Modern Pain Management

It’s a strange time for pain sufferers and their doctors. It almost feels like you could get in trouble for taking a Percocet. And pain management specialists hear that, loud and clear.

Interventional pain doctor Sina Samie, MD, did his fellowship training in the management of chronic pain conditions at USC and is building a comprehensive pain management program at Torrance Memorial Physician Network. He has seen this pendulum swing back and forth, and the “war” on opioid addiction with it.

“There was a period of time when there was a big push to prescribe more opioids because there was a perception that we were undertreating pain,” Samie says. “Some doctors even got sued, so many started overprescribing. And of course research on opioids convinced us they were not addictive in patients with pain. Now we know that not only is there potential for addiction, but also some of the medications previously prescribed are not supposed to be used for chronic pain. In fact, some can stop working and make pain worse.”

Samie explains, “Patients are very aware of these problems. And we doctors also know we can’t just give opioids without careful consideration because they have many side effects including respiratory depression. It is very easy for patients to misuse opioids accidentally, leading to increased tolerance and addiction.”

The strong cultural and medical reaction is appropriate, Samie says. “This is a public health crisis and needs to be addressed on all sides. Health care providers should be on the side of helping our patients and helping their lives get better—not contributing to the epidemic.”

In some ways, though, he admits the pendulum has swung too far. “I’ve heard people with severe chronic pain say, ‘I’m tired of being treated like a drug addict,’ and ‘The pharmacists looks at me funny,’ and ‘I used to get something that worked well for me, but my doctor stopped prescribing it.’”

It is clear that a one-size-fits-all approach doesn’t work for chronic pain management, and doctors like Samie are looking at more holistic, customized and multidisciplinary approaches. “There are so many psychological aspects to pain,” Samie notes. “It can affect a patient’s life in many different ways. You can’t just prescribe pills, and ignoring the mind/body factors only makes the pain worse.”

A holistic approach might include biofeedback and cognitive behavioral therapy, various injections, acupuncture, yoga and/or meditation. “I’m very open to alternatives,” he adds, “and everyone is different, but pain psychology is very important. Biofeedback, for instance, will show a patient how they can affect their pain, anxiety and blood pressure based on how they are breathing and other physiological parameters. Meditation, yoga and tai chi have been found to work very well for chronic pain, including fibromyalgia. We also recommend physical therapy and other exercise, and massage—anything that keeps you active and boosts your mental wellness.

There’s another alternative Samie says his patients are asking about: cannabidiol, or CBD, an analgesic compound derived from the cannabis plant. Recently research has shown CBD to have anti-inflammatory and anti-anxiety properties without the psychoactive effects of marijuana—the “high” or “stoned” feeling—and the Food and Drug Administration has just approved its use in preventing seizures.

“I think it’s very interesting,” he says, “and I don’t prescribe it because it’s not regulated yet. Now that it’s available over the counter, you can try it and see what works; just don’t drive after taking it, and be careful because doses can be unpredictable. So far there’s a bit of evidence, but most of the research is not yet from high-quality, randomized controlled studies. That will change in the future."

“But I do want to stress that as we age, our kidneys, liver and other vital organs don’t function at 100%, and you could be at more risk for over-sedation and other adverse side effects. Especially in the aging population, we need to be extra careful to avoid causing organ damage to the kidneys, liver, heart, stomach, etc., or causing dizziness, falls, fatigue or forgetfulness."

“Some exciting breakthroughs are catching on though,” Samie adds. “These include more interventional techniques, such as epidurals, nerve blocks and radiofrequency ablation and neuromodulation. Nearly 40% of back pain is due to arthritis in the spine, which often responds to a treatment in which we cauterize the tiny nerve endings that provide sensation to these worn-out joints. We can give patients over a year of relief with a short, outpatient procedure. So far it’s working very well, and patients are satisfied.

“The bottom line is that patients don’t have to live in pain and don’t have to be afraid of getting addicted to pain meds. There are many non-opioid medications and interventional treatments available to patients, thanks to technology. I urge them to come in and see a pain doctor; we will do everything we can to minimize their pain and improve their function and quality of life.” •