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Ouch
As America ages, an industry grows around pain management
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Business New Haven
12/22/2003
By: Melissa Nicefaro
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Pain is not just for old people.
Indeed, the majority of people with chronic (lasting six months or longer) pain are middle-aged.
Mark Thimineur, M.D. heads the Comprehensive Pain & Headache Center at Derby's Griffin Hospital, one of just a handful of such centers in Connecticut.
"A pain management center is typically a last stop for someone," Thimineur says.
The majority of patients at the Griffin Center are surprisingly young - between 20 and 65 - and many have experienced trauma such as a motor vehicle accident or a fall resulting in a head or a spinal injury. Many chronic pain patients have had multiple surgeries to their back or neck and are still navigating the long process of becoming pain-free.
Becoming pain-free can mean a perfect combination of treatments that may include therapy (physical and psychological), medication and surgical techniques. Pain treatment may mean peripheral nerve blocks and surgical techniques for implantation of pain-control devices.
Griffin's program integrates a number of treatment options and medical disciplines, and incorporates psychology, physical medicine and rehabilitation, as well as alternative therapies like stress reduction, yoga and meditation.
"It wouldn't be unusual to have a patient who has had five back surgeries and never got better," Thimineur explains. "There are young people with intractable pain and a lot of impairment, a lot of disability and they're having a hard time getting by with work or they're not working."
A study released in November by the Journal of American Medicine reports that American businesses are losing more than $60 billion annually to lost employee productivity. More often than not, these pained employees are showing up for work. The problem isn't absenteeism, but lack of productivity while on the job.
Getting to the root of the pain is a job that often lands in the hands of a pain-management doctor. These physicians work primarily through referrals, with patients coming from other doctors such as general practitioners and neurosurgeons.
Physicians who specialize in pain management typically deal with chronic pain, not acute or sub-acute problems. Thimineur notes that a minority of patients are sent to the Griffin Center early on: "For example, a patient with a disc herniation could have severe pain down the leg. An orthopedic doctor or neurosurgeon, or even a primary care, might send us a patient like that for a quick fix," he explains. "They are not a chronic pain patient, but will respond to a simple injection like a steroid injection."
These patients comprise a small percentage of pain patients and typically do not become chronic-pain patients.
About 60 percent of Thimineur's patients are female. "There is a decided difference [pathologically between the genders]," he says. "With women you see much more headache disorders, fibromyalgia and diffused chronic pain, chronic fatigue, temporomandibular joint syndrome (TMJ) and that kind of problem. Men are more strictly low-back pain, leg pain, and more focal in their pain. There are known gender differences in the way our brains and spinal cords work, and that's probably why we see this," Thimineur says.
Diagnosis can be difficult if pain doesn't stem from a trauma or other injury, so on occasion community doctors like internists and family practitioners will send patients on to a pain-management center without a diagnosis or cause for the nagging pain.
Many elderly people simply hurt. However, the age group of 65 and older represents only 20 percent of pain-center patients.
"Patients can be divided by age: There's an elderly population that basically has chronic pain because of age. That's often an arthritic condition," Thimineur explains. "Some older people are prone to post-herpetic neuralgia - the pain from shingles that never goes away. Elderly can have very arthritic spines and get spinal stenosis and can't walk or they simply have terrible knees."
"We get many consults from nursing homes for people like that," he adds. "These patients can no longer get by with Motrin or they might need something more potent. Sometimes the primary-care doctors don't want to bridge the gap between when a narcotic is appropriate [and when it is not]."
The introduction of narcotics to pain management can bestow a slew of new concerns to both doctors and patients. Drugs such as Oxycontin are highly efficacious in treating chronic pain, but are addictive - and very expensive. The most effective pain-killing drugs are for people with severe pain and are usually opioid-based medications, which are also the drugs with high abuse potential. Aside from patient addiction, these drugs can be diverted and sold.
Thimineur says that about five percent of all people in the general community have a potential for addiction based on genetics.
"We're constantly having to police that developing infrastructure in the practice to make sure we're not doing harm to anyone. If we have anyone who has a tendency to be addicted or has an addictive behavior, we can structure treatment around that. We also have to keep crime in mind as there are many people who want to get the drug, keep some of it and sell the rest. That's harder to police," he notes.
Insurance companies are eating the costs of high-priced prescription painkillers, but they are less apt to cover the psychological aspect of treatment, doctors say.
Griffin's program involves a psychological assessment and support to help the patient deal with pain and establish new ways of coping with daily activities, as well as managing relationships with work and family.
"On a very basic level, people with chronic pain have big changes in their lives, often leading to anxiety disorders, depression and family dysfunction," says Thimineur. "That's at a very basic level, and we have the ability to help with that.
"On another level, people with pain adopt behavior that is detrimental because of the pain," he adds. "It's not their fault, but they become different, their behaviors and attitudes can work against them. We try to offer them some behavioral management. It's not really get-inside-your-head sort of stuff, but teaching and education."
Thimineur says that psychology as a practice is under-funded by insurance companies. However, insurance companies generally cover a greater proportion of pain management than in recent years.
"But they're always going to be behind if they don't know what's appropriate to cover," he says. "There are many procedures, treatments and drugs that I think they have trouble understanding.
"Some of the things that don't make sense to the practitioners are they would cover any number of procedures, but they won't cover the psychology aspect. They look and see, 'This guy needs 50 visits; he's a wreck,' and he needs biofeedback and all these other psychologically driven treatments - but they won't cover it. Yet, if you want to do ten injections, they'll cover that.
"They're not really able to understand the long-term benefit of something that might look like it's more costly up front, but later it keeps people out of the emergency rooms and on lower doses of drugs, it keeps them off the antidepressants and other medications," Thimineur says.
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