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Physicians altering chronic pain treatment

The State Journal

09-29-17

Marshall: 'But the difficulty was with education of patients.'

CLARKSBURG - The medical profession has had to change its approach to treatment of chronic pain since the start of the opioid epidemic in West Virginia.

Dr. Thomas Marshall, medical director for the United Hospital Center Emergency Department, said many physicians noticed this was becoming a problem long before it became public.

"Many of us had already changed our practice," he said. "But the difficulty was with education of patients."

With the publicity the issue has since received, he said it's easier to educate patients as to why an opioid is not prescribed when it may have been prescribed before.

The epidemic was in part due to a campaign describing pain as the fifth vital sign, he said. (The original four vital signs were body temperature, blood pressure, respiration rate and pulse rate.)

"Fifteen years ago, we were taught if you give them some narcotics, they'll be better. But actually, it didn't work," said Dr. Eric J. Radcliffe, program director for United Hospital Center.

When viewed as the fifth vital sign, pain was seen as something that had to be treated, Radcliffe said, which was based on a model of treating cancer pain with narcotics.

"The intention was right. The intention was to treat chronic pain along the models of cancer pain," Radcliffe said, avoiding placing blame on the medical community.

"Who prescribed these millions of narcotics? Well, some doctor did, right?" he said. "But really, it's not where this came from. This came from a thinking of treating pain, helping patients with their pain based on a model of treating cancer pain."

The good intention backfired, he said, with pain persisting, leading to addiction in some cases.

Radcliffe said treatment has moved toward pain specialists, physical therapy and integrative medicine models rather than using narcotics full time to treat chronic pain.

Marshall included other treatments such as injection, nerve block, alternative medicine, counseling, relaxation techniques, physical exercise, anti-inflammatories, topicaltreatment such as lidocaine patches, muscle relaxants and acupuncture.

Marshall said the medical community has embraced a more holistic approach, treating the root cause instead of the symptoms.

"Patients had an expectation that they wanted to be fixed," Marshall said. "That was at one point an easy way to deal with things."

In response to the need for alternative treatment of chronic pain, West Virginia University Medicine has opened a comprehensive, integrated pain center that includes not only physicians but psychologists, psychiatrists, chiropractors, nutritionists and movement therapists.

West Virginia University Medicine's director of outpatient pain services Dr. Richard Vaglienti said this center is trying to get people away from thinking that a pill is the only answer.

This new approach of a wellness model includes a personal responsibility for things that can be modified like diet and exercise, he said, which is not only a cultural change for the medical community but for the population as well. Regardless of whether people are ready for this change, he said the system and the crisis are driving both the population and medical community to do something.

"I don't think that there is an option," he said of the changes.

This broader and more open-minded thinking across the entire medical community is something positive to come from the opioid epidemic, he said.

"Insurance companies are coming on board one by one by one because they can't really say that they are involved with stemming the opioid crisis without providing coverage for alternative care," Vaglienti said.

The approach combines the best of both western and eastern medicines, he said.

"If you need an anti-inflammatory, you can have an anti-inflammatory, and that will help you. But that may be also coupled with weight loss and mindfulness therapy and chiropractic. And so that eliminates the needs for opioids, but it gets you to the same result or usually a better result."

He said a wellness approach is not only the way chronic pain treatment is going, but the way treatment for many diseases is going.

Marshall added, "We've always tried to find the cause. I don't think that has necessarily changed, but I think the patient understanding that it takes time. It may take time to get to the bottom of things; it may take weeks or even months to get to the bottom of something and find that root cause, and you may hurt for a little while. I think patients are much more understanding of that now."

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