Redefining Pain: UW Medicine Takes a New View of Chronic Pain
by Deirdre Schwiesow
In the U.S., pain is one of the most common reasons for visiting the doctor. When it manifests as a by-product of a disease, illness or injury, it is fairly simple to treat. But when the disease is gone and pain lingers, or when a patient has pain without an identifiable cause, then pain itself becomes a disease. This type of chronic pain is a medical mystery for many physicians.
To solve the mystery of chronic pain and to make a positive difference in patients’ lives, Dr. John Bonica launched the world’s first pain clinic at UW Medicine in 1961, organized around his novel, multi-disciplinary approach to treatment. However, in the 1990s, managed care made Bonica’s collaborative, multi-provider model prohibitively expensive, and the UW Pain Center became all but dormant.
Then, in 2008, Debra Schwinn, M.D., UW professor and chair of the Department of Anesthesiology & Pain Medicine, invited internationally renowned pain specialist Alex Cahana, M.D., DAAPM, FIPP, to lead the newly formed Division of Pain Medicine. Cahana accepted on the condition that he be allowed to revive Bonica’s model of treatment around a new paradigm for pain: one that treats it as a disease, not simply as a symptom.
At UW Medicine, Cahana, the Hughes M. and Katherine G. Blake Endowed Professor in Health Psychology, oversees nine pain programs in five hospitals, including the flagship Center for Pain Relief based at UW Medical Center-Roosevelt. In the past two years, Cahana and his colleagues have been moving forward with a comprehensive agenda that addresses chronic pain from the perspectives of patient care, specialist training, research and legislation — all within the framework of the division’s mission of “predicting, diagnosing and preventing pain from becoming a disabling disease.” As a result of their efforts, the Center for Pain Relief received the 2010 American Pain Society Center of Excellence Award.
Listening, giving hope
Considering chronic pain as a disease in its own right — rather than simply the result of illness or injury — represents a paradigm shift in patient care, one that focuses on addressing the patient’s experience.
David Tauben, M.D., Res. ’82, UW clinical associate professor in the Department of Anesthesiology & Pain Medicine and the Department of Medicine, and director of medical student education in pain medicine, gave up a long-term private practice to support Cahana’s vision. “I literally dropped everything and came over to help build and participate in medical student and primary-care education,” he says.
People who have chronic pain — most commonly felt in the head, neck or back — typically suffer for three to seven years before seeing a pain specialist. By the time they arrive at UW Medicine’s pain clinic, they’ve seen many providers and have spent thousands of dollars. Often they’re on several medications, some of which may be ineffective or even actively harmful.
“Generally they come in without hope, with great disappointment at the failure of the medical system to properly care for them,” says Tauben. Staff members listen, he says, then shift the conversation back to the pain — the negative effect it’s having on the patient’s job, family, sense of self and future.
“Spending the visit focusing on the impact of pain on a patient’s life is very poorly reimbursed, but it’s crucial,” Tauben says. “People will say, ‘Just talking to you, I now have some hope,’ and that constitutes a successful initial visit.”
Alex Cahana, M.D., who leads UW Medicine’s Division of Pain Medicine, sees chronic pain as a disease in itself, rather than a symptom.
Characterizing complex pain
“Pain, on one hand, is a very private and subjective experience,” says Cahana. “But [now] we can characterize pain on a larger population base. We combine the phenotype (how people respond to pain) with the genotype, and we can also psychotype patients and sociotype them — by combining these metrics, we can define a patient’s individual experience of pain in a very objective way.”
Understanding the patient’s experience of pain is followed by precision diagnosis — often aided by selective anesthetic blocks or continuous nerve stimulation to identify the source of pain — and then appropriate, focused treatment.
Treating pain requires a solid foundation, Cahana explains. First, care has to be coordinated and multi-disciplinary, involving specialists in anesthesiology, internal medicine, neurology, neurosurgery, psychiatry, psychology, neuroimaging and musculoskeletal radiology, rehabilitation, sports medicine and vocational counseling. It also must be collaborative, with team members working together based on a shared model of pain treatment. Finally, because “we attach a dollar sign to the outcome,” says Cahana, care also must be measurement- and value-based.
When it comes to treatment, one of the primary options is opioids — that is, prescription painkillers — which are currently the subject of legislative reform (see sidebar). Often, patients with chronic pain are under-prescribed these medications because of concerns about addiction; in these cases, says Tauben, “the clinic can offer clarity, consistency and often validation on the need for those medications” to patients and their primary-care physicians.
At the same time, opioids pose risks. Not only can the drugs be addictive, but research also shows that, after 90 days on opioids, there are permanent changes to brain function. And in many cases, opioids actually have limited effectiveness.
Opioids, however, represent only one of the tools UW Medicine uses against chronic pain. “Pain is a complex problem, and it needs a complex solution,” says Cahana. Individualized treatments may range from leading-edge medical therapies such as pulsed radio frequency — a procedure pioneered by Cahana that sends an electric current through a nerve — to nerve blocks, occupational and vocational counseling and alternative medicine.
Educating pain specialists
Like Tauben, Andrea Trescot, M.D., UW professor in the Department of Anesthesiology & Pain Medicine, was drawn to UW Medicine by Cahana’s vision. Her focus is education. “We’re trying to improve the reputation of pain medicine and improve skills, both in the diagnosis as well as in the ethical, safe and effective treatment of patients,” she says.
Trescot directs the new, two-year pain fellowship program, which is supported by the ScanlDesign Foundation by Inger & Jens Bruun and by St. Jude Medical, Inc. The program is part of an overall effort to change the model of educating pain specialists. This effort also includes having pain recognized as a specialty by the American Board of Medical Specialties. (Pain medicine is currently recognized as a subspecialty of anesthesiology.)
The fellowship program has grown in step with the department’s new mission for pain. “We have dramatically increased the educational opportunities for the fellows by increasing the scope of techniques on which they are trained, including nerve freezings and taking cameras inside the spinal column. We’ve dramatically increased the number of patients that the fellows get to see, and arranged for a variety of outside rotations,” says Trescot. “This year, we had almost 100 applications for five positions,” she says.
Chances are good that the UW Medicine pain fellowship program will serve as a model for nationwide changes, and, Trescot says, the fellowship draws observers from Korea, France, Argentina and other countries. “By putting together a concept that is resonating nationally and internationally, Dr. Cahana has been able to bring people to the table who I never thought would sit down together,” says Trescot.
Education is happening at multiple levels. Medical students at the UW School of Medicine now receive pain education throughout their curriculum.
“Pain education that incorporates the whole-person experience has yet to be fully integrated into medical schools,” says Tauben. “We have the opportunity to teach broad concepts to first-year students, pharmacology and technology to second-year students, direct clinical application to third-years, and more detailed specifics of technology and more complicated disease management issues to fourth-years,” he says. The result? “The next generation of doctors — both primary-care and specialty-care physicians — will be familiar and comfortable managing patients not only with acute pain, but chronic pain,” Tauben says.
“When medical students apply, they almost always say that they want to relieve patients’ pain and suffering,” says Tauben. “UW students have a special opportunity to learn about pain and its best practice management.”
Research: finding the right treatment
In line with UW Medicine’s emphasis on research, patient care and education, the Division of Pain Medicine has launched a large-scale research initiative — the Center for Pain Research, Impact, and Measurement Evaluation (C-PRIME), funded in part by Millennium Laboratories. (See the related story on Millennium.)
C-PRIME is dedicated to research that increases the understanding of pain and its causes, improves pain management, and aids in the development of new treatments for pain and pain-related disability. According to Dennis C. Turk, Ph.D., UW professor in the Department of Anesthesiology & Pain Medicine, director of C-PRIME, and the John and Emma Bonica Endowed Chair in Anesthesiology and Pain Research, research is crucial in order to accurately tailor treatments to a patient’s individual characteristics.
“There are a whole range of treatments and techniques that are developed for chronic pain,” Turk says. “We tend to ask, ‘Does Treatment A work?’ But what we should really ask is, ‘Is Treatment A effective for patients with these characteristics, based on what outcomes measures, compared to what other treatments, and at what cost?’”
To that end, C-PRIME will conduct research, educate healthcare professionals and clinical investigators about pain research, and contribute to public policy discussions, all in the context of collaborating with researchers from academia, business and government. This work will start within UW Medicine. “We have a number of exceptional pain researchers at UW, but they’re in silos,” says Turk. “We hope C-PRIME will foster collaborations.”
C-PRIME’S data-driven research also should help focus treatments and costs. “We’re hoping to do outcomes research on the characteristics of patients who do well with each treatment, because we can’t keep offering hugely expensive treatments to patients whose outcomes don’t lead to functional improvements,” Turk says. Research can help determine how different pain treatments compare to each other along various axes, such as pain reduction and ability to return to work, among other criteria.
In addition to conducting a range of studies, C-PRIME will address treatment efficacy through the development and implementation of a first-of-its-kind National Pain Registry. Registry software, being piloted at UW Medicine, will chart the progress of patients with persistent pain and their response to treatment alternatives, providing pain researchers across the country with a large data repository to conduct studies.
Reducing the cost of pain
Pain treatment is a challenging field, and in pursuing it, UW Medicine’s faculty are motivated by the still greater challenges experienced by their patients. And by the toll that pain takes on society.
“Pain is so, so draining. It destroys patients and their families and is a huge healthcare burden,” says Andrea Trescot.
Under the leadership of Alex Cahana, UW Medicine is offering significant hope to pain sufferers. With a history of innovation in pain research dating back 50 years, and with recent initiatives in patient care, research, education and advocacy, UW Medicine stands ready to reduce the personal and societal burdens of pain.
Read more about pain medicine in our MEDEX Northwest feature.
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