PMTC Final test


Americans prefer pain management without drugs 78 percent prefer alternatives to pain meds


Sharing her journey Family Oriented Coordinator helps educate patients Seeing patients get better brings satisfaction

Working for


PMTC Founder Looks Back




CONTENTS To send a comment or question, write to: PAIN MANAGEMENT & TREATMENT CENTER, S.C. 8901 N. 76th St Milwaukee, WI 53223 INTERESTED IN MORE FROM PMTC? To learn more about our resources for living a healthy lifestyle, visit or call (414) 354-0772. PMTC Magazine is published by © Copyright 2018 by No part of this publication may be reproduced in any form or by any means without prior written permission of the publisher, excepting brief quotations in connection with reviews written specifically for inclusions in magazines or newspapers, or limited exerpts strictly for personal use. Printed in the United States of America. All rights reserved. 6830 W. Villard Ave. Milwaukee, WI 53218


6. THE SCIENCE OF BRINGING RELIEF PMTC founder looks back 7. Working for Family Starting a career in medical lab work 8. Sharing Her Journey Coordinator helps educate patients 9. Family Oriented Seeing patients get better brings satisfaction 10. Putting a Smile on Their Face Medical assistant enjoys boosting clients 11. First a Patient Now a Physician Bringing empathy to the task

in the news

16. New App Helps Patients Diagnose Their Pain Uses a 3-D model 17. New Anti-Addiction Bill Signed Into Law Packages more than 70 bills 18. Americans Prefer Pain Management Without Drugs 78 percent prefer alternatives to pain meds 19. Researchers Find “Extra” Pain Pills Fuel Opiate Epidemic Better prescribing practices needed 20. More Patients Trying TENS for Pain Relief Scientists cite limited research on results 21. OTC Drugs Just as Effective as Opioids Trial evaluated effectiveness for common injuries 22. September is Drug-Free Pain Management Month To raise awareness about risks and safer choices 23. Research questions value of opioids for chronic pain VA study looked at back, knee and hip pain 24. Pain-Relieving Compound Could Replace Opioids Scientist search for the ‘Holy Grail’


Since 1996, we have demonstrated a commitment to quality and efficient pain management care.


Our mission is to lessen the chronic, debilitating, all-consuming pain of our patients in order to have a profound impact on improving the quality of their lives. We accomplish our purpose by using a “cutting-edge” multidisciplinary approach built of the solid foundation of an understanding and empathetic relationshipwith our patients. In accomplishing this, wewill sustain and enhance the key relationships in our patients’ lives and be regarded as a significant contributor to our community. Our vision is to enjoy the excellent reputation of serving our patients and themedical community as strong leaders who use “state of the art” thinking in developing “cutting-edge” approaches to dealingwith pain, its management and treatment. Our patients will benefit from the best painmanagement and treatment, secure in the knowledge that we are committed in our relationship to putting their needs first.


414-354-0772 -5-


PMTC founder looks back

”I decided this was an

area where I could make a difference.” -- Pamela omas-King, M.D., founder, Pain Management and Treatment Center


SCIENCE IS EVOLVING e science of diagnosing and treating chronic pain has evolved over the course of her 20-year career.e one, recent development that has made the most news is a negative one: the epidemic of opiate addiction. It has heightened the challenge for physicians in managing their practices, she notes.ey need to Œnd the correct balance – “helping the patients who truly need pain medications, as opposed to those who are misusing these medications, and diverting them. “We don't want to go into practice not believing someone, but we also have a responsibility to the community and also to patients to make sure we are not helping them engage in addiction or illicit behavior. It makes things a little more complicated,” says Dr. omas-King, who is certiŒed in both anesthesia and pain management. Still, she is optimistic that some of the measures government regulators, drug makers, health systems and physician groups are instituting are starting to make a diƒerence in reducing abuse and addiction. “A number of things are being done. Maybe some doctors have been too lenient in prescribing. “But, one thing I don't want to see happen is that the pendulum swings so far to the opposite side that to patients who need these medications are not being treated adequately and appropriately.ere is a middle point – we can provide treatment within guidelines that are good for patients, with a certain amount of regulation, but not overdo it so patients aren't getting the care they need.” One positive development is that physicians in primary care and other specialties have become much more inclined to refer patients with chronic pain to pain management clinics where they can receive specialized

care, she says. And, “with some of the regulations that have been put in place, we will have a higher standard of care. at's all very good for the Œeld.” A COMPLEX CONDITION Chronic pain is “multidimensional,” Dr. omas King says, and has many causes that can represent a challenging puzzle for care providers. For that reason, PMTC takes a multi-disciplinary approach to care, with a staƒ that includes not only physicians and nurses but also physical therapists, and even a psychologist. Medication management can include both opiates and non-opiate medications, nerve blockers and techniques like radio frequency ablation that can provide quick relief from pain originating in the spine and nerves. “We attack pain from all diƒerent angles,” Dr.omas-King says. “We use opioids (usually low-dose opioids) as a last resort, as an adjunct to the other treatment we are providing. We try not to make the pain medications the center of treatment. “Treating pain has a lot to do with patients getting out and exercising, eating right and doing all of the things they need to do, so they don't need to depend on pills.” Looking ahead, at PMTC “we want to continue to be a staple resource in the community, where people who have chronic pain can receive the best care in a relaxing environment with the understanding that we take what we do seriously, and with the highest integrity.”

“We want to continue to be a staple resource in the community, where people who have chronic pain can receive the best care.” -- Pamela omas-King, M.D. P amela omas-King, M.D. founded the Pain Management and Treatment Center in October, 1996. But her interest in medicine dates back much earlier than that. “I decided I wanted to become a physician when I was 12 years old. I used to visit my grandmother who lived in rural Mississippi.e people there had such poor health care, I decided this was an area where I could make a diƒerence.” After earning her medical degree at the University of Wisconsin-Madison, Dr.omas-King completed a four-year residency in anesthesia at Duke University,followed by a one-year fellowship in pain management. In the process, she found her career. Diagnosing and treating chronic pain can be a complex challenge, but pain specialists can make a big and immediate diƒerence in making their patients' lives better. “I really like the fact that I can help people, which is why I originally went into medicine.”


family Working for STARTING A CAREER IN MEDICAL LAB WORK ” Working

for family is a wonderful feeling .” -- Kalief Walker, Medical Laboratory Trainee


When he graduated from high school in Madison earlier this year, 18-year old Kalief Walker was uncertain about his career plans. He was thinking about training as a plumber. But, since joining the Pain Management and Treatment Center sta in July as a lab trainee, he's decided to make medical lab work his career. Walker, who is the nephew of PMTC founder and owner Pamela €omas-King, M.D., says working at the clinic “has taught me a lot. And, working for family is a wonderful feeling.” He spends much of his time using the lab's analyzer to conduct urinalyses for patients, screening for traces of illicit drugs, such as THC, opiates or cocaine. His job also includes entering documents into the PMTC computer system. Walker is looking forward to attending Milwaukee Area Technical College to earn a Medical Laboratory Technician degree and get his career started. Photography by: Marcus BuckNarley -9-



IMPROVE QUALITY OF LIFE Our first priority is to improve our patients’ quality of life by developing a tangible, effective treatment plan.

UNPARALLELED CLIENT CARE PMTC has been treating Milwaukee area residents suffering from chronic pain for over twenty years.

TREATING CHRONIC PAIN Our staff evaluates, diagnoses and treats chronic pain by working as a team, collaborating upon a single treatment plan with combined expertise and specializations of all. INDIVIDUALIZED TREATMENT We develop individualized treatment plans, which include; medical management, physical therapy and counseling.



Sharing her journey Coordinator helps educate patients Aymie B., who has been the front desk coordinator at Pain Management and Treatment Center for 20 years, brings a unique perspective to her job assisting patients sta at PMTC. e Milwaukee native has suered from chronic pain for years, but was unable to ƒnd relief – or an accurate diagnosis – until she came to PMTC. Aymie had started suering from migraine headaches at age six, and hip pain starting at age 11. She also suered permanent back pain, after falling out of a hammock in 1981. “ere were days when I had to use a cane or walker,” she recalls. Over a 17-year period, she suered from “probably 20 dierent pain conditions. I had been told for so long that my pain was not 'for real,' so I just fought my way through it and didn't know where to turn.” A “medical mystery?” After her injury, “my mom took me to eight or 10 dierent specialists. All of them kind of ƒgured me to be a medical mystery – until I got my job here.” She considers her hiring by PTMC in 1998 a case of “divine intervention,” since it led to getting help for her pain. After starting her job at PMTC Aymie didn't seek help right away. “At ƒrst, I just observed, I was curious. When patients had injections I would ask them how it felt. Everything I observed here gave me hope, and made me want to pursue treatment.” •••••••••••••••••••••••••••••••••••••••••••••••• ••••••••••••••••••••••••••••••••••••••••••••••••

en she had a consultation with Dr. Pamela omas-King. “Just from me describing my symptoms, Dr.omas-King suspected the problem was probably a bulging disc, or something else in my low back.” An MRI exam conƒrmed that initial diagnosis, and through exercise and therapy, Aymie's condition “improved by leaps and bounds.” Dr.omas-King and sta members also “explained to me what was going on using diagrams to show where the nerves run from the (spinal) disks and explained why I needed to do both therapy and injections to get the pain under control.” Aymie received epidural injections (Lidocaine and a small dose of steroids) to reduce the pain she had felt shooting down her legs, and was also prescribed twice-weekly physical therapy, and home exercises, to strengthen the muscles around her bulging disks. “I got about 40 percent relief from the ƒrst epidural, and my legs stopped cramping and waking me up at night.”e second injections brought her pain to about a 70 percent reduction, and, ƒnally, after 23 months of 100 percent relief.


”I think this office should be a nationwide model for how a pain clinic should be run.”

Along with Dr.omas-King's care, Aymie also appreciated the physical therapists' eorts. “ey would not only explain how exercises should be done, but would sit down and show me how they should be done, then watch my technique and posture and explain whether I was doing them correctly.” Lasting relief from pain When she started treatment, Aymie estimated her pain at a 9 level; now, level 4 pain is a bad day. “I have more good days than bad.” Aymie says her own experiences with pain and treatment have enabled her to enlighten other patients who come to the clinic. “I always try to be positive and encouraging to patients and let them know that I have (pain) conditions and that I can share my experiences with them.” She recalls her own experience as a new patient, with an initial fear of receiving injections, “until they explained that the pain would be nothing worse than a mosquito bite.

“e doctors and sta is here are very knowledgeable and compassionate. ey are very big on educating as patients and employees and letting us know ourselves heal and get stronger. I think this oce should be a nationwide model for how a pain treatment clinic should be run.”

-- Aymie B.

”Everything I observed here gave me hope, and made me want to pursue treatment.”

-- Aymie B., front desk coordinator Photography By: Marcus BuckNarley




Reoccuring pain can strike ANYWHERE. ANYTIME. Don’t continue to suffer. Let us help!


New app he l ps pat ients d iagnose the i r pa i n USES A 3-D MODEL

A new app that enables patients to explain their pain to a physici n by drawing it on a 3-D model is one of the newest tools to diagnose acute or chronic pain. Developed by a University of Michigan-based startup named Moxytech, the GeoPain app makes it possible for users to highlight which areas of the body hurt, and indicate the severity of their pain. The app became available to consumers in September, and is now being used in by physicians across the state of Michigan. Moxytech Co-Founder Alexandre DaSilva, director of the University’s Headache and Orofacial Pain Effort, said the app takes some of the subjectivity out of the process of diagnosing pain. DaSilva developed the original concept while at Harvard Medical School, and various institutions have been using it in research and education for the past six years. “I’m a clinician, and when I was doing my doctorate I was looking at the brain of patients with pain, and with the technology they have, they were much more precise,” DaSilva, told the Michigan Daily. researchers-release-app-pinpoint-patient-pain “But in the clinic, it was always subjective. Even though I could look at very high- tech things in the research side, in the clinical side, to correlate things, it was much harder, because I had to ask my patients, ‘zero to ten, what’s your pain,’ which was very subjective.”


According to Nascimento, the app had helped him learn as a student as he studied under DaSilva. “Back in the day, with their first versions, just to be optimized, it was good for them to also use our feedback, not only the feedback from the patients, but ours (the students),” Nascimento said. “You have the theory in the classroom, and you try to apply the concepts. For us, it was like, ‘Okay, we learned that, but we don’t see it used in the app.’ So it was good for us to give them some feedback as well.” So far, medical researchers have tested GeoPain in treating pain caused by migraines, chronic

DaSilva said he started by creating a grid so the patient could put not only the intensity of the pain but where the pain was,” DaSilva said. “When I arrived here in Michigan, then I realized that the 2-D map, the drawing, was not really good for the patients, because a body is in 3-D. The patients in the studies, and even those in the clinics, they were excited about this. ‘Hey, I want to use that, for my own good, and show it to my doctor,’ (they said).” Thiago Nascimento, M.D.,a pain research investigator in the University Research Lab, was a student of DaSilva’s when the app was first being developed, Nascimento was a student of DaSilva’s, which gave him a chance to try it out. “The drawing of the pain (was useful). Every time somebody had pain, you ask them ‘one to ten,’” Nascimento told the Daily. “However, that doesn’t really paint the picture of how they’re feeling, it’s not very precise, not very accurate. We were studying the technique of giving the patient a 2-D or 3-D space, so they can visualize it, something better than a number. It’s easy for us to kind of to see what the patient is feeling, although it’s just a drawing.” Nascimento said the app is a way of bridging the gap between the basic medical knowledge of most patients and the expertise of the doctors. “You kind of find common ground,” Nascimento said. “You can remove that gap. The doctor-to-patient relationship, it makes it easier for them (the doctor) to explain what’s going on. We’d start with the app: ‘Okay, just tell me how you’re feeling and let’s try to see the picture and compare.’ Like, let’s look and see how you were feeling a few months ago, and how you’re feeling today … It was easier for us to even track the follow-up – Are you feeling better or not – instead of just choosing a random number, like, ‘Before it was a 7, now it’s a 6.’ You can really see, ‘Oh, you’re getting better.’ It was clear for us to see.”

TMD (temporomandibular joint disorders, neuropathic pain, and pain related to chemoradiotherapy.




Individualized Treatment Plans All of our patients’ needs are evaluated before recommending an individualized treatment plan with the ultimate goal of eliminating or reducing pain, t aching how to manage pain, and improving the overall quality of life

CALLANDMAKEANAPPOINTMENTTODAY 414-354-0772 CALLANDMAKEANAPPOINTMENTTODAY 414-354-0772 All of our patients’ needs are evaluated before recommending an individualized treatment plan with the ultimate goal of eliminating or reducing pain, teaching how to manage pain, and improving the overall quality of life



New anti-addiction bill signed into law Packages more than 70 bills

On October 24, 2018... President Trump signed a new, bipartisan bill to combat the opioid addiction epidemic. Politicians are hailing it as a major step forward, while addiction and treatment experts say it falls far short of providing enough resources – particularly funding – to have a significant impact on the problem.

A package of more than 70 bills introduced targeting the opioid crisis, the Support for Patients & Communities Act:

• Reauthorizes funding from the Cures Act, which put $500 million a year toward the opioid crisis, and makes some policy changes intended to give states more flexibility in using the funding. • Creates a grant program for “Comprehensive Opioid Recovery Centers,” which will attempt to serve the addiction treatment and recovery needs of their communities (in part by using what’s known as an ECHO model). • Removes restrictions on medications for opioid addiction, allowing more types of health care practitioners to prescribe the drugs.

• Expands an existing program that attempts to get more first responders, such as police and firefighters, to carry and use naloxone, a medication that reverses opioid overdoses. • Allows federal agencies to pursue more research projects related to addiction and pain. • Makes several changes to Medicare and Medicaid to attempt to limit the over-prescription of opioid painkillers within the programs and expand access to addiction treatment, including lifting some of the current restrictions that make it harder for Medicare and Medicaid to pay for addiction treatment.

• Advances new initiatives to educate and raise awareness about proper pain treatment among health care providers. • Attempts to improve coordination between different federal agencies to stop illicit drugs like fentanyl at the border, and gives agencies more tools to improve detection and testing at border checks. • Increases penalties for drug manufacturers and distributors related to the over-prescribing of opioids.


“This bill is a major victory for Ohio and for the country because it will strengthen the federal government’s response to the opioid crisis,” Sen. Rob Portman (R-OH), who helped put together the legislation, said in a statement after the Senate vote. “Importantly, this bill will increase access to long-term treatment and recovery while also helping stop the flow of deadly synthetic drugs like fentanyl from being shipped into the United States through our own Postal Service.” On the other side of the debate, Leana Wen, M.D., the former health commissioner of Baltimore (and incoming president of Planned Parenthood), said that the legislation “is simply tinkering around the edges.” Daniel Raymond, director of policy and planning for the Harm Reduction Coalition, said the bill is a case of too little, too late. “This is an election year bill to show they are doing something.That’s not always a bad thing, but I do think to some degree it’s a political document,” Raymond told the Washington Post. “When you drill down into it, it’s not that there aren’t good ideas, but it doesn’t reach the level of, this is what our nation needs right now.” The act authorizes a grant program through the Substance Abuse and Mental Health Services Administration (SAMHSA) to allow organizations to develop opioid recovery centers in a community. It also requires the Department of Health and Human Services to determine best practices and then create a grant program implementing those policies or procedures, such as the use of recovery coaches, which has proven effective in Massachusetts.

It also authorizes HHS to develop grants to support people who are in recovery transition to independent living and jobs, as well as develop a pilot program to provide temporary housing for those recovering from substance abuse. One of the most significant parts of the bill provides measures to prevent synthetic opioids like fentanyl from entering the U.S. According to the Centers for Disease Control, total opioid deaths did not increase in 2017, but deaths due to fentanyl overdoses did. Data shows the drug, which is about 50 times more potent than heroin, caused nearly 30,000 fatal overdoses last year. The bill also takes steps to increase access to medication-assisted treatment. It removes the cap on the number of patients to whom a qualified doctor can prescribe drugs like buprenorphine, a drug proven effective at limiting opioid cravings and easing withdrawal, from 100 to 275, and expands a grant program allowing first responders to administer medication-assisted treatments.


EndPainNow LivePainFree


The Pain Management and Treatment Center has been treating Milwaukee area residents su ering from chronic pain for over twenty years. UNPARALLELED CLIENT CARE

Our experience and quality of care are unparalleled.



Americans prefer drug-free pain management. While 22 percent of U.S. adults prefer to take pain medication prescribed by a doctor to treat their physical pain, 78 percent prefer to try other ways to address their physical pain before they take pain medication prescribed by a doctor. This conclusion is based on data collected from February through March, 2017 as part of the Gallup-Palmer College of Chiropractic Annual Study of Americans. Low back pain is one of the most common sources of pain. In fact, compared with migraine pain, neck pain and face pain, low back pain is the most commonly reported type of pain that lasted a whole day or more in the U.S., according to Centers for Disease Control research.

In the study of Americans, Gallup finds that nearly two-thirds of U.S. adults (64 percent) have had neck or back pain significant enough that they saw a health care professional for care at some point in their lifetime. About one in four adults in the U.S. (27 percent) have seen a health care professional for significant neck or back pain in the last 12 months. More than half of those adults (54 percent) have had an ongoing problemwith neck or back pain for five years or more.


Among those who have had ongoing neck or back pain for less than 12 months, seven in 10 said they have taken a nonsteroidal anti-inflammatory drug (NSAID), such as Advil, aspirin or Aleve, to manage the pain, and 45 percent have taken acetaminophen, such as Tylenol. One in four of these new neck or back pain suƒerers say they took an opioid for pain management. Multiple treatment options are available for adults who suƒer from significant neck or back pain. When asked how eƒective physical therapy, chiropractic care, back surgery, prescription pain medication and self-care are at treating significant neck or back pain, U.S. adults are most likely to describe physical therapy (41 percent) as “very eƒective.”

Nearly three in 10 (29 percent) describe chiropractic care as “very eƒective,” and 22 percent say prescription pain medication is “very eƒective.” Fewer describe back surgery (15 percent) and self-care (9 percent) as “very eƒective.” Nearly a third of Americans say prescription pain medication is either “not very safe” (23 percent) or “not safe at all” (8 percent). Few Americans (12 percent) describe prescription pain medication as “very safe.” Adults are more likely to say that physical therapy methods are “very safe” than to say this about the other treatment options given. About two-thirds of adults (68 percent) describe physical therapy as “very safe,” and one-third say the same about chiropractic care. Back surgery is the least likely to be described as “very safe” (6 percent)

About half of Americans (53 percent) say they would prefer to see a medical doctor if they were to experience significant neck or back pain and they knew the cost would be the same to them, regardless of which health care provider they saw. About one in four adults would prefer to see a chiropractor over other health care professionals for significant neck or back pain. While public perceptions of options for drug-free pain management vary, Gallup says its findings suggest that Americans are aware of the dangers associated with opioid misuse and are open to drug-free alternatives for pain management. As concern over the opioid epidemic has grown, non-drug pain management options have gained more attention and acceptance within the medical community. Medical organizations, such as the Joint Commission and the American College of Physicians, have taken important steps to tackle the national opioid epidemic. The Joint Commission, the largest U.S. accreditation body for healthcare facilities, revised its hospital performance measures for pain management to include a requirement that hospitals provide drug-free pain treatments.


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As an epidemic of opiate addiction has spread across America, public health officials have cited improper disposal of prescription pain pills as a major contributing factor. A review conducted by researchers at Johns Hopkins University supports that belief. The review indicates that most opioids prescribed after surgery go unused, resulting in leftover pills that increase the risk they will be used inappropriately. In a review of six different studies involving 810 total patients, a team led by Dr. Mark Bicket, assistant professor of anesthesiology and critical care medicine at Hopkins’ School of Medicine, found that two out of three patients did not use their entire opioid prescription after surgery, and did not dispose of the pills afterward.

The study notes that dosage instructions provided with opioid prescriptions are often too vague – for example, suggesting one pill every four hours "as needed" for pain. Bicket said this causes a disparity between what people are prescribed and what they need. The unused pills increase the risk of abuse, he told The Baltimore Sun. “Many patients who use heroin transition from using opioids," Bicket said. In a review of half a dozen published studies in which patients self-reported use of opioids prescribed to them after surgery, John Hopkins researchers reported that a large majority of patients used only some or none of the pills prescribed, and more than 90 percent failed to dispose of the leftovers in recommended ways.


A summary of the review, published August 2 in JAMA Surgery, emphasizes the need for more personalized pain management to avoid overprescribing opioids and reduce risks caused by improperly storing opioids in the home. “Physicians write a lot of prescriptions for patients to fill for home use after they have inpatient or outpatient surgery, but our review suggests that there’s a lot we don’t know about how much pain medication people really need or use after common operations,” Bicket says. In their review, Bicket and his team found that 67 to 92 percent of a total of 810 patients in the six studies did not use their entire opioid prescription, yet kept their pills, increasing the risk of misuse, says Bicket. Bicket says physicians need to do a better job of personalizing prescriptions and dosing for each patient. He also advises prescribers to spend more time assessing postoperative pain and prescribe smaller amounts of opioids or alternatives, as appropriate. “If we can better tailor the amount of opioids prescribed to the needs of patients, we can ensure patients receive appropriate pain control after surgery yet reduce the number of extra oxycodone and other opioid tablets in many homes that are just waiting to be lost, sold, taken by error, or accidentally discovered by a child.” The researchers found that between 67 and 92 percent of patients reported unused opioids. A small number of patients either did not fill their opioid prescription (range of 0 to 21 percent) or filled the prescription but did not take any opioids (range of 7 to 14 percent). Overall, the researchers report, between 42 and 71 percent of prescribed pills dispensed went unused among the 810 patients.

A majority of patients reported they stopped or used no opioids due to adequate pain control, while 16 to 29 percent of patients reported they stopped due to medication side effects, such as nausea, vomiting or constipation. “We need to do more research into why some people need more medication than others. Perhaps there are some characteristics in a patient, such as whether he/she is on opioids before the surgery or has certain genetic markers, that can let me determine that one needs more pain medication than another,” Bicket says. The high rate of unused opioids found in the review indicates that doctors often prescribe more than patients need, he adds. The most important message, Bicket says, is that “we need better data and tools to ensure patients have access to adequate pain relief after surgery while reducing the risks of opioid overprescribing.”


PAINMANAGEMENT&TREATMENTCENTER We evaluate, diagnose and treat chronic pain utilizing the diversified, but combined, skills of our specially trained and highly skilled teammembers.

IMPROVING YOUR QUALITY OF LIFE Many people suering fromchronic pain fail to receive adequate treatment. Our first priority is to improve our patients quality of lifeby developinga tangible, eective treatment plan.

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MOREPATIENTS TRYING TENS FORPAINRELIEF Scientists cite limited research on results

As patients and physicians seek non-opioid treatments to manage pain, one modality that has been growing in popularity is Transcutaneous Electrical Nerve Stimulation devices, or TENS units. Transcutaneous electrical nerve stimulation (TENS) therapy involves the use of low-voltage electric currents to treat pain. Electrodes or mediums for electricity to travel to the body, placed on the body at the site of pain deliver electricity that travels through the nerve fibers. The electric currents block the pain receptors from being sent from the nerves to the brain. A patient will receive a small, battery operated TENS machine to use at home. In most cases, a doctor, physical therapist, or acupuncturist adjusts the machine to the correct settings. The provider shows the patient how to use the machine before sending him or her home with the TENS device. The first modern, patient-wearable TENS was patented in the United States in 1974. It was initially used for testing the tolerance of chronic pain patients to electrical stimulation before implantation of electrodes in the spinal cord dorsal column. The electrodes were attached to an implanted receiver, which received its power from an antenna worn on the surface of the skin. “A few studies have produced objective evidence that TENS may modulate or suppress pain signals in the brain.” -32-

Some patients found relief Although intended only for testing tolerance to electrical stimulation, many of the patients said they received so much relief from the TENS itself that they never returned for the implant. Physical therapy and chronic pain clinics have been using TENS for chronic pain for decades. TENS therapy can be used to treat both chronic (long lasting) and acute (short-term) pain. According to the Cleveland Clinic, the most common conditions that TENS therapy is used to treat are: • Osteoporosis-related joint, bone, or muscle problems • Fibromyalgia-related joint, bone, or muscle problems • Tendinitis (muscle tissue inflammation) • Bursitis (inflammation of the fluid- filled pads that cushion the joints)

• Neck pain • Labor pain • Cancer pain

“Some medical device companies have begun offering over-the- counter versions of TENS devices which patients can use at home.” Some medical device companies have begun offering over-the-counter versions of TENS devices which patients can use at home. They range in price from $50 Scientists caution that not enough research has been conducted to prove the medical effectiveness of TENS. The fact that some patients find relief could be a case of placebo effect. A few studies have produced objective evidence that TENS may modulate or suppress pain signals in the brain. In 2014, the U.S. Food and Drug Administration approved the first TENS device a head-mounted TENS device called Cefaly, for the prevention of migraine headaches. The Cefaly device was found effective in preventing migraine attacks in a randomized sham-controlled trial. This was the first TENS device approved by the FDA for pain prevention, rather than pain suppression. to $500. Many can be purchased online. More research needed

Transcutaneous electrical nerve stimulation may also represent an effective treatment for the prevention and management of migraine, according to a meta-analysis published in the Journal of Headache and Pain. Although promising, the findings presented by the researchers are based on low quality of evidence. A limitation of this analysis includes the low number of randomized trials, all of which had small patient cohorts, the authors noted. Another review of TENS results indicated that it may not provide relief from lower back pain, but may be associated with short-term improvement in functional disability. The review was

published in the journal Regional Anesthesia and Pain Medicine. Investigators evaluated 12 randomized controlled trials examining patients with low back pain undergoing TENS, control therapy (eg, placebo, sham, or medication only), or other nerve stimulation therapies (eg, electroacupuncture, percutaneous electrical nerve stimulation or percutaneous neuromodulation therapy). TENS was found to provide pain relief

comparable with that of a control therapy. At follow-up, (less than six weeks after treatment), other nerve stimulation therapies provided greater pain relief than TENS, but not at more than six weeks after treatment. TENS was also found to provide greater improvement in functional disability than control therapy less than six weeks later six weeks, but not at follow-up more than six weeks later. There was noticeable variation in intervention duration across studies, which could have affected the review’s findings, the authors said. ”Examination of more subjective parameters such as satisfaction with TENS treatment and outcome and overall perception of the treatment would add value to determination of the value of TENS treatment in [chronic back pain],” the study authors concluded.



OUR ULTIMATE GOAL: Eliminating or reducing pain

Teaching how to manage pain

Improving the overall quality of life



Trial evaluated effectiveness for common injuries

Four Groups of Patients The patients were randomly assigned to one of four groups. One group received a pill for their acute pain that contained a combination of ibu- profen and acetaminophen, the ingredients in Advil and Tylenol. The other groups were given a pill for their pain that contained a prescription opioid as well as acetaminophen, either oxyco- done and acetaminophen (Percocet), hydroco- done and acetaminophen (Vicodin), or codeine and acetaminophen (Tylenol No. 3). All the patients were asked to rate their pain immediately before taking the pain medication and again both one and two hours afterward (before they left the emergency department). The assessments were done using an 11-point scale (0 = no pain; 10 = worst possible pain). The study found that the intensity of pain was similar among all four groups before they took the medication, with a mean score of 8.7 on the scale. The pain then declined over time in all

As the over prescribing of opioid pain medications has become a major public health concern, health care providers have been paying more attention to over-the count- er-drugs that could be used instead, without the risk of addiction. A recent study published in the Journal of the American Medical Association (JAMA) has confirmed that OTC meds ibuprofen and acet- aminophen are just as effective as prescription opioids at reducing acute pain caused by com- mon injuries.It is one of the few “real world” studies that has made the comparison. A team of researchers led by Andrew Chang, M.D. of Albany Medical College, studied 411 patients (aged 21 to 64) who had sought med- ical care at two urban emergency departments after having sprained, strained or broken an arm or leg. (About 20 percent of the patients had fractures.)


individuals can become addicted even after only taking opioid pain meds for a few days. One study found that one in five people given a 10-day supply of opioid painkillers became long-term users. More M.D. Education Needed Don Teater, M.D., medical adviser of the non-profit National Safety Council, says doctors need more education to understand the draw- backs of prescribing opioids. “Doctors get a lot of training in the physical aspects of health, but not the mental aspects,” says Teater, a family physician in North Carolina whose practice focuses on treatment of pain and the treatment of opioid use disorder. “We don’t get training in addiction. Often, a doctor will start a patient on opioid pain med- ication and continue it for awhile. Then if the doctor feels the patient is asking for too much medication, the doctor will cut them off, and abandon them. There needs to be a greater understanding of the emotional component to pain. We also need to have a better under- standing of the disease of addiction.” According to a white paper from the Council, there is little evidence that opioids are helpful when used for chronic pain.

four groups – and by similar levels: 4.3 points in the ibuprofen/acetaminophen group, 4.4 points in the oxycodone/acetaminophen group, 3.5 in the hydrocodone/acetaminophen group and 3.9 in the codeine/acetaminophen group. The researchers said the major limitation of the study is that it had the patients assess their pain only while they were in the emergency department. The study did not evaluate how the ibuprofen/acetaminophen combination would work in comparison to opioids once the patients went home. Also, the participants had a specific type of acute pain – from sprained or broken arms and legs. “Preventing new patients from becoming addicted to opioids may have a greater effect on the opioid epidemic than providing sus- tained treatment to patients already addicted to opioids, in whom it may take many years to achieve recovery,” Demetrio Kyriacou, M.D., a senior editor at JAMA and a professor of emer- gency medicine at Northwestern University, wrote in an accompanying editorial. Yet, as Kyriacou also acknowledges, “stemming the opioid addiction crisis will … require reex- amination of the long-standing assumptions that opioids are superior to

non-opioids in most clinical situations requiring man- agement of moderate to severe pain.” Studies have shown that nearly one-third of adult patients seeking care at U.S. hospital emergency departments are given prescriptions for opioid painkillers, even if their visit was not pain-relat- ed. That is a dangerous practice, since some

“In fact, some evidence shows they may be detri- mental and increase risk of addiction and premature death,” the paper says.

There is little evidence that opioids are helpful when used for chronic pain.


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Is Drug-Free Pain Management Month

U.S. who wage an ongoing battle with acute and chronic pain and are searching for instant relief. They often turn to prescription pain medications for treatment of headaches, including migraines, low back pain and/or general aches and pains. Pain is associated with a wide range of injury and disease, and is sometimes the disease itself. Some conditions may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be conditions in which pain constitutes the primary problem, such as neuropathic pains or headaches. The effects of pain exact a tremendous cost on our country in health care costs, rehabilitation and lost worker productivity, as well as the emotional and financial burden it places on patients and their families, according to the AAPM. The costs of unrelieved pain can result in longer hospital stays, increased rates of rehospitaliza- tion, increased outpatient visits, and decreased ability to function fully leading to lost income and insurance coverage. As such, patient’s unrelieved chronic pain problems often result in an inability to work and maintain health insurance.

eptember, 2018 has been designated as Na- tional Drug-Free Pain Management Aware- ness Month: an opportunity to raise public awareness about the dangers of prescrip- tion and over the counter (OTC) pain medications. It is also an opportunity to educate consumers about drug-free options to safely and effectively relieve chronic pain. In 2016, the Centers for Dis- ease Control and Prevention (CDC) documented over 42,000 individuals in the U.S. died from an opioid-related overdose, totaling more than 115 fatalities per day. Last year alone, the number of deaths associated with opiate painkillers increased by 27.7 percent. Also, over-the-counter pain relievers increase the risk of health complications when misused or taken in higher doses than what is recommended. Risks include ulcers, gastrointestinal bleeding, liver and kidney damage and increased risk of cardiovascu- lar events. Nearly 200,000 Americans who misuse OTCs wind up in the hospital each year. An Everyday Battle With Pain According to the American Academy of Pain Med- icine (AAPM), there are 100 million people in the


According to a recent Institute of Medicine Re- port: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, pain is a significant public health prob- lem that costs society at least $560-$635 billion annually, an amount equal to about $2,000 for everyone living in the U.S. This includes the total incremental cost of health care due to pain from ranging between $261 to $300 billion and $297-$336 billion due to lost productivity (based on days of work missed, hours of work lost, and lower wages). While acute pain is a normal sensation triggered in the nervous system to alert you to possible in- jury and the need to take care of yourself, chronic pain is different, according to the AAPM. Chronic pain persists. Pain signals keep firing in the ner- vous system for weeks, months, even years. Chronic pain has many causes There may have been an initial mishap – sprained back, serious infection, or there may be an ongo- ing cause of pain – arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults. Common chronic pain complaints include head- ache, low back pain, cancer pain, arthritis pain, neurogenic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself). A recent market research report indicates that more than 1.5 billion people worldwide suffer from chronic pain and that approximately 3- 4.5 percent of the global population suffers from neuropathic pain, with incidence rate increasing in complementary to age. Because much more needs to be done to meet these challenges, raising public awareness of the chronic pain problem is one of the missions of the AAPM.

Pain is a significant health problem that costs society at least $560 to $635 billion annually.



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WE utilize every tool available to them to achieve pain relief for patients. When it is not possible to completely get rid of the pain, we can assure patients that we do our best to make the pain tolerable in order to improve the quality of their lives.


VA study looked at back, knee and hip pain

re opioid medications the most effective treatment for chronic pain, in spite of the addiction risks they pose?

Half Received Opioids Half were treated with opioids and half with non-opioid medications – either common over-the-counter drugs like ac- etaminophen or naproxen, or prescription drugs like topical lidocaine or meloxicam. Patients were recruited from 62 Minneap- olis VA primary care clinicians from June, 2013 to December, 2015 Patients were randomly assigned to either an opioid group or a non-opioid group, both starting with low-intensity drugs but able to move to stronger medication, if necessary. After 12 months, the results showed that patients given alternative drugs did just as well as those taking opi- oids in terms of how much pain interfered with their everyday life. And, they reported slightly less pain and experienced fewer side effects.

Over the past 20 years, opioids have become many physicians’ “go to” answer to helping their patients with chronic pain. However, a study published earlier this year in the Journal of the American Medical Association (JAMA) produced a surprising answer to that question. The Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) study was the first long-term, randomized, controlled trial comparing opioids with non-opioids for treating chronic pain. Beginning in 2012, the study funded by the U.S. Department of Veterans Affairs and conducted at the University of Minnesota, involved 240 veterans with chronic back pain or pain from osteoarthritis of the knee or hip. They also all had pain that was on- going and intense.

The trial’s lead author, Erin Krebs, M.D., conceived the study after becoming aware

To be eligible for the study, patients had to have been experiencing chronic pain while also being on an analgesic drug; patients could not already be using a prescribed opioid for chronic pain.


group had less pain intensity and the opioid group had more side effects,” such as constipation, fatigue and nausea, Krebs says. The study didn’t explore why, but Krebs believes the reason is opioid tolerance.“Within a few weeks or months of taking an opioid on a daily basis, your body gets used to that level of opioid, and you need more and more to get the same level of effect,” she says. “This study adds the long-term evi- dence that shows that opioids really don’t have any advantages in terms of pain relief that might outweigh the known harms that they cause.” People suffering with chronic back or arthritis pain, are better off not starting on opioids, Krebs says “Medications have some role, but they really shouldn’t be the primary way we are treating chronic pain,” she says. “For osteoarthritis pain, the strongly recommended treatments are exercise treatments,” she says, and it’s import- ant to maintain a healthy weight. “The same things go for back pain,” she says. For that, pain management experts recommend exercise, rehabil- itation treatments, yoga and cognitive therapies, among others.

of a lack of scientific evidence com- paring the effectiveness of opioid versus non-opioid medications. “Long-term opioid therapy became a standard approach to managing chronic musculoskeletal pain despite a lack of high-quality data on benefits and harms,” the JAMA article notes. Patients were then randomly placed into two groups. In the first group, pa- tients would be prescribed an opioid medication, whereas in the second group, they would be prescribed a non-opioid alternative medication. Placebo Effect Studied “The studies that we had out there were short-term studies and mostly compared opioids to placebo medi- cations, Krebs told NPR. “From those studies, we knew that opioids can improve pain a little bit more than a placebo, or sugar pill, in the short term, but that’s all we knew,” says Krebs, a Core Investigator at the Minneapolis VA Center for Chronic Disease Outcomes Research and Associate Professor of Medicine at the University of Minnesota. Doctors and patients knew what group they were in, Krebs says.“We found at the beginning of the study that patients who were enrolled really thought that opioids were far more effective than non-opioid medications,” she says. But after about nine months, even with those expectations, the non-opioid group reported their pain was slightly less severe than the opioid group. At the end of the year, “there was re- ally no difference between the groups in terms of pain interference with ac- tivities. And over time, the non-opioid

Source: National Insititutes of Health (NIA)


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