North American Neuromodulation Society

Non-Addictive Treatment Options for Chronic Pain

Chronic pain is complex. Many patients will try a variety of treatments in their search for relief. Maybe you have tried several of the other treatments but still have disabling pain that limits your functional capacity. Or perhaps the other treatments you have tried, like high- dose medications, were associated with significant side effects that limited your function.

Neuromodulation is different because it’s not a medication nor invasive surgery. Instead, it’s a proven non-addictive treatment option for chronic pain. It works by stimulating a nerve or set of nerves using controlled electrical impulses to alleviate pain.

The complexity of different treatments and multitude of providers means that there is a great deal of variability in the level of training and quality of care. A patient, therefore, must become an active participant in his or her own care. The North American Neuromodulation Society (NANS) helps you understand the differences among providers so you can select the type of physician to best treat your particular pain condition. 

"A Drug-Free Approach to Manage Chronic Pain"

Watch here to see Joshua Prager, MD MS and his patient Andrea discuss how she handled her pain management with a spinal cord stimulator. After being hurt at work, Andrea was put on opioids, had surgeries, and tried countless doctors, but all the while could not find pain relief. After she received her SCS system, her pain subsided so significantly that she was able to sleep for the first time in seven years.

"Non-Addictive Treatment Options"

NANS president, B. Todd Sitzman, MD MPh and his patient Michael Lott highlighted how Michael handled pain management with SCS. Michael received an SCS system after seven years of relying on 90mg of opioid prescription painkillers a day. During the interview, Michael told the reporters that he finally feels like he’s back to living a normal life and enjoying his favorite pastimes. Listen here.

 

“Matter of Fact: State of Addiction”

This is a part of a national program hosted by Soledad O’Brien to inform local audiences of the opioid crisis and efforts to develop solutions. Please click here to view the full special  via the NBC Sacramento website featuring Dr. Snook.  

Neuromodulation Therapy

Excerpt from “Pain Wise” by DAVID KLOTH, M.D. ANDREA TRESCOT, M.D. FRANCIS RIEGLER, M.D.

Pain management is one of the most misunderstood specialties, and it means many different things to different people. No doubt your head is swimming with all the treatment options being thrown at you. With so many options to choose from, you are probably wondering what exactly “pain management” is. Pain management is a subspecialty of many different kinds of doctors. You can walk into the office of a doctor who promotes himself or herself as a pain management physician and see a psychiatrist, a physiatrist, a surgeon, an anesthesiologist, a chiropractor, an acupuncturist, or a variety of other physicians. In today’s world, all of these different types of physicians may call themselves pain management doctors, and so this won’t differentiate them from the more highly skilled and trained physicians who practice the subspecialty of interventional pain management (IPM). Interventional pain physicians are experts at diagnosing and then treating chronic pain conditions using precision-guided injections or minimally invasive therapies. The types of physicians that may perform interventional pain management most commonly include anesthesiologists and physiatrists, but interventional pain management treatments are also performed by many other specialists, including radiologists, neurologists, neurosurgeons, orthopedists, and general practitioners. In some areas, a nurse practitioner or a physician assistant may perform these procedures.

Introduction

The complexity of different treatments and multitude of providers means that there is a great deal of variability in the level of training and quality of care. A patient, therefore, must become an active participant in his or her own care. You must be knowledgeable about your choices. Finding a doctor who will meet your needs and expectations requires at least as much research as buying a car. You wouldn’t walk into a car dealership without knowing what kind of car you needed, what a reasonable price might be for that car, and what you should expect from your new vehicle. In the same way, you should walk into a pain management office knowing what type of doctor you’re seeing, what his or her qualifications are, and what type of treatment you can expect. It is important that you understand the differences among providers so you can select the type of physician to best treat your particular pain problem.

The authors of this book strongly believe that the practice of interventional pain management is the practice of medicine and must only be performed by properly trained physicians and never by an independently practicing nurse or physician assistant. Interventional pain management physicians require extensive training to become proficient; the procedures are complex and can be very risky if not performed properly, so it is necessary that the physician has the proper background and training. The advice offered in this text comes from physicians who are actively practicing interventional pain management doctors. Interventional pain management is a specialty that focuses on determining the cause of symptoms and applying treatment options to manage and alleviate chronic pain. We are not simply generic “pain management” doctors. Interventional pain management physicians have a specific skill set. We hope that this information will assist you in differentiating between the various interventional pain therapies and help guide you in both selecting a physician and learning about the various treatment options available today. We have tried to include the more common treatments used today, but by no means is this meant to represent all possible therapies that are available.

Finding a Doctor

There are a couple of ways to size up your doctor. First of all, don’t be afraid to ask questions. Here are some key criteria, listed in order of importance, to help you evaluate your physician:

  • Certification: Does the doctor hold a certificate in pain management from any board? You can go to the American Board of Medical Specialties (ABMS) website (www.abms.org) to see if your doctor is ABMS certified and if they hold a specialty certificate in pain management from an ABMS member board. ABA (American Board of Anesthesiology) added Qualifications in Pain Management is the only ABMS recognized exam although there are several others including the ABIPP (American Board of Interventional Pain Physicians), FIPP (Fellow of Interventional Pain Physicians – an international certification) and ABPM (American Board of Pain Medicine). ABIPP is the most rigorous exam and if you want to confirm that your doctor has an ABIPP certificate, check their website (www.abipp.org). Surgeons will typically be certified by their respective surgical societies and may have additional training and/or certification in pain and/or functional neurosurgery.
  • Training: Where did the doctor do his or her residency? In what specialty? Did he or she do a fellowship in pain management?
  • Level of involvement: Ideally, your doctor practices pain management or IPM full time or at least a majority of their time.
  • Credentials: Does your doctor have credentials at a local hospital or surgery center to practice interventional pain management? You can easily check with the hospital or local surgery center. Credentialing is different from board certification, but if a hospital or surgical center has granted the physician privileges, they have theoretically checked at least for basic competence.
  • Experience: How long has the doctor been practicing IPM—not just practicing medicine but practicing pain management in general and IPM in particular? Is his or her whole practice dedicated to pain management, or does he or she just dabble in the field? Given the complexity of this field, a true pain physician should dedicate at least 50% of their professional time to practicing pain management.
  • Society membership and meeting attendance: One of the ways that doctors stay current in their field is to attend meetings where they can learn and network with other doctors in their specialty. Because IPM is a rapidly changing field, it is critical for your doctor to stay current, and the societies and meetings are a good source of new information.
  • Peer recommendation: Your other physicians may be able to give you a referral to a physician who specializes in pain management. Unfortunately, this may be the least reliable method, because some referring physicians may not understand the differences in pain medicine training that we discussed earlier.

Implantable Techniques: Spinal Cord Stimulation, Spinal Drug Delivery System, Peripheral Nerve/ Field Stimulation

You and your doctor by now should have a pretty good understanding of what is causing your severe chronic pain. Maybe you have tried several of the other treatments but still have disabling pain that limits your functional capacity. Or perhaps the other treatments you have tried, like high- dose medications, were associated with significant side effects that limited our function. Implantable techniques involve insertion of a semi-permanent device into the body to control pain and may be an option to consider at this point. Implantable therapies work by acting on the nervous system to block or distract from the sensation of pain and are referred to broadly as neuromodulation therapies.

The documents below explain Spinal Cord Stimulation and Spinal Drug Delivery System, how to get started on the techniques, how they work, side-effects and complications.

Dorsal Root Ganglion (DRG) Stimulation

DRG stimulation is used to treat focal neuropathic pain and allows physicians to target a different part of the nervous system from the spinal cord and by so doing often achieve coverage of nerve distributions that previously yielded suboptimal results with conventional SCS. Dorsal root ganglion (DRG) therapy is a newer form of neurostimulation designed to manage difficult-to-treat chronic pain in specific areas of the lower body, such as the foot, knee, hip or groin. If you suffer from this kind of pain, DRG therapy may work where other therapies have not—or may have provided only partial relief. Some physicians have used DRG in combination with SCS to improve coverage and thereby pain relief.

Sacral Nerve Stimulation (SNS)

SNS is used by Urologists to treat bladder dysfunction/incontinence and more recently by general surgeons to treat chronic fecal incontinence. SNS is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. Similar to SCS a trial is performed and if successful at controlling the indicated symptoms then the patient will proceed to final permanent implantation of SNS device. Some clinicians have used sacral nerve targets to treat pelvic pain of various etiologies including pudendal neuralgia and other neuropathic pain syndromes.

Peripheral Nerve/Field Stimulation

Peripheral nerve stimulation (PNS) uses similar principles to SCS to treat pain. By stimulating peripheral nerves one can also provide treatment of a variety of painful conditions that affect a discrete localized area. Examples include occipital nerve stimulation for headaches, sacral nerve stimulation for pelvic pain, and subcutaneous field stimulation of the abdominal wall for treatment of post-herniorrhaphy pain. With this technique, stimulating leads are placed near, or directly on, peripheral nerves to provide ‘coverage’ of the painful area. When subcutaneous nerve stimulation is utilized, some refer to this as field stimulation to separate it from direct peripheral nerve stimulation. In general, these are new areas of study, and much work remains in the study of this form of stimulation.

To learn more about neuromodulation, please click here.


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