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It is a few years that I started treating Chronic Pain. It seems I entered in a very challenging time when the difference between chronic pain and the acute pain was not very well known by doctors. In 1986, the World Health Organization (WHO) developed a simple model for the slow introduction and increased the dose of painkillers that became known as the WHO analgesic stepladder. Before this, people were dying in unnecessary pain because drug regulations introduced earlier in the century had increased the stigma and fear associated with both prescribing and taking opioids.
In the start of my practice, we had to fight against ignorance of pain. Doctors tend to ignore what they do not know. As a physician, I remember those days that my nightmare was seeing a patient with chronic back pain. I felt miserable, helpless and a failure to help my patients. That was why I ask questions about depression, which I knew better and treated that symptom. I do not, for a second, judge people who did not want to prescribe narcotics to chronic pain patients, in the fear that they may get addicted.
In 2009, many other up-to-date doctors and I felt obligated to ask for seeing and believing chronic pain and accepting it as a chronic disease that needs treatment. WHO has already given us a very amazing tool, why not using it. I am admitting that I was wrong. WHO was wrong. All Western Medicine got it wrong.
Based on the classical teaching of the medicine of acute pain, every time I saw the patient, I asked him/her about the intensity of pain. According to the response, I increased the dose of narcotics. This is a practical, accurate and acceptable way of finding the right dose of the painkiller for a patient after an operation.
In 2003, an article published in one of the very relevant journals that started waking us up. In this article pointed out that every pain in human, unrelated to the anatomical or etiology, always accompanying with some change in the brain. We all know that some of us have more tolerance for the same pain. In this article, the author suggested that in acute or cancer-related pain, the amount of pain is related and relevant to the tissue injury, the bigger the damage, the more pain. However in Chronic Pain that is long lasting, the amount of pain is not relevant to the size of the damage. In fact, after a while, emotions and psychosocial factors are more relevant to the reported pain by the patient!
Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive to emotional circuits. Brain 2013;136:2751-68.
Therefore asking a patient with a chronic long standing pain to score the pain and prescribe narcotics, was an entirely a mistake! I feel I was part of the problem and these days, I am doing my best to destroy the monster that I was involve creating.
We still don't know what the right way is. Honestly, this science is so young that we are learning every day. We just learn how to "see" pain effect on the brain. By using an fMRI, the scientist started seeing some amazing relevance between the increase of the blood flow to some parts of brain and intensity of pain. The issue is, they still could only inflict an acute pain, like a small electric shock. The results and findings would probably have no relevance to chronic pain patients. It is only one more step forward.
In the end, I would like to hear from you, over 5000 patients that I know since 2009. Do you think being on chronic painkillers had increased your quality of life? Could you work? Could you go back to the activities that you have loved to do? What parameter is more relevant to your well being?
Sleep? Appetitle? Walking distance? The amount of time you could stand in one place? How many laugh you had in the last 24 hours? How many times have you cried in the last week? How many meals you enjoyed making in the last week? Last 24 hours? Help us making it right.
A few days ago, a friend was defending the capital punishment and was saying "as most of the world believe, an eye for an eye". Then I read this sentence :
An eye for an eye only ends up making the whole world blind.
• do you want to live in a blind world?
How lucky I am.
When I left Chatham, I never believed that I would be this lucky. In the last 3 years, every day I had 1-5 of my patients who followed me all the way to Toronto. I probably never officially said "thank you, for making me the happiest doctor in pain management"; so here it is.
I am attending in a conference in USA. todays' topics were mostly about evidence based medicine in pain medicine and the appropriate evidence. the new idea was the fact that RCTs (Randomised Control Trials) are not the only and the best evidence and we need to see if the interventions that we provide, would make people more active, more functional and could reduce the medication usage. As well the outcome studies are very important regarding the decisions for continue an intervention or not.
for Complex Regional Pain Syndrome, even though there is not enough evidence yet, selective nerve root stimulators are very promising.
I have seen over 100 people with OTN technology. Just one word can tell you about this technology: AMAZING. I sit behind my computer, remotely and safely connect to our EMR- Electronic Medical Record program in one monitor, and connect to different cities in Ontario in another monitor. At the end of one each hour, I move to another city, sometimes over 500 km away from each other and see the next patient. I saw a patient from Windsor at 0900 and another one from Sudbury at 1000. Then again at 1100 saw someone in Chatham. It is unbelievable. My speciality is one of the very unique one and people would travel long distances to talk to someone in my area of work, and now, they go to an office in their home town and would see me by OTN.
In January we celebrated out first year and many doctors who had never believed we could survive if we follow the rules and do not overcharge the patients, as almost all the other pain clinics in Ontario do, smiled and express their desire to join us. Already 5 new doctor added to our group, 3 of them are the big names in the Chronic Pain Programs in the Universities of Canada. I am so proud of our clinic.
Fortunately some of new doctors would like to work on Saturdays. I work one Saturday a month and together; we are able to provide services, in 3 Saturdays of the month.
Traditionally, Epidural Steroid Injections (ESI) have been recommended for early use in a client experiencing acute herpes zoster to prevent the development of postherpetic neuralgia (PHN). Current evidence now supports the use of intrathecal steroids to provide pain relief in clients experiencing PHN (Benzon H, Chekka K, Darnule A, et al., 2009).
Studies conducted by Owlia et al., concluded that a 40 mg dose of a corticosteriod know as methylprednisolone achieved greater pain relief effects and fewer adverse effects than were achieved with a 80 mg dose(Owalia M, Salimzadeh A, Alishiri G, Haghighi A, 2007).
An additional randomized, double-blind study conducted by Kang et al., that evaluated the effects of steroid dosing during TF ESI, found no difference in the level of benefits experienced by clients receiving 10, 20 and 40 mg doses of the corticosteroid triamcinolone; A 5 mg dose failed to produce the same benefits (Kang S, Hwang B, Son H, et al., 2011).
Furthermore, a randomized study conducted by Revel et al., found that when a steroid was injected in a 40 ml volume of saline it provided superior pain relief for a client than when the same dose of steroid was injected independently of the 40 ml volume of saline in an 18 month follow-up with the same clients (Revel M, Auleley g, Alaoui S, et al., 1996).
In the past it had been reported in the literature that depo-medrol or intrathecal methylprednisolone acetate (MPA), when injected intrathecally during an ESI procedure, could use polyethylene glycol as a vehicle to initiate an inflammatory response in the body, causing arachnoiditis (Kotani N, Kushikata T, Hasimoto H, et al., 2000). However a recent study that used MPA for treatment of PHN failed to produce evidence of either aspect meningitis or arachnoiditis in 89 patients who had been treated with 4, 60 mg injections. Patients in this study underwent diagnostic lumbar punctures and magnetic resonance imaging for a two year follow up period (Kotani N, Kushikata T, Hasimoto H, et al., 2000).
It has been reported that repeated steroid injections have been associated with Cushing syndrome and adrenal suppression in some patients. In susceptible patients it is unlikely this complication can be avoided even with only a single, relatively small steroid dose. For the general patient population, the general guiding principle to use for repeated steroid injections is to provide it only to those patients who experience significant benefits from the procedure. Another guiding principle involves spacing the injections at long enough intervals to allow for complete recovery of adrenal function. If a patient is undergoing surgery within a few weeks of receiving a depo-steroid injection, best practice would include an evaluation of this patient for adrenal suppression and they should receive stress steroid coverage during the perioperative period.
Studies report that the chance of traumatic spinal cord injury due to needle trauma is increased in a client who receives sedation or general anaesthesia during an epidural injection, especially those who were unresponsive during the treatment (Rathmell et al., 2011). We can use the results of these studies to influence what a patient is offered during an epidural injection, rather then sedation or general anaesthesia, a client should be offered anxiolytics to reduce the chance of tramautic spinal cord injuries in patients receiving an ESI.
The number of epidural injections required to achieve optimal pain relief is not specified in the literature as of yet, however from experience, and through reviews of the literature available, it appears that the ideal approach for epidural injections would be 2 injections, 2 weeks apart, using no more than a 40 mg dose of steroid for the injection, although each dose would be personalized to the patient by the doctor.
When considering whether a patient should discontinue their use of anticoagulants before an ESI, one must recognize that discontinuing anticoagulants can actually cause 3x more complications then complications that may arise from bleeding during the procedure. A safe option for practitioners to consider would involve conducting a caudal before an ESI and, if safe, continuing with the patients usual anticoagulant schedule to prevent adverse effects associated with discontinuation.
Benzon H, Chekka K, Darnule A, et al. Evidence-based case report: the prevention and management of postherpetic neuralgia with emphasis on interventional procedures. Reg Anesth Pain Med. 2009;34:514Y521.
Kang S, Hwang B, Son H, et al. The dosages of corticosteroid in transforaminal epidural steroid injections for lumbar radicular pain due to a herniated disc. Pain Physician. 2011;14:361Y370.
Kotani N, Kushikata T, Hashimoto H, et al. Intrathecal methylprednisolone for intractable postherpetic neuralgia. N Engl J Med. 2000;343:1514Y1519.
Owlia M, Salimzadeh A, Alishiri G, Haghighi A. Comparison of two doses of corticosteroid in epidural steroid injection for lumbar radicular pain. Singapore Med J. 2007;48:241Y245.
Rathmell J, Michna E, Fitzgibbon D, et al. Injury and liability associated with cervical procedures for chronic pain. Anesthesiology. 2011;114:918Y926.
Revel M,AuleleyG,AlaouiS,etal.Forcefulepiduralinjectionsforthe treatment of lumbosciatic pain with post-operative lumbar spinal fibrosis. Rev Rhum Engl Ed. 1996;63:270Y277.
From 01DEC13, another author has started adding important pain related article to our blog. Laura V. is a registered nurse who is helping us in Allevio Pain Management and would add article in English and some with Italian translation to our blog.
Since a few months ago, I started offering PRP treatment in Allevio Pain Management. Many of the patients had questions about how this treatment could help them. Today I found an interesting video in this regard that I added to the video section of the site. Enjoy watching...
We could not be more proud to announce our bringing video conference for patients into our practice! For a long time, distance between patients and their doctors was a big reason for less than acceptable level of care in parts of Ontario for some services.
Over the last 10 years, technology has made it possible to bring people closer, and physicians are no exception. For example, a dialysis patient who needs to see the nephrologist occasionally can now connect virtually with a hospital that owns the dialysis machine, so the patients do not need to physically travel to the hospital for every checkup.
This amazing improvement is still very costly. Some units that enable this type of doctors appointment cost between$10,000 and over $20,000 (based on what is needed for the machine). For private offices like the majority of the pain doctors in Ontario, this price was not affordable. To use this, a doctor like myself who loves to help his brothers and sisters from small cities of Ontario where the farmers and their work would actually "put bread on our tables", the technology was simply out of reach.
A few months ago, we were approached by a group who was founded by the government of Ontario to start a low cost service of consultation that is compatible with TeleMedicine. OTN.ca started by writing a secure program that would let the physician and patient connect together in a secure and realistic environment, face to face. It is true that the patients still have to travel to us for a procedure, the first consultation and all followup sessions after can be done on this TeleMedicineplatform.
If you are interested to be seen by myself or any of the other great specialists I work with, please talk to your doctor to arrange for a referral by TeleMedicine consult. Almost every hospital in Ontario has the unit and many of the Family Health Teams are equipped with TeleMedicine units.
Once we get the referral and medical history from your physician, and we receive your pre-consult questionnaire, we will book your Telemedicine consultation at a location near you and let you know when it is.
Dr. R. Safakish
Dr. Ramin Safakish, anesthesiologist and pain interventionist, is a full time pain interventionist in Allevio Pain Management.