FALL 2008 Spinal Column · found myself in situations that made me so anxious I was most relieved...

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FALL 2008

In ThIS ISSue:

Identifying Patients p. 2

Central Sensitization p. 4

Surgical Management p. 6

Addiction and Pain p. 8

Chronic Pain Program p. 12

Pain of spinal origin (e.g., back pain) is multi-factorial.

The majority of causes are not compressive (e.g., disc

herniation, pinched nerve, etc.) or unstable in nature.

Most cases of back pain are not associated with factors

that can be ‘seen’ on imaging studies. Yet patients will

insist that there exists an offending factor, a ‘pain gen-

erator,’ and, if removed, will make them all better.

Physicians often comply by looking for such — fre-

quently to no avail. This can be harmful in two ways.

It can, and usually does, result in an avoidable infla-

tion of the cost of medical care. More importantly, it

changes or redirects the focus from the true ‘cause’ of

the pain to the search for the elusive ‘pain generator.’

Sadly, many patients have undergone unsuccessful

surgery with that quest in mind.

This issue of Spinal Column presents the multiple fac-

ets of pain of spinal origin and associated treatment

modalities. This compendium illuminates the lack of

clarity associated with the definition of the ‘pain gen-

erator,’ while pointing out treatment modalities that

perhaps should often be used earlier in the course of

Edward C. Benzel, MD

Dr. Benzel can be contacted at 216.445.5514 or [email protected].

pain, pain, pain — can’t You Just Find the cause and Fix it? A Message from Edward C. Benzel, MD

pain (e.g., medical or non-surgical interventions) and

surgical procedures that perhaps should be employed

before the search for that elusive pinched nerve or

unstable spine. It may even be most appropriate to

employ a conservative medical approach or a well-

conceived and individualized chronic pain program.

So, let’s not jump on every complaint as if the com-

plaint defined the solution. Instead, let’s look at the

entire patient and work as a team to individualize

therapy. This issue helps us accomplish just that.

“Can you just find the cause and fix it?” No, but we

should be able to, with the help of the patient, select

a course that makes everyone happy.

for More InforMATIon To learn more about the Center for Spine Health, please

contact Dr. Benzel at 216.445.5514 or our administrator,

Kathy Huffman, at 216.445.8442. To refer patients, call

216.444.2225 or 800.553.5056, ext. 42225.

pain is one of the most common reasons for seeking medical care in our society. Most patients,

and many physicians, assume that there exists a simple ‘cause-and-effect’ relationship between

an offending factor (e.g., herniated disc, pinched nerve, unstable back, etc.) and the pain. although

this can be true, it often is not entirely true and, in fact, turns out to be farthest from the truth in the

majority of cases.

spinal coluMn | Fall 2008 clevel and clinic center For spine health 2 spinal coluMn | Fall 2008 clevel and clinic center For spine health

Most patients with back pain do not seek out a spine

specialist and, once they do, it often is because the

pain has persisted beyond the time that one would

expect to see spontaneous resolution of the pain. For

those patients whose pain does not resolve within a

relatively short time, some will go on to develop dis-

abling chronic pain.

The societal and individual costs of chronic debilitat-

ing pain in this country are staggering. 2003 esti-

mates show 149 million lost work days due to pain,

at a cost of about $19.8 billion per year. The earlier

we can identify patients who will go on to develop

chronic pain, the earlier the appropriate treatment

can be recommended, and treatments more likely to

do harm, such as unneeded surgeries and other inter-

ventions, can be avoided.

Psychosocial variables have long been shown to have

a significant impact on pain perception and, in turn,

disability due to pain. Specifically, the intensity of the

pain, the degree to which it interferes with activities,

and the extent to which it disrupts mood all predict

chronicity of back pain. Identification of the presence

of such possible co-morbid problems can guide ap-

propriate early intervention. The added benefit is that

many patients prefer to be treated by a practitioner

who understands them “as an entire human being”

rather than just a “pain in the back.” When patients

believe their practitioners care about them, they are

more compliant with treatment recommendations,

Judith Scheman, PhD Guest Medical Editor

Dr. Scheman can be contacted at 216.444.2875 or [email protected].

Identification of Patients Who Likely Will Need More Than analgesics and physical therapy for their Back pain By Judith Scheman, PhD

and less likely to be angry and litigious when and if

treatment fails to help them. Within the context of a

busy practice, however, it can seem difficult to iden-

tify, let alone address, both the physical and psycho-

social variables.

In actuality, the assessment of pain intensity, func-

tion and mood can be addressed relatively quickly us-

ing psychometrically sound tools that take just a few

minutes for the average patient to complete, and are

easily scored and cost effective. The most frequently

used tool to measure pain is the visual analog scale,

most commonly scored with zero indicating no pain

and 10 being the most extreme pain.

Impairment in functionality due to pain easily is as-

sessed using the Pain Disability Index (PDI), a seven-

item scale in which each item is its own domain of

function (see figure 1). Patients rate the degree to

which their function in each domain is affected by

their pain on a zero to ten-point scale where zero

is no disruption and 10 is total impairment. Just a

glance at each domain tells you the level of impair-

ment. The scores of each domain can be added for

a composite score.

The Depression Anxiety Stress Scale (DASS) is a

42-item assessment of depression and anxiety in

which patients identify if a statement such as “I

found myself in situations that made me so anxious

I was most relieved when they ended” (anxiety) or “I

Back pain is an enormous problem for patients, doctors, families, employers and society. in the united

states in 2006, the estimate for the proportion of all physician visits attributable to back pain was 2.3

percent, or 20.47 million patients. Most patients seeking care from a spine specialist do so because

of complaints of pain. Because the natural history of most spine pain is self-limiting, almost anything a

healthcare provider recommends is likely to lead to the patient reporting a decrease in symptoms in a

matter of days or weeks (with the exception of bed rest, which has now been well shown to do more

harm than good).

spinal coluMn | Fall 2008 clevel and clinic center For spine health spinal coluMn | Fall 2008 clevel and clinic center For spine health clevel andclinic.org /spine 3

couldn’t seem to experience any positive feeling at all”

(depression) is true for them never (0), sometimes (1),

considerably (2) or always (3). Scoring consists of add-

ing the responses for each item classified as measur-

ing anxiety, depression or stress. Cut-off scores are

supplied by the authors.

The McGill Pain Adjective check list is a set of adjec-

tives used to describe pain. They are categorized

roughly in two categories: somatosensory pain (throb-

bing, aching, sharp, burning or tingling) and affective

or suffering component of pain (agonizing, unbear-

able, torturing, etc.).

This index measures the impact of chronic pain in a patient’s everyday life. A score of 0 means no disability at all. A score of 10 means that all have been disrupted or prevented by the pain.

Family/home responsibilities: This category refers to activities related to the home or family. It includes chores and duties performed around the house (e.g., yard work) and errands or favors for other family members (e.g., driving the children to school).

Recreation: This category includes hobbies, sports and other leisure-time activities.

Social activity: This category includes parties, theater, concerts, dining out and other social activities that are attended with family and friends.

0 1 2 3 4 5 6 7 8 9 10

No disability

Total Disability

SevereModerateMild

Figure 1: Pain Disability Index

Occupation: This category refers to activities that are directly related to one’s job. This includes nonpaying jobs as well, such as that of a homemaker or volunteer worker.

Sexual behavior: This category refers to the frequency and quality of one’s sex life.

Self-care: This category includes personal maintenance and independent daily living activities (e.g., taking a shower, driving, getting dressed).

Life-support activity: This category refers to basic life-supporting behaviors such as eating, sleeping and breathing.

Once you have identified patients who likely will need

more than an analgesic and some physical therapy for

their back pain, you also will find that addressing their

psychosocial problems along with the physical is likely

to lead to a better outcome.

Judith Scheman, PhD, is Program Director of the Chronic

Pain Rehabilitation Program at Cleveland Clinic.


Edwin Capulong, MD

Dr. Capulong can be contacted at 216.445.8080 or [email protected].

central sensitization: From theory to clinical reality By Edwin Capulong, MD

Central sensitization reflects increased responsive-ness of the central nervous system to afferent stimuli and is the consequence of a cascade of events that ultimately lead to dysfunctional central pain pro-cessing. In essence, the CNS is not “hard-wired,” but

“plastic” or adaptable to a changing neurochemical environment. Unfortunately for some patients, this neuroplasticity contributes to the maladaptive situa-tion of chronic pain.

Mechanisms of central sensitization

From peripheral to dorsal horn stimulation. Acute tissue injury produces an inflammatory reaction that stimulates peripheral nociceptors A delta and C fiber. This event leads to propagation of neuronal excitabil-ity at the dorsal root ganglion. Simplistically, certain neurotransmitters are involved that send signals to the dorsal horn, where NMDA receptors are stimu-lated. Due to persistent NMDA stimulation along the neuraxis, the rapid and overly efficient firing of C fibers (‘wind up phenomenon’) leads to long-term potentiation of pain. In addition, expansion of the receptive painful field involving other segments of the adjacent spinal cord level may occur, clinically defined as “widespread pain” (see figures one and two).

Spinal to cortico-limbic sensitization. Along the cortico-thalamo-limbic circuitry, there are at least five brain centers that are activated: the thalamus, soma-tosensory cortex, frontal lobe, insula and cingulated gyrus. One might hypothesize that with frontal cortex involvement, cognitive and executive dysfunction occurs with eventual limbic augmentation of the pain. This leads to depression, anxiety and sleep disorders.

Supraspinal inhibitory/excitatory control. The brain stem, specifically the ventromedial medulla, plays a role in modulating pain through serotonergic adren-ergic pathways. In conditions where the inhibitory control is disturbed, increased sensitivity to pain oc-curs, contributing significantly to pain amplification.

in the past decade, much has been learned about the pathophysiologic mechanisms underlying chronic

pain. the phenomenon of central sensitization now is believed to be responsible for ongoing, chronic

pain in patients in whom the inciting trauma or event has long healed. Features of central sensitization

have been described on functional brain imaging in patients with diffuse myofascial pain syndromes

including fibromyalgia and chronic nonspecific low back pain.

Over time, these neural pathways become severely dysfunctional, leading to a diseased state that has no ability to distinguish between noxious vs. non-noxious stimuli.

Clinical diagnosis

Clinical assessment and diagnoses are more focused on identifying sensory abnormality, differentiating neuropathic pain vs. nociceptive pain. In myofascial pain, the pattern is mixed. The characteristic pain description is a combination of A delta and C fiber stimulation — i.e., aching, throbbing, burning and sharp pain — in a localized to diffuse manner, depending on the stage of the disease.

Localized tenderness appears during ‘early chronic stage’, identified clinically as trigger points. In ‘late chronic stage,’ diffuse pain (similar to fibromyalgia) is

changes underlying the evolution of acute to chronic pain with central sensitization are: 1. A delta and C fiber stimulation gives way to

predominantly C fiber firing

2. Nociceptive-specific (e.g., aching, throbbing) pain descriptions yield to mixed neuropathic/nociceptive pain (e.g., burning, aching, pins and needle sensation) descriptions

3. Localized pain becomes diffuse

4. Primary hyperalgesia (pain along the site of injury) is overshadowed by secondary hyperalgesia and/or allodynia

5. Peripheral excitability becomes less important than central neuronal excitability

6. Cortical to limbic sensitization


more common. In addition, limbic sensitization, i.e., depression, anxiety and sleep disruption, is present. Innate biological and environmental factors may play a role in the severity of the disease.

All diagnostic tests usually are negative, unless there are underlying secondary causes of pain.

Treatment

A multimodal approach seems to be the most effec-tive treatment to help reduce the pain. This includes physical treatment (e.g., exercise and modalities) and pharmacological treatment (membrane stabilizers like gabapentin and pregabalin; antidepressants like venlafaxin, duloxetine, amitriptyline and maprotiline and NSAIDs.

Spinal cord stimulators (SCS) can be used as an alter-native treatment for patients with intractable pain from failed back surgery syndrome, CRPS, peripher-al neuropathy and even peripheral vascular disease. In addition to SCS, intrathecal pumps also are used for chronic nonmalignant pain (see article on page 6). It is known to be efficacious in cases where noci-ceptive pain is the primary mechanism.

Interdisciplinary chronic pain rehabilitation is a more comprehensive approach in treating chronic pain with significant depression (see article on page 12). This treatment entails a multidisciplinary approach from behavioral, physical and medication management. The goal is to teach patients to achieve control of their pain through various physical and behavioral modalities. This paradigm appears to be the most efficacious treatment for chronic pain.

Overall, with the proper approach and good patient selection, pain and functional improvement can be achieved with the use of these treatment modalities.

Edwin Capulong, MD, is a physical medicine and

rehabilitation specialist with Cleveland Clinic’s Center

for Spine Health. He utilizes interventional spine

procedures, including radiofrequency ablation, and

specializes in peripheral joint injections and acupuncture

for musculoskeletal pain.

figure 2: hyperalgesia

DORSAL HORN

Spinothalamic Tract

Thalamus

Cortex

DRG

A delta C fiber

Glutamate receptor stimulation

Neuronal repetitive firing

Wind up

Hyperalgesia

figure 1: pain pathway

DORSAL HORN

Spinothalamic Tract

Thalamus

Cortex

Limbic System Frontal Lobe

DRG

Efferent-Inhibitory Pathway

Afferent-Excitatory Pathway

ne/5ht

Peripheral nociceptors

substance p glutamate receptor stimulation

cgrp, vip, endorphin, aa, glutamates


surgical Management for chronic spinal pain By Andre Machado, MD, PhD

chronic (benign) pain of spinal origin includes several diagnoses: low back pain, neck pain, chronic

radiculopathy and pain modified by surgery or maintained after surgical interventions (post laminectomy

syndrome or failed back surgery syndrome). Most americans will have an episode of low back pain at

least once in their lifetime. Fortunately, most episodes of low back pain, with or without associated leg

pain, are self-limited and will resolve spontaneously or with a number of self-prescribed treatments such

as rest or over-the-counter medications. Medical attention usually is sought when the pain becomes

persistent or frequently recurrent.

Andre Machado, MD, PhD

Dr. Machado can be contacted at 216.444.4270 or [email protected].

In practice, it is common to treat the first episode(s) of low back pain with symptomatic medications with no or minimal diagnostic work-up. The options for diagnostic studies and treatment modalities for those with chronic pain are numerous and indirectly indi-cate that no single method or treatment is excellent or universally preferred. A few of the treatment alterna-tives include various pharmacological combinations, physical therapy, minimally invasive fluoroscopy-guided analgesic or steroid blocks (i.e., epidural blocks), pain rehabilitation programs, psychological pain coping techniques, biofeedback, transcutaneous electrical nerve stimulation, chiropractic techniques, massage therapy and acupuncture.

Patients with severe or refractory pain often are evaluated as potential surgical candidates. Even then, a number of approaches can be considered includ-ing posterior approaches with or without hardware instrumentation, anterior approaches for interbody fusion or implantation of modern devices such as artificial disks.

Failed back surgery syndrome (FBSS) is defined as persistent or recurrent pain after spinal surgery (see figure 1). This represents a subpopulation of patients who not only suffer from low back pain, but who also have failed medical and surgical treatment. Spinal cord stimulation (SCS) or implantation of pump sys-tems for the chronic infusion of narcotic agents are valid alternatives for the long-term management of failed back surgery syndrome, along with several non-invasive therapies. Patients experiencing persistent chronic pain after major surgical interventions may suffer from significant overlay of psychological prob-lems and sometimes personality disorders. Formal evaluation by an experienced psychologist, therefore, can be very helpful in identifying the best candidates for additional intervention.

Spinal cord stimulation

Candidates for spinal cord stimulation usually first undergo a percutaneous trial with an external pulse generator for four to seven days. The stimulation is programmed so that the patient feels paresthesias (resulting from activation of the large diameter fiber pathways) over the area of pain. Patients who have sus-tained relief of at least 50 percent of the pain are con-sidered candidates for internalization of the system.

The permanent SCS system can be implanted with ei-ther a percutaneous technique or through a laminec-tomy. Percutaneous electrodes are implanted with the patient under sedation and local anesthesia. Once the electrodes are anchored in the correct place, connec-tion to the implantable pulse generator can be per-formed either under sedation or general anesthesia.

Laminectomies can be used for implantation of plate (paddle) electrodes, either under epidural or general anesthesia. Although more invasive, this technique al-lows for the implantation of electrodes that are more stable and for proper fixation to the spinal elements, thus decreasing the odds of late migration and conse-quent loss of efficacy. Laminectomy has been associ-ated with better long-term outcomes for patients with FBSS when compared with percutaneous implants.

In the majority of patients, plate electrodes can be im-planted through “mini” laminectomies that require the resection of the yellow ligament and small por-tions of the lamina without the need for a complete laminectomy. This technique also is used frequently at Cleveland Clinic for replacing previously implanted percutaneous electrodes that failed due to technical complications such as hardware failure or loss of ef-ficacy due to electrode migration.


Implantation of intrathecal pumps

Intrathecal opioid infusion with implantable and programmable pumps is an effective form of pain control in selected patients. The direct delivery of the opioids translates to the employment of smaller doses of medication and results in fewer side effects than systemic delivery.

The implantation of a drug infusion system gener-ally is done in two stages. A screening is done, first by administering intraspinal morphine via a lumbar puncture or percutaneous catheter, either by bolus injection or continuous infusion. The response is considered positive if the patient reports at least a 50 percent reduction in pain with tolerable adverse ef-fects. The patient then is selected for implantation of a drug delivery system.

The catheter and pump generally are implanted under general anesthesia. The appropriate intraspinous interval is identified via fluoroscopy and the catheter is placed and anchored to the underlying fascia. The pump is implanted in a created abdominal subcu-taneous pocket and the catheter is tunneled to the pump pocket and connected to the pump, which is placed and secured in the pocket. An external pro-grammer can communicate with the pump to change parameters to fine-tune the pain control.

Multidisciplinary management leads to best outcomes

In today’s specialized medical environment, it is com-mon to use multidisciplinary approaches to complex medical problems. The multifactorial and often elusive etiology, the multiple treatment options and the interplay of social and psychological issues makes chronic pain of spinal origin an ideal condition for multidisciplinary evaluation and treatment planning. At Cleveland Clinic’s Neurological Institute, patients with challenging chronic pain conditions and those who have failed standard therapies often are evalu-ated by spine surgeons, functional neurosurgeons, medical spine experts and pain psychologists before a decision is made on the course of treatment. This al-lows for tailoring treatments for the individual’s con-dition, co-morbidities, expectations and occupation, regardless of the training background of individual professionals. The goal of this multidisciplinary interaction is to help select the options that are more likely to enhance long-term quality of life while con-trolling for the risks. Although medical management is always preferred first, surgical procedures often are advantageous options for the most refractory cases.

Andre Machado, MD, PhD, is a staff neurosurgeon with

Cleveland Clinic’s Center for Neurological Restoration.

He specializes in deep brain stimulation for Parkinson’s

disease and movement disorders, and the surgical treat-

ment of medically refractory pain and spasticity.

Figure 1: This patient presented with significant chronic neck pain. A CT and X-ray demonstrate prior fusion surgery (note plate), disc herniation at C3-4 (which is a consequence of the prior fusion surgery) and a previously inserted spinal stimulator. The patient has a history of multiple prior operations, including the stimulator, as well as evidence of a new problem that is of clinical significance (C3-4 disc herniation).


Although the prevalence of addictive disorder in CNMP is disputed, and most studies are of poor quality, active addiction is present in about one-fourth of chronic pain patients in rehabilitation hospitals and more than 30 percent in pain clinic patients. An additional 9 percent may have addiction in remission.1-3 Present ad-dictive disorder tends to magnify complaints, impede diagnosis and confound interventions. Nevertheless, these patients can be treated successfully, and they commonly demonstrate the same gratitude for their recovery as do addicted persons in whom pain is not a factor.

Diagnosing addiction in those with CNMP poses spe-cial challenges. Two of the major diagnostic criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), tolerance and physical dependence, are virtu-ally universal in chronic opioid therapy and do not distinguish the person with addictive disorder. Since opioids and benzodiazepines are nontoxic (except in overdose), the physical sequelae of alcohol and illicit drug use are typically absent. The medically addicted person is unlikely to experience medical consequenc-es beyond sedation and constipation. Continued use despite adverse consequences, a major clue in addiction to recreational substances, is less obvious in addiction to prescribed drugs, since such conse-quences as irritability, drowsiness, poor concentra-tion, regression, reduced libido and economic losses can be attributed to pain.

Diagnosis

Diagnosis also is hindered by the lack of consensus as to what constitutes appropriate use. It is now ac-cepted practice to prescribe doses of opioids that were unheard of only a few years ago, and it can be unclear whether they are an asset or liability. An illusion of benefit results when patients are unable to detect the cumulative deleterious effect of a medication when each dose reduces pain — peak serum levels are more comfortable than trough levels. Families who witness

addressing pain and addictionBy Edward C. Covington, MD

unwanted drug effects may believe them to be un-avoidable and preferable to unrelieved suffering. Such patients, their families and their physicians often are surprised at the reduction in pain and suffering that can occur after gradual elimination of the drug.

Clues to the presence of addiction in pain patients include frequent intoxication, mood changes, inat-tention to hygiene, inappropriate behaviors and impaired coordination. Another indicator is provided when, despite generous analgesia, sick role behavior remains disproportionate to pathology. The patient who uses analgesics in a non-addictive fashion, in contrast, is likely to have improved function. Combin-ing other intoxicants with prescription drugs is an obvious clue. Urine toxicology facilitates the diag-nosis of substance use disorder; however, it must be remembered that typical “dip stick” (immunoassay) technology does not identify synthetics or semisyn-thetics and gas chromatography-mass spectrometry may be needed. State electronic prescription moni-toring programs (e.g., Ohio Automated Rx Reporting System) can help identify multi-sourcing.

Loss of control may be shown when patients who are incapable of rationing themselves use a month’s supply in a few days, despite knowing they will have increased pain and withdrawal symptoms when their supply is depleted. Additional signs include multi-sourcing and family/physician concern about their medication consumption. Usually a patient who has no history of alcohol or drug abuse, who becomes physically dependent on benzodiazepines or anal-gesics in the course of pain treatment, who obtains the drugs legitimately, and who has not been drug impaired is not addicted. That is, the fact that chronic, high-dose opioids are ineffective does not confirm the presence of an addictive disorder.

of the problems that beset patients with chronic non-malignant pain (cnMp), perhaps none is more insidi-

ous and difficult to manage than addiction. Although it is more difficult to diagnose in the presence of

cnMp, its treatment is essential, since addiction recovery seems to be a sine qua non for pain recovery.

Edward C. Covington, MD

Dr. Covington can be contacted at 216.444.5964 or [email protected].


Management

Conceptually, there are two issues — the treatment of addiction in pain patients, and the treatment of pain in people with addiction disorder. There seems to be no data as to which treatment should be first, but experience suggests that the pain patient who has an addiction to cocaine, marijuana or alcohol often responds to traditional addiction care in a setting appropriate to the severity of the disease. In contrast, the person who has become iatrogenically addicted (and perhaps the person who has an “iatrogenic relapse” after a period of sobriety) seems to respond better if treatment is initiated in a pain treatment program. Acceptance of the diagnosis is facilitated when patients can interact with peers who also have developed addiction “through no fault of their own” and without engaging in antisocial behaviors.

The treatment of pain in patients with comorbid addiction raises the question of whether to use opi-oids and, if so, how to protect the person’s sobriety. Although it is considered unethical to withhold opioid analgesia from addicts, patients should not be given useless or harmful treatments. A patient’s former drug of choice has the strongest potential to trigger relapse, which may explain the clinical impression that opioid therapy with recovering alcoholics is often more successful than is the case with recovering opi-oid addicts. Nevertheless, because of cross addiction, a patient with any prior addiction is at heightened risk for new addiction, even to unrelated substances.

Appropriate treatment of comorbid pain and addic-tion remains controversial and there is little data on which to base therapy. We must rely on “clinical wisdom,” while remembering how often it has proved wrong when data has become available.

Opioid treatment

A 1991 survey of state medical board members found that 58 percent considered it a probable violation of regulations to prescribe opioids for CNMP in a person with a history of opioid abuse.4 A subsequent survey demonstrated a liberalization of this attitude;5 however, many remain reluctant to prescribe opioids to those with substance abuse disorders. Studies of chronic opioid therapy in patients with addictive disorder are small and uncontrolled.6-8 They suggest that those who abuse medications tend to do so early. Those who do not were likely to be in AA, to have

stable support systems, and not to be recent polysub-stance abusers. Strict controls and accountability and perhaps avoidance of prn “breakthrough” drugs may be important strategies. It is reasonable to conclude that chronic opioid analgesic therapy can help some patients with CNMP if managed meticulously, but the risk-to-benefit ratio is clearly less favorable than in those without addiction. Ensuring adequate addiction treatment is essential to managing the patient with co-morbidity. See the table on page 10 for suggestions on treating the patient with chronic pain and addiction.9-11

Several strategies have been used to help opioid users remain in control. They should be asked to bring their prescription bottles to visits for pill counts. Some physicians call and request that patients bring in their prescriptions at random times, the idea being that the unpredictable oversight will help the patient to take the drugs as prescribed. Patients who cannot reliably ration themselves may handle multiple, small, dated prescriptions better. Patients may be required to return used trans dermal patches in order to receive a prescription for new patches, thereby demonstrat-ing that they were neither sold, opened nor cut into pieces. Intrathecal analgesia is somewhat appealing as a strategy for providing opioid therapy to patients who have difficulty controlling their use. Although this route of administration seems resistant to abuse, resourceful addicts have been able to defeat it.

Clues to the presence of addiction in

pain patients include frequent intoxication,

mood changes, inattention to hygiene,

inappropriate behaviors and impaired

coordination.


Additional medications

Comorbid psychiatric symptoms are the rule in pain

and addictive disorder, and their management also

should be conducted with an eye to protecting sobriety.

There seems little justification for prescribing con-

trolled substances for anxiety, “muscle spasm” and in-

somnia, since nonaddicting alternatives abound. Most

antidepressants have anxiolytic properties and are not

subject to abuse. This is equally true of the antiepilep-

tic drugs (AEDs) commonly used in pain treatment.

Most so-called muscle relaxants are not habituating,

with the exception of carisoprodol, which has no role

in the addicted patient. When needed, drugs from both

categories (antidepressants and AEDs) that have seda-

tive properties can be selected to minimize polyphar-

macy and unnecessary exposure of vulnerable patients

to addicting substances.

Non-opioid treatments

Many patients with chronic pain are more comfort-able and functional without opioids. Lacking accurate predictors, we are limited to therapeutic trials to as-certain which patients will show improved pain, func-tion and mood. Here at Cleveland Clinic, we studied 527 patients treated in a pain rehabilitation program (physical reconditioning, cognitive behavioral thera-pies, and aggressive use of antidepressants and AEDs), one third of whom had comorbid addiction.12 Opioids and benzodiazepines were weaned. While those with addiction were twice as likely to drop out of treatment

treating the patient with chronic pain and addiction

• Avoid addicting agents if pain can be managed with NSAIDs, antiepileptics, antidepressants or topicals

• If opioids are required, use only slow-onset, long-acting preparations to minimize euphori-genic effects

• Regularly document the “4 As” to demonstrate benefit and safety of treatment:

analgesia (0-10 scale)

activity level (pain disability index, sheehan disability scale)

adverse effects (sedation, concentration, constipation)

aberrant behavior (multi-sourcing, running out early, stolen/lost prescriptions)

• Stop opioids if they are ineffective, harmful or diverted. Indefinite prolongation of failed treatment is high risk.

• Address the belief that chronic opioids can eliminate chronic pain. At best they reduce it.

• Require an “opioid contract”

• Document informed consent, including the risk of addiction

• Educate patients about toler ance, withdrawal and drug interactions

• Optimize adjunctive medications and nonphar-macologic strategies, e.g., physical condition-ing, coping skills and lifestyle modifications

• Address psychiatric symptoms

• Include families in treatment

• Obtain random urine testing

• Require addiction treatment as a condition of receiving opioids

• Titrate opioids to maximum comfort, function; expect only slow escalation over time

• Re-evaluate for addictive disease if drug seeking persists

• Do not replace lost medication

• Treat relapse, don’t abandon the patient

It is now accepted practice to prescribe

doses of opioids that were unheard of only

a few years ago, and it can be unclear

whether they are an asset or liability.


R EF E R E NC E S

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2. Moore RD, Bone LR, Geller G, et al. Prevalence, detection, and treatment of alcoholism in hospitalized patients. JAMA. 1989;261:403-407.

3. Smothers BA, Yahr, HT. Alcohol use disorder and illicit drug use in admissions to general hospitals in the United States. Am J Addict. 2005;14:256-267.

4. Joranson DE, Cleeland CS, Weissman DE, et al. Opioids for chronic cancer and non-cancer pain: a survey of state medical board members. Fed Bull. 1992;79(4):15-49.

5. Gilson AM, Joranson DE. Controlled substances and pain man-agement: changes in knowledge and attitudes of state medical regulators. J Pain Symptom Manage. 2001;21(3):227-237.

6. Dunbar, MB, Katz NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. J Pain Symptom Manage. 1996;11(3):163-171.

7. Kennedy JA, Crowley TJ. Chronic pain and substance abuse: A pilot study of opioid maintenance. J Subst Abuse Treat. 1990;7:233-238.

8. Currie SR, Hodgins DC, Crabtree A, Jacobi J, Armstrong S. Outcome from integrated pain management treatment for recovering substance abusers. J Pain. 2003;4(2):91-100.

9. Miotto K, Compton P, Ling W, et al. Diag nosing addictive dis-ease in chronic pain patients. Psychosomatics. 1996;37:223–235.

10. Passik SD, Kirsh KL: Opioid therapy in patients with a history of substance abuse. CNS Drugs. 2004;18(1):13-25.

11. Covington, EC. Pain and addictive disorder: challenge and opportunity. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE (eds). Raj’s Practical Management of Pain, 4th Edition, Elsevier/Mosby. Philadelphia. 793-808.

12. Scheman J, Van Keuren C, Smith S, et al. Treatment response to chronic pain rehabilitation program among those with an active addictive disorder. Presented at: The 6th International Conference on Pain and Chemical Dependency; February 7, 2004; Brooklyn, N.Y.

(31 percent vs. 16 percent) as those without, their outcome was equally good when they completed treatment. Mean pain decreased by 40 percent, mean Beck Depression Inventory decreased from severely depressed to normal, and mean Pain Disability Index decreased from markedly to mildly impaired. This suggests a viable option to treating patients with ad-dictive disorder who respond poorly to opioids.

Physician protection

Addicts may seek compensation from physicians who they claim caused their addiction. Iatrogenic addic-tion, albeit uncommon, does occur and may consti-tute a compensable injury. A greater risk, however, is that a patient who had a pre-existing addiction may falsely believe or claim that the physician caused it. Risk of litigation and sanctions can be minimized by:

a) obtaining written informed consent that notes the risk of addiction

b) meticulously documenting prior addiction

c) carefully documenting unambiguous benefit from opioids (as independently confirmed by family)

d) weaning when benefit is unclear

e) monitoring for development of aberrant behaviors

f) requiring addiction assessment/treatment as a condition of further opioid prescribing should they appear

Edward C. Covington, MD, is a pain specialist and the

Director of the Cleveland Clinic Neurological Institute’s

Center for Pain. His specialty interests are chronic pain

and pain management.

Many patients with chronic pain are more

comfortable and functional without opioids.


What is Left When Medication and Interventions Have FailedBy Judith Scheman, PhD

Your patient has persistent spine pain. she is not a surgical candidate; no one wants to do the seventh

surgery. You have recommended physical therapy, and the patient reports no benefit or, worse yet, that

it increased her pain. You have tried a variety of medications, from nsaids to opioids to antidepressants

and maybe even anticonvulsants, all with little to no benefit. The opioids “take the edge off.” Epidural

steroid injections and spinal cord stimulation have not helped. You are at the point where you want to

say, “There is nothing more that I can do to help you,” or “It is all in your head.” These, we are told, are

the things they least want to hear from their doctor. Try instead, “I know just what to recommend …”

Judith Scheman, PhD Guest Medical Editor

Dr. Scheman can be contacted at 216.444.2875 or [email protected].

Use the screening tools introduced in the article on page 2 of this issue. With these, you can point out to them that you are aware how significantly depressed and anxious they feel; that they have a lessened qual-ity of life; that their functioning is severely impaired; and clearly they are indeed suffering and you want to help. When pain has such an overarching effect, it takes a team of professionals to help. These patients with chronic pain may require a comprehensive, interdisciplinary approach to their rehabilitation in a chronic pain rehabilitation program.

Interdisciplinary chronic pain rehabilitation pro-grams are designed to help patients with disabling chronic pain get their lives back. Interdisciplinary (as opposed to multiple disciplines working separately) is a team approach where all the members of the team, including the patient, work together towards common goals. Disciplines include physical therapy, occupational therapy, nursing, psychology, medicine and vocational rehabilitation, as well as chemical dependency counseling when needed. Most programs are intensive, and three to four-weeks long. Cleveland Clinic’s program includes day-long schedules with:

• activephysicaltherapyandreconditioning

• occupationaltherapywithanemphasisonbodymechanics

• groupandindividualpsychotherapy

• cognitivebehavioraltherapy

• psychophysiologicalpainandstressmanagement

• medicationmanagement

Some programs, including ours at Cleveland Clinic, incorporate a weaning off of all habituating substanc-es. When vocational and addiction needs are identi-fied, these services also can be offered as part of the holistic approach to rehabilitation.

Persistent, debilitating chronic pain is a multifacto-rial problem that does not lend itself well to a single modality solution. Therefore, the necessary approach is one that can address the profound physical decon-ditioning that usually accompanies the persistent pain, mood and sleep disorders and other psychoso-cial factors such as job loss and addiction.

The bad news is that, despite the fact that interdisci-plinary chronic pain rehabilitation programs have proven to be both efficacious and cost effective, they are becoming increasingly hard to find. Cleveland Clinic’s Chronic Pain Program is one of the few re-maining of its kind in the country.

Judith Scheman, PhD, is Program Director of the Chronic

Pain Rehabilitation Program at Cleveland Clinic.


Who Do I Refer to a chronic pain program?

A careful medical evaluation should be conducted first to ensure a correct diagnosis including some possibly overlooked, non-spinal cause, including:

• Musculoskeletal

shoulder periarthritis

osteoarthritis of the hip

trochanteric bursitis (greater trochanteric pain syndrome)

piriformis syndrome

• Medical

Malignancy

polymyalgia rheumatica (pMr)

diabetic polyradiculopathy

ankylosing spondylitis

Fibromyalgia

endometriosis

The other aspect of the evaluation is to ensure that the prior treatment hasn’t been excessively passive, e.g., “go to bed for a month.” Once these have been ruled out, other signs to refer a patient include:

• Apparent disparity between structural spinal “disease” and one or more of the following:

pain level

functional impairment

medication requirement

• Presence of red flags, including:

every treatment approach (including multiple surgeries) has failed or made things worse

Coexisting significant depression

disabled spouse

Asking for specific drugs

“No one tells me what is wrong” — after many different physician contacts

extreme somatic focus/obsession with pain — pages of written notes detailing symptoms

prior history of substance abuse

november 5-7, 2008

11th Annual Neuroscience Nursing Symposium

Course Director: Kimberly Hunter

Hilton Garden Inn Hotel, Downtown Cleveland

Cleveland, Ohio

February 20-22, 2009

3rd Annual International Symposium on Stereotactic Body

Radiation Therapy and Stereotactic Radiosurgery

Course Directors: Lilyana Angelov, MD, Gene Barnett, MD,

Edward Benzel, MD, Sam Chao, MD, and John Suh, MD

The Grand Floridian Resort and Spa

Lake Buena Vista, Fla.

Contact Martha Tobin at 216.445.3449 or

800.223.2273, ext. 53449, or at [email protected]

for seminar details.

upcoMing

symposia


Cleveland Clinic

9500 euclid Ave.

Cleveland, ohio 44195

216.444.BACK (2225)

Independence Family Health Center

5001 rockside road

Independence, ohio 44131

216.986.4000

Lutheran Hospital

1730 West 25th St.

Cleveland, ohio 44113

216.363.2410

Solon Family Health Center

29800 Bainbridge road

Solon, ohio 44139

440.519.6800

Strongsville Family Health and Surgery Center

16761 SouthPark Center

Strongsville, ohio 44136

440.878.2500

Westlake Family Health Center

30033 Clemens road

Westlake, ohio 44145

440.899.5555

Willoughby Hills Family Health Center

2570 SoM Center road

Willoughby hills, ohio 44094

440.943.2500

Prospective outcomes evaluation of decompression with or without instrumented fusion for lumbar stenosis with degenerative grade I spondylolisthesis

edward Benzel, Md 216.445.5514

Randomized, controlled trial of Duragen plus adhesion barrier matrix to minimize adhesions following lumbar discectomy


An assessment of P-15 bone putty in anterior cervical fusion with instrumentation

iain Kalfas, Md 216.444.9064

OP-1 putty

Michael steinmetz, Md 216.445.4633

A prospective, multicenter, randomized controlled study to compare the spinal sealant as an adjunct to sutured dural repair with standard of care methods during spinal surgery

ajit Krishnaney, Md 216.445.3777

CSM study


The effectiveness of physical therapy for patients with lumbar spinal stenosis

daniel Mazanec, Md 216.444.6191

Locations Clinical Trials

cleveland clinic center For spine health

cleveland clinic center For spine health


Co-editor:

edward C. Benzel, MD

Director, Cleveland Clinic Center for Spine health

Co-editor:

Daniel J. Mazanec, MD, fACP

Associate Director, Cleveland Clinic Center for Spine health head, Section of Spine Medicine

Guest Medical editor:

Judith Scheman, PhD

Marketing:

Colleen Burke

Managing editor:

Christine Coolick

Art Director:

Anne Drago

Spinal Column is published by Cleveland

Clinic’s Center for Spine health to provide

up-to-date information about the center’s

research and services. The information

contained in this publication is for research

purposes only and should not be relied upon

as medical advice. It has not been designed

to replace a physician’s independent medical

judgment about the appropriateness or risks

of a procedure for a given patient.

Spinal ColumnfALL 2008

innovative new

buildings improve patient

access, experience.

the cleveland clinic Foundation Spinal Column 9500 euclid avenue / ac311 cleveland, oh 44195

For referrals to cleveland clinic’s center for spine health, call 216.444.2225

spinal coluMn | Fall 2008 | chronic pain

this fall, cleveland clinic is introducing the future of healthcare with the opening of the sydell and arnold Miller Family pavilion and the glickman tower.

these buildings, which represent the largest construction and philanthropy project in cleveland clinic history, embody the pioneering spirit and commitment to quality that define Cleveland Clinic. These structures are a tangible expression of institutes, our new model of care that organizes patient services by organ and disease.

at 1 million square feet, the Miller Family pavilion is the country’s largest single-use facility for heart and vascular care. the 12-story glickman tower, new home to the glickman urological & Kidney institute, is the tallest building on cleveland clinic’s main campus. Both will help us improve patient experience by increasing our capacity and by consolidating services, so patients can stay in one location for their care.

With 278 private patient rooms, more than 90 ICU beds and a combined total of nearly 200 exam rooms and more than 90 procedure rooms, patients will have faster access to cleveland clinic cardiac and urological services.

For details, including a virtual tour, please visit meetthebuildings.com.

i n t r o d u c i n g

the Future oF healthcare

08-neu-004

FALL 2008 Spinal Column · found myself in situations that made me so anxious I was most relieved...

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