UCSD’s Mark Wallace wants to educate physicians that treating pain is ‘no different than treating high blood pressure or diabetes.’ (photo/alandeckerphoto.com)

Pain. We’ve all had it and we’ve all dealt with it. But at what point does it move from a nagging irritation to something needing a doctor’s care, and how aggressively should pain be managed?

Primary care doctors report pain as the top reason patients seek their care. It also can be one of the most difficult things for a doctor to treat. Patients in pain can be difficult to deal with and the regulatory restrictions on prescribing pain medications make it risky for doctors to prescribe too much or too little.

“For a long time pain was looked at as a psychiatric problem,” says Dr. Mark Wallace, head of UCSD’s Pain Clinic at Thornton Hospital. “It was never taken seriously in medical schools, never really taught in medical schools, but it has always been the No. 1 reason patients seek health care. Because primary care doctors were never trained in pain management, it was pushed aside. Doctors would treat underlying disease. Over time, pain has been viewed as a symptom of a chronic illness.”

Physicians are taught to diagnose and treat. “However, as medical doctors we spend 90 percent of our time treating symptoms of underlying conditions that can’t be cured,” Wallace says. “Pain is not a diagnosis. It is a symptom of something being wrong. Many of these patients don’t have diagnosis, they just have pain. Now we are trying to teach the physicians to view pain as a symptom of a chronic illness. It would be no different than treating high blood pressure or diabetes.”

Wallace says measuring and treating pain should be a general part of health maintenance and this practice is starting to come along. “The community is starting to view it as a major health care problem,” he says. “However, the biggest barrier is the fear of the medical board coming after (physicians) for giving out too much pain medication.”

Many Dimensions Of Pain

Most patients with pain who come to San Diego Hospice will have relief within 48 hours, says Charles F. Von Gunten.

Pain management practices vary greatly, but programs throughout San Diego are working to help doctors, nurses and hospitals around the county improve their treatment approaches.

“Pain is multidimensional,” says Dr. Charles F. von Gunten, provost and vice president for the center for Palliative Studies at San Diego Hospice. “It has physical, emotional, practical and spiritual dimensions.” In response, hospice programs have developed effective approaches to relieve pain for patients with a terminal illness. “For patients who are admitted to San Diego Hospice and Palliative Care, we can control the patient’s pain to their satisfaction within 48 hours of admission in nearly 100 percent of cases,” von Gunten says. Does that mean patients are drugged beyond feeling to make them comfortable? Definitely not, von Gunten assures. Not just medication but counseling, solving practical issues and dealing with the spiritual person all lead to pain reduction.

In addition to providing care to patients with a prognosis of less than six months, hospice provides pain consultation to hospitalized patients who expected to recover. “It should be evident that you shouldn’t have to be terminally ill to get good pain management,” von Gunten says. “A recent effort has been made to disseminate what we have learned about relieving pain to the rest of the health care system.” San Diego Hospice has education programs for more than 1,300 health professionals each year, which includes UCSD medical students and physician residents from nine training programs in San Diego. “We also conduct research so that our ability to relieve pain and improve quality of life continues to improve,” von Gunten says.

Fitting Patients With Treatment

UCSD operates the Center For Pain Medicine, a multidisciplinary group that provides patients with medical management, electrical stimulation, physical therapy, acupuncture, psychologists and interventional therapy like spine injections and steroids. “There are different components to pain management,” Wallace says. “There is no one treatment that is the mother lode. Patients do better when you combine different modalities. We tailor the treatment to the patient rather than the masses.”

Operating within a closed system, UCSD’s primary care doctors consult with in-house pain specialists when treating a patient. Physicians and specialists must work together to relieve the patient’s pain. “I would like nothing more than to take care of every single chronic pain patient in San Diego,” Wallace says. “But I can’t. There are too many of them and not enough hours in a day. Primary care doctors send patients to Wallace for a consultation. Wallace then informs the doctor of treatment options and allows the doctors to do ongoing management. He gets involved again only if the patient gets off track or needs another consultation.

In addition to multidisciplinary clinical care, UCSD provides research and teaching opportunities. Wallace is a professor of clinical anesthesiology. He says 25 years ago, there was no such thing as a pain fellowship. Today, UCSD offers an American Council on Graduate Medical Education accredited fellowship. Students go through medical school, complete residency and then complete a fellowship training program in pain management. The program teaches how to treat patients from head to toe: from headache to the most chronic pain. The most common pain is back pain. The pain management specialty is one of the newest subspecialties in medicine. California is now requiring doctors get 12 hours of educational credits in pain management to maintain their medical licenses.

Monitoring Prescription Drug Risks

Dr. Joseph Shurman

When treating pain with medication, doctors have to take into account situations where chronic pain patients become addicted or misuse their prescriptions. When taken exactly as prescribed, opioids are safe, effective and rarely cause addiction, says Dr. Joseph Shurman, chairman of Pain Management at Scripps Memorial Hospital La Jolla. However, with all the national attention about the misuse of these drugs, including that of radio talk show host Rush Limbaugh, physicians are now less inclined to take on medicated pain patients or prescribe opioids. This has made it difficult for patients to get the care they need. In response, a pain management model is in place at Scripps La Jolla to protect patients and physicians.

Called Share the Risk, this program is for patients where little outside of prescription medication can lessen pain. Patients begin with a visit to an addictionologist to assess any genetic predisposition to addiction. Every patient sees a psychotherapist for the risk of depression and potential of suicide. Cognitive testing for driving under medication is done. To keep on top of prescription treatment, Shurman says, the San Diego medical community meets every few months to bring all the medical specialists together and assess ongoing changes. “Things are getting better as people are working together,” Shurman says. “We also use other devices to get people to use less drugs and have less surgeries.”

That’s where the Scripps center comes in. Surgeries, injections and medications don’t work in every case so the Center for Integrative Medicine is widening the scope of available treatment. Mind-body approaches, acupuncture, biofeedback and massage can all make a tremendous difference, as long as doctors start to think about them as options, says Robert A. Bonakdar, director of integrative pain services and a member of the Scripps Green Hospital Pain Management Committee.

Patient programs include a 12-week umbrella course with information on diet, exercise, spirituality and group support. And two eight-week sub-programs provide pain management essentials through mindful stress reduction. These are active pain treatment programs that provide patients with tools for their own use. “For every pain patient,” Bonakdar says, “it is important to determine how big their toolbox is to deal with the pain.” Even with all the medicine and procedures out there, these programs are important in teaching patients how to cope actively from day to day.

Coping With The Unseen

Robert A. Bonakdar

Pain is not visible. It does not show up on an X-ray and is challenging to measure. Treating it requires trust between doctor and patient. “People are living longer,” says Dr. Cheryl Wright, who heads a pain management program at Sharp and sits on the board for Sharp Rees-Stealy Pain Recovery Program. “Everything that is involved in pain starts wearing out sooner rather than later. We, especially in America, are an instant-gratification nation. And that’s unfortunate because pain doesn’t go away immediately. It is a process.” To get people through that process, which usually takes four to six weeks, Wright suggests physical therapy, stretching and medication.

The outpatient SRS Pain Recovery Program offers classes on coping with pain and stress reduction. “What we are trying to do is help people before they get to the chronic pain stage,” Wright says. That means identify patients while they are in physical therapy and get them involved in a pain recovery program before they have to rely on high-level medication. Wright says getting patients to therapy can be difficult because the last thing somebody suffering from pain wants to do is move.

“The coping with pain class is taught by a licensed psychologist and teaches patients how to understand pain, how to live a more normal life and how to manage pain,” she says. The clinic introduces the patient to a variety of ways to reduce stress: breathing, restorative yoga, biofeedback and things that take people’s minds off pain. “Our goal is to make the pain go away,” Wright says. “However, if people have chronic pain, often that is not possible. But we do have measures that we use before and after the person participates in these pain clinics to see if they can function better. If we can get them 50 (percent) to 100 percent better in regard to their pain management, then that is deemed a successful outcome.”

The program offers six weeks of group therapy for $100. “We found that when things aren’t free, they are worth more,” Wright says. And the group setting is more successful as doctors report seeing patients helping other patients. “It is not about the pills,” Wright says. “We can only do so much with medication.”

Focusing On The Aging Population

Dr. Bill H. McCarberg

Health care providers anticipate increasing numbers of older patients requiring intervention for pain management as the population continues to age. At Kaiser Permanente primary care providers are urged to learn more about pain management and care of the elderly. “Many advances have occurred to treat pain,” says Dr. Bill H. McCarberg, founder of Kaiser Permanente’s Chronic Pain Management Program. “The newest interventions, including disc replacement, Botox injections and advanced anesthesia, are available at our integrated facility at Kearny Mesa.”

Kaiser’s pain management clinic provides anesthesiology, physical medicine, pain psychiatry and physical therapy all at one place. Treating pain patients with the full range of available treatment options is the motto at Kaiser, McCarberg says, including the physical and emotional aspects. Patients are urged to take classes on biofeedback and coping strategies for pain management. Other treatments include chiropractic and acupuncture while the hospital’s online services include educational sites available to patients to learn about their disease.

Aging is inevitable and so it seems is an experience with chronic pain. “Our knowledge is growing so much,” von Gunten says. “We have new drugs and new combinations of therapies. Elements of care don’t change during the end of life. Quality of life becomes more important as you have less life.”