Between 1999 and 2014, 165,000 people died from prescription painkillers. So, what does next-generation chronic pain management look like? As multifaceted as the thing it seeks to treat.

For years, opioids were the gold standard of chronic pain management. But, increasingly, comprehensive pain-management plans include non-steroidal anti-inflammatories (NSAIDs), as well as antidepressants or anticonvulsants to reduce nerve pain. Serotonin-norepinephrine reuptake inhibitors, such as duloxetine (Cymbalta) and venlafaxine (Effexor), are prescribed for pain at doses lower than are effective for depression. The most commonly used anticonvulsant used to treat chronic pain is gabapentin (Neurontin). Though developed to mitigate other conditions, these drugs can play a key role in reducing pain signals — and they're set to get better.

"Currently, some of the main drugs in this category cause fatigue, forgetfulness and weight gain," says Adam Kramer, MD, MSPT, interventional pain management specialist with Valley Pain Consultants, which has offices throughout Arizona. "But as they're further developed, we can expect cleaner side-effect profiles."

Additionally, ketamine infusion centers for treating chronic pain are popping up around the country. "Payers are not recognizing this as anything other than experimental," says Matthew McCarty, MD, founder and president of Balcones Pain Consultants and founder of Waterleaf Surgery Center in Austin, Texas. "But we pain physicians know that patients suffering from migraine headaches or complex regional pain syndrome really do experience a significant benefit."

This doesn't mean that opioids will disappear from the roster entirely — for some cases, it would be inhumane to withhold them, particularly as a last resort. But strategies for monitoring patients in order to prevent addiction are improving.

The FDA is approving more abuse-deterrent opioids. And urine drug testing to detect misuse or abuse has improved beyond giving a positive or negative result for illicit narcotics. Now, these toxicology reports detect whether a patient is taking drugs from another prescriber, and they're able to distinguish a false positive so that a patient who may have used, say, a Vicks VapoRub inhaler for allergies won't be flagged as a methamphetamine user. One validity test developed by Dr. McCarty called ToxID goes so far as to match a patient's DNA with the DNA of her urine, to authenticate samples and help disrupt the $1 billion urine adulteration industry. Such improvements help mitigate issues caused by patient dishonesty or poor memory.

Also evolving is the science of pharmacogenetic testing, which lets a physician analyze a patient's genetic code in order to determine how he'll react to a specific medication. What is the likelihood of experiencing a serious side effect? Or addiction? And what is the best dosage?

"Reimbursement from insurance companies has held this back," says Dr. McCarty. "They want more evidence that it matters. Some of the newer drugs being released come with companion diagnostics that provide information on the genes responsible for metabolizing a drug or turning it into an active form. So there's more motivation on the part of the drug manufacturer to advise patients and lobby for coverage."

"A decade ago, doctors believed they needed to prescribe painkillers, or risk being reported to their medical board.
But what I teach people is that this is not the only way. More and more, physicians are open to embracing alternatives."

— ???Robert Saenz of VIP Medical

Evolved ablation
Trigger point injections and peripheral nerve blocks are increasingly being incorporated into chronic pain management protocols. While they are not new, the way doctors are administering them is.

"Fluoroscopy X-ray has allowed this specialty to grow," says Dr. McCarty. "In the past, these injections and blocks were done blindly. Now, with the use of this machine, we're able to make better diagnostic decisions and deliver medication for therapy in a more effective way. While the technology has been in use for 20 years, it's now becoming the expected standard."

Meanwhile, the use of ultrasound for administering blocks and injections is increasingly becoming standard as well, since it lets a physician easily identify potential complications. "In some cases, the two machines are used simultaneously," says Dr. Kramer.

Both technologies have made the use of blocks safer, and this is important, since a nerve block can open additional avenues for a chronic pain sufferer. If a patient experiences relief via a diagnostic block, for example, she may be a candidate for radiofrequency ablation (RFA), a minimally invasive procedure in which heat is applied to a nerve via a probe in order to disrupt that nerve's pain signal. This temporary treatment will ward off the patient's pain until the nerves grow back in 6 to 12 months.

Recently, improvements to the technology — namely, a cooling mechanism — have expanded its scope. During cooled radiofrequency ablation, cool water is run through the tip of the probe, allowing a physician to heat a greater area of tissue without charring it and causing additional pain. In other words: "This gives you a better chance of ablating the nerve you're intending to ablate," says Dr. Kramer. "They've basically improved upon technology that's been used for spinal arthritis for more than 20 years, making it applicable to pain in the joints as well."

New neurostimulation
Three therapies — spinal cord stimulation, peripheral nerve stimulation and pain pumps — reduce pain without extensive surgery. Some of the most exciting advancements in the treatment of chronic pain are in the area of neurostimulation. During a minimally invasive procedure, a small device — like a small pacemaker — is implanted under the skin where it delivers electrical impulses to the spinal cord in order to interrupt pain signals.

About 3 years ago, these devices were the size of a hockey puck. Today, they're the size of a Double Stuf Oreo, meaning they're far more comfortable for the patient. They're also Bluetooth-enabled for the first time, which means a patient can control her level of stimulation from an iPod, whereas previously she'd need to hold an antenna over the implant — a not-so-consistent or comfortable way of modulating pain.

Additionally, these implants are now being made with primary cell versus rechargeable batteries, so patients no longer have to sit still for an hour or 2 a week hooked up to a recharging station. Instead, the device simply needs to be replaced in a minimally invasive, 10-minute procedure once every 7 to 10 years. The devices are operating at a higher frequency than ever before, meaning the patient feels less vibration. And, because of gyroscope technology that uses the earth's gravity to determine orientation, a patient is able to move more freely than ever before, without the fear of feeling minor zaps. Finally, the devices are MRI compatible for the first time.

"Spinal cord stimulators are our bread and butter," says James McClung, BSN, RN, director of nursing at the Center for Specialty Surgery in Austin, Texas. "It's an amazing feeling being able to watch people walk away after receiving an implant without feeling any pain."

Since April of last year, chronic pain physicians have been able to stimulate not just the spinal cord, but the dorsal root ganglion, or the "Grand Central Station for all pain impulses entering the central nervous system," says Dr. McCarty. "This means we're able to treat pain we were never able to treat before, including chronic complex regional pain syndrome of the lower extremity. It's been a real breakthrough."

Treating the mind
Research supports the fact that chronic pain is inextricably linked to a person's mental state. Therefore, pain management centers are increasingly equipping patients with tools for understanding and navigating the mind-body connection. Alternative treatments — things like biofeedback, cognitive therapy, guided imagery, acupuncture, cryo-therapy and even massage, along with physical and occupational therapies — are key to a multidisciplinary approach to targeting pain and achieving functional restoration. "You'll see a greater integration of these things at pain management centers that have the resources," says Mr. Saenz. "Those that don't can refer patients to other places. It's not about keeping people under one roof anymore. Physicians have to put proper care above fear of losing a patient." OSM