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Living the Shadow of Pain

Posted Apr 02 2009 12:53pm

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Doctors today have more ways to offer relief than ever before. So why are so many people in New Jersey and beyond still suffering?
Weshon Hornsby has returned to his first love-painting. His pictures-lively, colorful, at times oddly whimsical-include portraits of people and animals, still lifes, landscapes, and cityscapes. In Heat Stroke, which depicts a cartoon-like city skyline, the high-rise buildings themselves are wilting under a midday summer sun. It was not too long ago that Hornsby, a native of Neptune who was raised in Asbury Park, thought he would never be able to paint again. In 2000, while operating a machine that digs trenches for laying electric cables, he herniated a disc in his lower back. His pain after the accident was intense. "Except for doing my physical therapy, I was pretty much bedridden for sixteen to eighteen hours a day," he says. Hornsby, 37, underwent two unsuccessful back surgeries that probably exacerbated his underlying nerve damage. In 2003, he visited pain-management specialist Scott E. Metzger, who had recently opened a practice in Shrewsbury. Metzger placed Hornsby on a combination of medicines, including a narcotic, an anti-inflammatory, and Methadone, a synthetic opioid. Following a disappointing six-month evaluation, Metzger altered the mix of medicines. The revised treatment relieved some of Horns-by's back pain but did little to alleviate the pain that was radiating down his legs, causing them to shake. At this point, Metzger referred Hornsby to his new practice partner, Peter S. Staats, an internationally known pain expert and founder of the division of pain medicine at Johns Hopkins University in Baltimore. (Staats, like Metzger, is among New Jersey Monthly's top doctors.) After tweaking Hornsby's medication regime yet again, Staats decided his patient might be a good candidate for spinal cord stimulation, a procedure requiring simple surgery that uses an electrical current to treat chronic pain. A trial run in which a stimulator was inserted through the skin produced positive results. Immediately, Hornsby experienced a roughly 80 percent reduction in his pain, both in the lower back and down his legs, which no longer shook uncontrollably. Prior to the trial, he was not able to sit upright in a chair for more than a half hour before his pain grew so intense he was forced to lie down. After Staats's initial procedure, Hornsby says he could "sit up for three to four hours straight and work on my art." Encouraged beyond his expectation, Staats performed a second procedure to implant the stimulator more permanently. "Before the treatment, Weshon would come into the office with a grimace on his face," Staats says. "Afterward, you could see his face open up. He was just like a different guy once the shadow of pain was lifted." Weshon Hornsby's story has a happy ending, one that has altered not only his life, but the lives of his wife and two daughters. Yet despite success stories like his, chronic pain still affects millions of Americans. Studies indicate that one in four U.S. adults have endured a day-long bout of pain in the past month or so. An alarming one in ten pain sufferers-three out of five in the 65-and-older age group-report their pain has lasted a year or more, according to a study released in 2006 by the National Center for Health Statistics. By this measure, more than 800,000 New Jersey residents may be suffering from chronic pain. Among neurological ailments, headaches at all severity levels are the most common, followed by lower back pain. Not surprisingly, the incidence of severe joint pain increases with age, with women in the government survey reporting such pain more often than men. Other conditions causing pain include arthritis, cancer, diabetic neuropathy, fibromyalgia, spinal cord injuries, and failed back surgery, like Hornsby's. A big reason pain lingers is that people delay getting help. In a 2004 survey conducted on behalf of the American Chronic Pain Association, nearly half of the people interviewed said they had waited more than a month before talking with a doctor; 30 percent of these said they had waited more than three months. Most people sought help only after their pain had become significantly more severe. But even proactive pain sufferers sometimes have problems. "People don't always know where to turn," says Will Rowe, CEO of the American Pain Foundation, which advocates on behalf of patients. Pain medicine itself is still a relatively new field. And even some primary care physicians have a limited understanding of the issues and referral sources. But the situation is improving, thanks in part to greater public awareness of pain generally and to better training of nonspecialists. Still, says Rowe, more needs to be done to educate pain sufferers about where to turn and what treatment options are available to them. If you are among the thousands of New Jersey residents living with chronic pain, now may be a good time to take action: Getting started: For mild or moderate pain, do not overlook your primary care doctor as the first line of assistance. "Any physician in the U.S. should be aware of how to manage pain, whether acute or chronic," says Michael E. Goldberg, an anesthesiologist and pain-management specialist at Cooper University Hospital in Camden (and another of this year's top doctors). For more severe or intractable pain, your primary care physician might refer you to a specialist. "The majority of our referrals are still from PCPs," says Metzger. The remainder of his referrals, he adds, are from a variety of other sources, including surgeons, orthopedists, physical therapists, chiropractors, and workers' compensation groups. Even with your referral source's blessing, it is wise to check out your specialist's credentials and experience. Currently, the only practitioners eligible for board certification in pain medicine by the American Board of Medical Specialties are anesthesiologists, physiatrists (or rehabilitation physicians), and neurologists. (The American Board of Pain Medicine, another certifying body, permits a wider group of practitioners to be certified.) Besides board certification, your specialist should, ideally, be a full-time pain specialist; have experience treating different types of pain; offer a range of treatment options; and have access to an array of multidisciplinary services, should they become necessary. Your first visit: As with any initial doctor visit, your physician will begin by taking a full history. He or she will want to know when you first experienced your pain, whom you have seen about it, what if any medications you have taken to control it, what diagnostic tests have been conducted, and so on. "The more a patient can tell us, the better," says pain management physician and anesthesiologist Michael E. Rudman of Morristown and Basking Ridge (who, along with his partner Richard P. Winne, also made this year's top-doctors list). Your physician will also ask you to gauge your current level of pain, usually with the help of a pain scale, where 0 is the complete absence of pain and 10 is the worst pain you can imagine. This inventory, typically repeated each visit, will be one of the yardsticks your physician uses to gauge your progress, or lack of it. If you have seen other physicians, your specialist will almost certainly request copies of your medical records. As part of your initial visit, your specialist will also conduct his or her own physical exam, ordering follow-up tests as necessary. Among the most commonly ordered are blood tests (to detect arthritis or signs of infection), X-rays, bone scans, CAT scans, MRIs, and EMG and nerve conduction studies (to learn about the health of your peripheral nerves). With this data in hand, your specialist will put together a diagnosis. "It's critical to establish an accurate diagnosis in order to come up with the right treatment plan," says anesthesiologist Rudman. A treatment plan: In the popular imagination, the typical treatment for pain is a course of strong, potentially addictive medications. Certainly, narcotic medication, especially for the control of cancer-related pain, remains a powerful weapon in the pain-management arsenal. But today, there is a range of other weapons, including non-narcotic medications and anti-convulsants that have proven effective in controlling certain types of pain. Other therapies include relatively straightforward anti-inflammatory treatments, a variety of injections to block nerves, and spinal cord stimulation or other forms of neuromodulation (nervous system alteration). What's more, as mind-body research progresses, doctors are increasingly incorporating deep breathing, visualization, biofeedback, meditation, and other behavioral techniques into their plans, either as primary treatments or additional therapies. The best option-or set of options-for you should be determined in consultation with your physician. "There's no one-size-fits-all treatment for pain patients," says Metzger. And while most treatment options are generally very safe, risks do exist and should be discussed with your physician. "Anytime you put a needle into someone, you risk bleeding and infection, although this is rare using proper techniques," says Rudman. Errant nerve blocks also pose the risk of nerve damage or paralysis, although this too has been minimized with techniques like fluoroscopic and ultrasound-guided nerve blocks. And, of course, narcotic medications pose the risk of addiction if their use is not managed properly. The best treatment plan is no guarantee of success. Even the concept of "success" can be problematic in pain management, since what you consider a success, your neighbor may not. "Some patients who come in at an 8 on the pain scale and go down to 6 are tickled to death," says Metzger. "Others want to be 100 percent pain free, and anything short of that is a failure in their minds." Complicating matters further is that pain relief is not the only measure specialists use to gauge success. A patient's level of physical functioning is-or should be-equally important to the doctor. "If I have you pain free, but you can't get out of bed, or go to work, or hold your child, or take care of your family, that's not a successful treatment," Metzger says. This level of physical functioning, however, is sometimes hard to achieve. Ross Cohen of Florham Park sustained a crush injury when a car ran over his left foot. The injury and resulting nerve damage led to complex regional pain syndrome (CRPS), a chronic neurological condition characterized by burning pain, acute skin sensitivity, changes in skin temperature, and swelling, among other symptoms. In 2004, the orthopedist who had treated Cohen's injury referred him to Rudman, who following an evaluation began a series of nerve blocks, along with a medication regimen, since modified. To supplement his physical therapy, Rudman referred Cohen for behavioral therapy (biofeedback and visualization), which Cohen, 41, found of limited help, perhaps, as he says, because "I didn't fully buy into them." To date, there has been significant progress. "The pain is constant, but I don't need the nerve blocks as often as I did when I started," says Cohen. And if from time to time his pain level spikes dramatically to the point where "you just want to be sedated and put to bed," he visits Rudman sooner than his typical three-to-five-week intervals of three sessions per week. "I went from being in unbearable pain and not wanting to get up, not wanting to live, to being able to manage it," he says. And Rudman, Cohen adds, has been "wonderful," concerned about his mental as well as his physical condition and "willing to try new techniques and procedures to help me improve even more." Still, Cohen's chronic pain has up-ended his life, physically and psychologically. He can no longer work. Two of his favorite sports-golfing and skiing-are out of the question. And life with his children has changed. "I can no longer coach my kids in Little League or chase them around," he says. "I've lost patience with them, too. It's a much more passive fatherhood." Brenda Trosky of Mine Hill, another of Rudman's patients, has also been diagnosed with CRPS. She has not only achieved good pain relief, but also a fairly high level of functioning has been restored. After a series of nerve blocks failed to relieve the pain in her feet, Rudman suggested they try spinal cord stimulation, which proved very successful. "It gave me back my life," says Trosky, 61. "I can do all things I couldn't do before-walk without a cane, drive, tend to the house, cook. It's been miraculous." In the end, giving someone back his or her life, or some reasonable semblance of it, is what good pain management is all about. Still, patients have to take the first step and seek help. As Trosky puts it, "Given what doctors know now, there's no reason on God's green Earth that most people should have to walk around in pain."
Wayne J. Guglielmo is a freelance writer and the former senior editor at Medical Economics.
By Wayne J. Guglielmo NJ Monthly Wayne J. Guglielmo NJ MonthlySphere: Related Content
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