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Video Transcript: Pain Management

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. An estimated 85 million Americans are living with chronic pain which adds up to billions of dollars in healthcare expenses and loss of productivity, not to mention the discomfort people suffer. We'll talk about strategies today for treating chronic pain. My guest is Dr. Thelma wright, she is the director of the University of Maryland Pain Management Center, which is located at Kernan Hospital. Dr. Wright is also an assistant professor of anesthesiology at the University of Maryland School of Medicine. Welcome to the show.

Thelma Wright, M.D.: Thank you.

Ellen Beth Levitt: How do you defined chronic pain?

Thelma Wright, M.D.: Chronic pain is usually defined as the pain that lasted more than three months and Acute pain is pain defined as pain has lasted less than three months.

Ellen Beth Levitt: So a lot of people have chronic pain. I'm wondering, how does that develop? Is that sometimes the evolution from an acute episode of pain, or is it from different sources?

Thelma Wright, M.D.: Usually, if you have an acute process that’s not treated early, that may develop into chronic pain. For instance, if the patient has surgery and it is not treated with pain medicine if they have pain, it can usually develop into chronic pain afterwards.

Ellen Beth Levitt: Really? What are some of the common sources of chronic pain?

Thelma Wright, M.D.: Patients can have pain in the lower back or the neck. Pain from arthritis. Migraine headaches that can develop into chronic pain and knee and joint arthritis that can develop into chronic pain.

Ellen Beth Levitt: Are there some types of injuries as well, among the patients that eventually see you on the pain?

Thelma Wright, M.D.: You have patients also involved in motor vehicle accidents that can lead to chronic pain actually stroke patients can also have pain and chronic pain developing you have patients who have sports injuries.

Ellen Beth Levitt: There is a wide range of different types of causes?

Thelma Wright, M.D.: Yeah.

Ellen Beth Levitt: And is there a complex something that continues? I'm not sure what it's called. I’ve heard there are some people for whom the pain just continues, even if the problem itself has been dealt with, sort of a continuous loop, I guess, between the brain and the central nervous system.

Thelma Wright, M.D.: So I believe you are talking about complex regional pain syndrome which used to be formally known as RSD, reflex sympathetic dystrophy. With patients who had previous injuries, sprain, surgery, may end up developing pain wake up one day with swelling, changes in color in their lower extremity. They may also have difference in temperature some sort of break the cycle, if you will?

Ellen Beth Levitt: Do children sometimes have chronic pain issues?

Thelma Wright, M.D.: Definitely. Especially children with sickle-cell anemia. They have chronic pain. They will have pain in the cleft or hips. You have patients rheumatoid arthritis, lupus, and they may all develop into chronic pain. Children with cancer and each the treatments used to treat cancer can actually cause pain.

Ellen Beth Levitt: Do you often get referrals for these types of folks as well to help them out?

Thelma Wright, M.D.: Yes, we do have referrals from pediatric specialists and also from practitioners who refer these kids to us.

Ellen Beth Levitt: It is good to know there are pain management specialists out there. Are medications usually the first line of treatment?

Thelma Wright, M.D.: Well, not necessarily. It depends on what kind of pain it is. If a patient has had a muscle strain they can do bed rest or heat or ice. You will have patients who will go to the pharmacy and get over the counter medication. They may take Tylenol or Ibuprofen to help. Exercise can also help. So not necessarily medications are used as first line.

Ellen Beth Levitt: I'm wondering how the medications work. If you take something like Ibuprofen, Advil or Motrin or Tylenol, you swallow them, they go into your stomach. Somehow they make it to the brain and then go to the site of the pain. How does that actually work?

Thelma Wright, M.D.: Right. When you take Ibuprofen, an anti-inflammatory, basically it targets the areas of inflammation. It doesn't necessarily go to that area, but he treats the inflammation in the areas. If you use narcotics, they have receptors in the brain and spinal cord if they work in those areas, too.

Ellen Beth Levitt: Is there a difference between aspirin and Tylenol and the no one steroid al anti-inflammatories in terms of effectiveness for pain? Or is it an individual thing? Other people get relief instead.

Thelma Wright, M.D.: Well that happens. You have patients who will tell you ibuprofen doesn't work for me but Tylenol does. There may be some genetic variance to that report but yes some patients will do better with some medications versus the other.

Ellen Beth Levitt: Should people be concerned if they are taking these medicines long-term?

Thelma Wright, M.D.: Yes they should be. Because there are side effects through every medication you take long-term. Patients who take ibuprofen should be aware there are side effects such as GI bleeding. Patients who take Tylenol and drink can also have problems with your liver. There is liver toxicity. There are limits to taking them on a daily basis. Tylenol you need to take a total dose a day of four grams. You don't want to go above that.

Ellen Beth Levitt: Can you build up a tolerance or resistance to these medicines? Will they stop working after a certain amount of time?

Thelma Wright, M.D.: Not necessarily the Ibuprofen or Tylenol medications? But the narcotics you will build a tolerance to them, yes.

Ellen Beth Levitt: I was going to ask you about the opioid drugs you mentioned. Some people call them narcotics but that is not the professional term for them?

Thelma Wright, M.D.: We prefer to use opioid medications. A lot of people call it narcotics but we prefer to use opioid. I usually would use it in the acute pain setting. In the chronic pain setting, there is a time when you could possibly use it; however there really haven't been any studies to show the long-term use of opioid do interfere with patient function. However for cancer patients there is definitely a role for using opioids in that setting.

Ellen Beth Levitt: Can they become addictive?

Thelma Wright, M.D.: They become tolerant. They can also become physically dependent. Addictive? Well if you are taking the medication for the wrong reasons and you are not taking them as prescribed, yes you could get addicted to them.

Ellen Beth Levitt: When should somebody come to see a pain management specialist?

Thelma Wright, M.D.: Usually when patients have pain that they haven't been able to manage with over the counter medication, they will go to their primary care physician. However, if the primary care physician exhausts all their modalities of treatment, they will send them to a pain management physician.

Ellen Beth Levitt: I would imagine it is pretty stressful for people who live with chronic pain?

Thelma Wright, M.D.: Yes, it is. It definitely takes a toll on the job the ability to perform activities of daily living, even their relationships. A lot of people whether or not don't have pain do not understand patients who don't have pain.

Ellen Beth Levitt: Right are people usually referred to you by other specialist or family doctor? Is that what usually happens?

Thelma Wright, M.D.: Usually we prefer patients to be referred to us by the primary care fiscal the neurologist or the neurosurgeon. Most patients get referred by another physician.

Ellen Beth Levitt: Do you have a pain psychologist on your staff?

Thelma Wright, M.D.: Yes we do. Most patients have conditions such as depression or anxiety. She helps the patients cope, gets them on therapy, biofeedback. She really is a great addition to the clinic.

Ellen Beth Levitt: Pain can actually lead to people becoming depressed. Or I would think anxious or having some psychological issues as well. Obviously if you are living in pain, it is not a happy thing.

Thelma Wright, M.D.: Definitely. It plays a big role in a lot of patients that are not able to work. There is a problem with getting money or taking care of the family. Patients have to get on disability and it is a struggle to even get disability when you have pain. Usually you have to go through you know going to the disability office, the social security office to prove that you really have pain. We have to help the patients get on disability when they actually cannot perform their duties any more.

Ellen Beth Levitt: Right. Because pain is so subjective, also. And I guess it must be frustrating for some people who have chronic pain to tell people they are in pain, but others might not appreciate that. Do you find that to be the case?

Thelma Wright, M.D.: We find that a lot. We find patients coming in. Yes they have been through different pain specialists. They haven't had treatment or have been able to get the correct treatment for their pain because people don't believe them. Or you know there is no pathologist seen on MRI or X-ray or exam. However pain is really what the patient says it is.

Ellen Beth Levitt: Do you think that is changing when you go into a hospital now, the doctor will say do you have pain? If so, where is it on the scale of 1-10? It seems like there is a greater appreciation of pain, at least in the hospital settings now.

Thelma Wright, M.D.: Apart from the blood pressure, the heart rate and oxygen sat, you have to definitely ask the pain whether they have pain. That is a good thing.

Ellen Beth Levitt: Great. We have to take a break. But when we come back, we'll talk about some specific innovative treatments for back pain. So stay with us. We'll be right back.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I’m Ellen Beth Levitt. We are talking about treating chronic pain. My guest is Dr. Thelma Wright. She is the director of the University of Maryland Pain Management Center located at Kernan Hospital. Dr. Wright is also an assistant professor of anesthesiology at the University of Maryland School of medicine. When we think of anesthesiologists I think most of us picture you in the operating room with the mask on managing the person's airway and keeping them alive and pain- free while the surgery is going on. But I guess more and more anesthesiologists are specializing in treating chronic pain, is that right?

Thelma Wright, M.D.: We keep the patients pain-free in the operating room and are extending that to the outpatient setting. We are able to treat it because we already treat it in the acute pain setting. That is why a lot of anesthesiologists are branching out into pain management because we already do it nor.

Ellen Beth Levitt: You have a model of a skeleton and that is the back. And back pain is one of the most common sources of chronic pain. Is that true?

Thelma Wright, M.D.: I should say that is where a lot of patients complain of pain when they come in to see us.

Ellen Beth Levitt: Do you want to show us on the model there where some of the major sources of back pain are, when someone has back pain? Maybe they are told they have a bulging disk or something like that.

Thelma Wright, M.D.: When a patient is told they have a bulging disk. These can actually push out. Or what they call herniation. So you have a disk which will push out and impinge on this nerve which usually would go down to supply your legs and patients will complain of numbing sensation or tingling sensation going down the legs and that is because this is starting to press out on this nerve. You have patients with arthritis of the facet joints. And patients who have pain in the back, it doesn't go down the legs.

Ellen Beth Levitt: Occasionally they may have pain going down the leg but not all the way to their seat. That is why you can feel the pain if the disks bulge or rupture or something like that?

Thelma Wright, M.D.: Right and impinge on the nerve. Imagine if you have a back-up thinking disk and it is going to impinge on the nerve you are going to have pain going down your leg.

Ellen Beth Levitt: Most people don't have surgery for this because they are told that what is it? 90% of all back pain goes away on its own? Or 95%? Something like that. So most of the time people have episodes of back pain. It will resolve on its own.

Thelma Wright, M.D.: It wouldn't go straight to surgery. Occasion where his you would have surgery is when a patient has weakness. That is definitely a reason to have surgery if you are falling or losing your bowel and bladder, this is a reason to have surgery. If you have too much of a herniation and you are really impinging on that nerve. 100% of the time then you would have to have surgery to actually take a little bit of the disk off and relief the impingement.

Ellen Beth Levitt: If someone has what they call foot drop or real weakness in a foot or something like that, that is a more serious situation.

Thelma Wright, M.D.: When a patient keeps come in we find out how they hurt themselves. We also ask them what medications they have tried in the past. We examine them from the examination. We are able to get a lot of inflammation. Also we look at the MRI if they have had an MRI, we look at X-rays. Depending on what we see in an exam or what we determine is wrong with a patient, we would offer different medications or interventions.

Ellen Beth Levitt: How do you find the exact source of the pain? There is something called a functional discogram that you do?

Thelma Wright, M.D.: Right it is a procedure we perform to help the orthopedic surgeons and the neurosurgeons, if they believe the pain may be coming from the disk we go into the operating room and inject the disk we think may be the cause and put local anesthetic into the disk. And if the patient has pain relief, we can extrapolate that the pain is coming from those disks.

Ellen Beth Levitt: So that helps if the person is he going to have surgery?

Thelma Wright, M.D.: Exactly.

Ellen Beth Levitt: Do people sometimes get relief just from that test? Because you are injecting pain medicine at the source and.

Thelma Wright, M.D.: They do get relief but it is not going to be long lasting.

Ellen Beth Levitt: What are some of these new, innovative, kind of high-tech treatments that are now available? Do you actually at some. Do injections of pain medicine for people?

Thelma Wright, M.D.: Yes. We do several injections we do what we call ep durale steroid injections. That is really similar to what we do in the laboring patient. What we do is decrease the inflammation by injecting steroids into the epidural space. We give steroids in the epidural space to decrease the inflammation. There are other blocks where we go straight to the nerve or close to the nerve and inject local anesthetic and steroids to that area to decrease the inflammation also.

Ellen Beth Levitt: Is that what we are seeing an example of?

Thelma Wright, M.D.: Yes that is definitely what we are seeing on the screen.

Ellen Beth Levitt: How long would this kind of procedure last?

Thelma Wright, M.D.: It varies. It varies from patient to patient. I would do one injection on a patient and i would not see them for two to three months. We usually like to do a series of injections, however if I do a first and second injection and the patient is pain-free there is no reason to bring them back for a third one. We'll wait to see if the pain will return and repeat it.

Ellen Beth Levitt: Is a nerve block the same thing as the spinal injection?

Thelma Wright, M.D.: Most people use it interchangeably. You do a block where you put medicine into the CSF space. However a nerve block is where you actually go close to the nerve and inject local anesthetic and steroids close to the nerve. You are not going midline; you are going through the side.

Ellen Beth Levitt: Is exercise or physical therapy sometimes beneficial for people who have chronic back pain?

Thelma Wright, M.D.: Definitely. Exercise is a mainstay of pain management. Patients who have had chronic pain and who have not been very functional will benefit from physical therapy, especially when they have patients who are deconditioned.

Ellen Beth Levitt: I have heard if you strengthen the abdominal muscle that is important in keeping your spine in good condition and preventing back pain?

Thelma Wright, M.D.: That is true too, yes.

Ellen Beth Levitt: For the people who have the chronic, serious back pain, I know there are some newer devices, for example, like a pain pump, that could be surgically implanted that would deliver pain medicine on a continuous basis, is that true?

Thelma Wright, M.D.: Yes that is true. There are subsets of patients who will benefit from a pain pump. Patients who have tried oral medications who are having increased side effects from the oral medications or patients with cancer, we will consider using a pain pump. And this is an example of the pain pump that we would usually use in a patient. Of course, when we do this, we do undergo a trial which is where we try the medication and see where the medication did help, then we go ahead and take them to the operating room and implant the pump.

Ellen Beth Levitt: Here's an animation showing the pump implanted and the catheter that goes from the little pump into the spine.

Thelma Wright, M.D.: Yes this is an example of the catheter. Basically we go into the space, we have the catheter here, we go here and thread it up and this provides medication, constant continuous infusion of medication.

Ellen Beth Levitt: Where is the space?

Thelma Wright, M.D.: It is actually you go through the epidural space and just beyond the epidural space you find it. This is where when patients have lumbar punctures, that is the space we go into, where you get this fluid coming out.

Ellen Beth Levitt: How long can somebody keep a pump inside now?

Thelma Wright, M.D.: These pumps do have a length of time that they work. After seven to nine years we would have to replace the pump.

Ellen Beth Levitt: Is there also something called electrical stimulation?

Thelma Wright, M.D.: Spinal cord stimulation.

Ellen Beth Levitt: Okay.

Thelma Wright, M.D.: This is another new innovation that pain doctors have been using these days. So patients who have had surgery in the past patients who have lower extremity radiculopathy or burning sensation going down their legs would benefit. This is a procedure this time we are in the epidural space and we are actually stimulating the nerve root that supply the area of the pain.

Ellen Beth Levitt: We actually have an nation here that we are watching. Is that sort of like a pacemaker device?

Thelma Wright, M.D.: You would say it is a pacemaker for pain, yes. Basically what we are doing is confusing the brain and replacing the pain sensation with a different sensation more tolerable to the patient.

Ellen Beth Levitt: How would you decide whether to use the pain pump or the stimulator?

Thelma Wright, M.D.: Patients who have lower extremity pain I would use a spinal cord stimulator. Most of the times the pumps are saved for patients who have cancer, patients who have tried oral opoids but have an increased side effect.

Ellen Beth Levitt: Do you want to show us what the --

Thelma Wright, M.D.: This is a generator we would use with a spinal cord stimulator. This gets implanted under the skin after the patient has done well with the trial. We usually perform a three to five-day trial and if the patient comes back and is very happy with the trial, we go ahead and actually implant the stimulator.

Ellen Beth Levitt: So is the trial done as an out-patient?

Thelma Wright, M.D.: Yes, it is m it is done as an out-patient and everything is out of the patient except the stimulator itself.

Ellen Beth Levitt: Right. I understand that you are doing some research. You are very interested in some of these devices and so forth. Could you tell us a little bit about your research?

Thelma Wright, M.D.: So currently, we have two research protocols going. It is with these new innovations. One of the studies involving using spinal cord stimulation on patients with diabetic neuropathy. We have patients that have done very well with spinal cord stimulation.

Ellen Beth Levitt: Could you explain what that is a little bit? People get nerve pain when they have diabetes?

Thelma Wright, M.D.: Patients with diabetes their nerves start to deteriorate and they end up having burning pain in their feet. We use the spinal cord stimulator to replace the pain sensation they are having in the lower extremity. Basically we are replacing the pain they are having with a different sensation which is more tolerable to the patient.

Ellen Beth Levitt: How does this connect with the brain? I know a lot of times obviously the brain is very important in how we perceive pain?

Thelma Wright, M.D.: What the spinal cord stimulator does is block the impulses from being transmitted back to the lower extremity. So those pain impulses we perceive are actually blocked by the spinal cord stimulator.

Ellen Beth Levitt: The brain is sending a signal of pain but it is being blocked, like running interference with that?

Thelma Wright, M.D.: Exactly.

Ellen Beth Levitt: Is there another type of research you are also interested in?

Thelma Wright, M.D.: Using the spinal cord stimulation with patients with abdominal pain and pelvic pain. For patients who have failed all conservative therapy.

Ellen Beth Levitt: I have heard chronic pelvic pain is a significant problem.

Thelma Wright, M.D.: It is a significant problem. It is very challenging and a lot of gynecologists or urologist will refer patients to us because they have used up all the conservative therapy and at that time we try these other therapies.

Ellen Beth Levitt: I guess people of all ages tend to come to you for their pain relief?

Thelma Wright, M.D.: Yes.

Ellen Beth Levitt: Okay. Well it must be gratifying when you help people?

Thelma Wright, M.D.: Yes.

Ellen Beth Levitt: Thank you so much for being our guest on Maryland Health Today.

Thelma Wright, M.D.: Thank you. Thank you for having me.

Ellen Beth Levitt: I have been speaking with Dr. Thelma Wright. She’s the director of the University of Maryland Pain Management Center located at Kernan Hospital. And Dr. Wright is also an assistant professor of anesthesiology at the University of Maryland School of medicine. If you would like to reach Dr. Wright or any other university of Maryland physician, call 1-800-492-5538. Or there is a website you can visit where there is a great amount of health information and you can also see other Maryland Health Today programs. That address is www.umm.edu. Take good care of yourself—we’ll see you next time for Maryland health today.

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This page was last updated on: June 25, 2009.

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