Other than opioids

When many people think of a pain medicine doctor, they tend to think of pills rather than medicine as a holistic science. That’s not surprising. Abuse of painkillers—with potentially fatal consequences—has reached epidemic proportions in the United States, to the extent that it became an issue on the presidential campaign trail heading into the primaries.

Yet there’s a whole branch of pain medicine that does not involve a patient taking a pill. It’s called interventional pain management. This area within the specialty involves procedures (i.e., interventions) directed at the nerves themselves.

Injections—sometimes guided by X-ray or MRI scanning—reduce inflammation or muscle spasms or deliver numbing solution directly to flaring nerves. Other procedures involve the spine: adjusting vertebrae to alleviate pressure on the spinal cord, desensitizing nerves with heat, implanting electrodes leading to the equivalent of a pacemaker that overrides pain signals.

Dr. Shawn Furst, an interventional pain management specialist in Chico, advocates a multidisciplinary approach because it’s difficult to predict what will work for each patient. “Multiple treatment modalities are sometimes required for optimal treatment of pain,” he said.

Indeed, interventional pain management provides alternatives, and the opportunities for this care are increasing across Butte County.

Oroville Hospital recently hired a new specialist, Dr. Nick Brar, for its Comprehensive Pain and Spine Center. Feather River Hospital in Paradise offers pain procedures through its Medical Imaging department, performed by interventional radiologists. In Chico, Furst is one of a half-dozen pain management doctors, three of whom are affiliated with Enloe Medical Center.

Furst prescribes a range of procedures and a specific set of medications, including just one strong opioid: buprenorphine. Patients seeking hydrocodone (Norco), oxycodone (Percocet), morphine, etc., must seek another doctor, though Furst still will treat them otherwise.

“As a lot of people are aware of now, there is a big crisis in this country with opioid abuse and dependency and accidental death,” he said. “In the 1990s, a lot of doctors and experts felt a lot of opioids were fairly low-risk to prescribe, and so a lot of patients were put on escalating doses … a lot of people who take opioids develop a tolerance, and they find they need a higher and higher dose to treat the same amount of pain.”

That notion took off in the 2000s. The Centers for Disease Control and Prevention (CDC) reported in May that the amount of prescription opioids sold in the U.S. has nearly quadrupled since 1999 without an overall change in the amount of pain reported by patients. Also spiking in the same proportion: the number of overdose deaths involving opioids.

“On one hand, we’re always trained to help people; we like to offer as much help as we can to patients, so it was thought if they had a lot of pain and tried a lot of other things, opioids would be a good choice,” Furst said. “Now, we’re much more conservative, and feel we should prescribe them much more sparingly, particularly on a long-term basis.”

Furst has taken a particularly conservative stance by limiting his prescribing to buprenorphine and two more mild opioids, codeine and tramadol. Buprenorphine, too, is a lower-tier painkiller, but it has enough potency that Furst also uses it to “convert” patients from other opioids.

Dr. Bill Whitlatch understands Furst’s position. As a neurosurgeon, he needs to prescribe medication to alleviate postoperative pain. He, like most doctors, takes greater care with how he prescribes, but doesn’t go as far as Furst—nor, Whitlatch said, do all pain specialists.

When he trained in the ’90s, opioids were “sold as a panacea for pain” as physicians felt pressed to ease patients’ suffering. “In medical school, all these people came and gave us lectures saying, ‘We’re not treating enough pain; give more medicine,’” Whitlatch said. “So we gave more medicine. Now there’s all this stuff in the news saying, ‘You treated all this pain and now we have all these addicts [and] prescription drug abuse.’”

Letting patients know how a procedure can trump medication isn’t always easy.

“It is certainly understandable that people are anxious about needles and they’d rather take a pill,” Furst said. “What I tell everyone is that as long as the doctor has good training and experience in whatever procedure they’re doing, [these interventions are] very low risk….

“I thoroughly explain the benefits versus risks to patients, and I certainly don’t force anything on them.”

Injections—cortisone, steroids, lidocaine—sometimes can be administered in a regular exam room, but other times require imaging equipment to guide the doctor’s needle placement.

Radiofrequency ablation (RFA) is typically performed on nerves stemming from the spine but sometimes in joints. The physician uses electricity-induced heat to desensitize an area of nerve tissue for a period of months.

Neurostimulators offer longer-term relief. For this, pain doctors work in conjunction with neurosurgeons who implant electrical “leads” in the spinal cavity and a small device internally near the waist. Whitlatch calls the neurostimulator effect “white noise for the spine,” as the low-power buzz masks the pain signals generated by neurons lower in the body.

“It’s a pretty good option for treating pain that nothing else works for,” Whitlatch said, “especially legs.”

While Whitlatch performs more intensive operations, when structural issues cause pain, he refers patients for minimally invasive interventions, too.

“You have to make sure you’re doing it for the right reasons,” he said, “and get a proper referral.”