Ask a Doc: Pain Management Options

• By:  Emily Laubham
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Dr. Abraham "Jack" Kabazie, system medical director of the division of pain medicine at Allegheny Health Network (AHN), has spent decades treating patients who have chronic pain. He has lead development of organizational policies around opioid prescribing and provided expert testimony to legislative bodies grappling with the ongoing crisis around opioid use disorder and overdose deaths.

As part of AHN's Enhanced Pain Management Program, Dr. Kabazie has also witnessed the value of alternative pain management approaches. But, he points out, there is no one-size-fits-all solution for the approximately 50 million Americans who suffer from chronic pain (lasting more than 12 weeks).

"You can't just cherry pick options, and if they don't work, tell a person to go away," he says. "If you're going to be a pain physician, be a pain physician — you have to work with each patient to find the best solution."

In our interview, we discussed the range of pain management options, issues around prescribing opioids, and avoiding a scenario where someone dealing with significant pain is “cut off” from opioids and either turns to illicit drugs or suffers silently, potentially creating additional physical or mental health problems.

The evolution of pain management

Emily Laubham: Can you describe how pain management has changed over the years?

Dr. Jack Kabazie: In the late 1980s and 1990s, the thought process regarding opioids was completely different. Based on faulty data, doctors were prescribing a lot of opioids, thinking it was safe. Later, in light of overdoses and other problems, we realized we had a runaway horse. You can think of what followed as a sort of over-correction. The fear of God was put into physicians about prescribing opioids, and many primary care providers (PCPs), which prescribed the most as a group, stopped prescribing opioids entirely. Unfortunately, that included patients who could benefit from opioids. To be clear, reducing opioid prescription rates is an important piece of the puzzle. But, by itself, it hasn't stopped the problem of heroin overdoses, and the more recent increase in overdoses involving synthetics like fentanyl.

We were and still are faced with the dilemma of deciding when opioids are appropriate. The reality is that opioids have their place in pain management — but it's a smaller subset than we once believed. And when opioids are not appropriate, we still have to address the issue of effectively managing someone's pain, and if they are on opioids, safely weaning them off.

Emily Laubham: Pennsylvania and other states have prescription monitoring programs — does AHN have its own policy regarding prescribing opioids?

Dr. Jack Kabazie: Yes, we first developed a policy in the 2000s. It took about a year to develop, but that policy still exists today. A key point is that physicians who prescribe opioids for longer than three months are responsible for referring the patient to one of the pain medicine specialists we have throughout the system. That doesn't mean the initial physician is doing anything wrong — we're just building in a specialist evaluation to assess whether it's reasonable to continue prescribing. If not, or if the physician is uncomfortable with continuing to prescribe, we can take over care of the patient, safely wean them from opioids, and offer other treatment options.

We also developed a patient-physician opioid agreement. Both parties sign, and then we monitor use through drug screens, pill counts, etc. We've been deeply involved in the broader enterprise response around opioid use disorder over the past several years as well.

Managing the risks of opioid use

Emily Laubham: Can you discuss the criteria used to determine whether someone is a good candidate for using opioids as part of pain management?

Dr. Jack Kabazie: The initial evaluation is very important. There's a genetic component, and we ask about family history — has anybody in the family suffered from a substance use disorder, whether it's alcohol, opioids, or some other substance? We also ask whether the person is currently on opioids or has been on opioids before.

A perfect candidate has a well-defined pain generator that can't be addressed in any other way. They have very little (if any) psychological overlay, function at a high level, and have failed to get relief from other procedures. Good examples would be someone who has had multiple back surgeries or someone with severe rheumatoid arthritis who is on disease-modifying drugs without improvement in their pain.

Many cases have gray areas. For example, a 70-year-old patient may have a pain generator that could be addressed with surgery, but they have so many underlying comorbidities that surgery isn't a good option. The better choice in that case might be low-dose opioids that help them manage the pain and improve day-to-day functionality. If we're not sure what is causing pain, that creates a gray area. Some types of pain, including most neuropathic pain for example, don't respond well to narcotics. Another gray area would be a patient who has pain that's out of proportion to the medical findings.

Emily Laubham: If someone is a candidate for starting opioids, how can a health system reduce their risk of developing opioid use disorder?

Dr. Jack Kabazie: There's no fool-proof way, but first, we start low and slow. Second, the closer the patient is monitored, the better off they will be. Monitoring is a big undertaking, and some practices just don't have the personnel to do it well. That’s one reason they send patients to us. We do drug screens, including urine tests, and pay very close attention in general so we can spot any red flags and intervene as soon as possible.

I'll add that it's not true that everyone on opioids ends up having to increase their medication dosage. Many patients stay on the same dose for years, even underutilizing it sometimes, with great results.

Emily Laubham: What are some scenarios where you want to stop or reduce opioids, and how do you ensure that people aren't "cut off" in a way that might result in them turning to street drugs?

Dr. Jack Kabazie: We have patients come in who have been prescribed more opioids than necessary. That's not their fault, or even necessarily their doctor's fault — but it's something we address. Another example would be a patient who has morphine or other substances in their urine that aren't supposed to be there. That's probably the most difficult situation, legally and ethically. My first priority is keeping the patient safe, and I can't give someone opioids if they're taking additional medication that could cause them harm. Another common situation is where we've done a procedure, opioids were used to manage the initial pain, but they're doing really well, so now it's time to wean them off slowly.

Weaning slowly is key, and we factor length of time using and dosage into just how slowly we wean. During the weaning period, we monitor for abstinence syndrome or withdrawal. We're very experienced at weaning people. We also have an opioid use disorder program that uses buprenorphine. Those patients do extremely well. Some people see this as just replacing one drug with another, but that's not true. Buprenorphine is part of evidence-based treatment — it's medication to treat a disease.

Non-opioid pain management options

Emily Laubham: Do you certify for medical marijuana as an alternate to opioids?

Dr. Jack Kabazie: Yes. I used to be a naysayer on medical marijuana, but we studied it, we saw the benefits, and then we created policy to make sure we do it right. Like anything else, marijuana doesn’t work for everyone. However, it's often a reasonable alternative to opioids — we've used it to keep people from having to start using opioids, and to get hundreds of people off opioids or significantly decrease their opioid load.

We don't charge people for a medical marijuana certification, but they have to visit us to determine if they're a candidate, which insurance usually covers. If they're a good candidate, we teach them about different types and strains — it's a lot of education. And, again, we then do urine drug screens to make sure someone is using their medical marijuana appropriately. We also have patients sign a medical marijuana consent form.

Emily Laubham: Can you give us a high-level overview of some alternative pain management approaches that don't involve medication at all?

Dr. Jack Kabazie: We've had success with acupuncture and medical massage. We'll do an initial set of sessions with those, and if more are needed we then refer someone to others in the community. We have behavioral health specialists embedded with us who teach coping skills and use cognitive behavioral therapy (CBT). And we also have a biofeedback machine.

Whether there's medication prescribed or not, we'll do everything in our power to help, but I want the patient to understand that they have a role to play in pain management, too. I don't practice paternalistic medicine.

Emily Laubham: Can you give some examples of what the patient can do?

Dr. Jack Kabazie: It's the basics. If you own a car, you have to put gas in the tank, change the oil, rotate the tires. With your body, I tell all my patients that exercise is medicine — and it can be as simple as taking a walk. What you eat and whether you're sleeping well also have an impact. And I talk to patients about cigarettes and alcohol.

Emily Laubham: Does that kind of conversation ever elicit frustration?

Dr. Jack Kabazie: It depends how you present it. We talk about those basics as part of pain management, but you also have to validate a person's pain first. If someone comes in with pain, take them at their word. If you don't do that, you'll lose them from the get-go. Whatever you might ultimately recommend as part of treatment, patients are not likely to engage unless you validate their pain. Good medicine is about gaining trust and building a relationship over time.

Lower back pain

Emily Laubham: Let's talk about one of the most common problems: lower back pain. How does treatment play out across the spectrum?

Dr. Jack Kabazie: 80% of the population will have back pain at some point, whether that's acute or chronic back pain. Back in the day, we would tell people to take bed rest for two weeks. Now, we know that's terrible advice. Maybe a couple days of rest, but in general, you should get up and move.

More often than not, isolated low back pain in someone who is otherwise fairly healthy will get better after a day or two of rest, some physical therapy (PT), and nonsteroidals. However, a subset of patients will have back pain that lingers for weeks or months, sometimes worsening, other times remaining at a consistent level. This can interfere with their sleep and day-to-day living. PT would usually have a major role here, and for patients who can't tolerate land therapy, we'd use aqua therapy and/or acupuncture. In some cases, also seeing a chiropractor may be a good option.

With lower back pain, especially acute pain up to four to six weeks duration, another point to make is that diagnostic imaging isn't always helpful. We don't want people to go through the time and potential costs of getting imaging done unless we think it will have value. Similarly, on the treatment side, there is a growing body of evidence about when certain surgical procedures will be effective and when they won't.

Enhanced Pain Management Program

Emily Laubham: Let's talk about the Enhanced Pain Management Program specifically. What is it doing differently?

Dr. Jack Kabazie: The main difference is how our program brings everything under one roof — acupuncture, massage, CBT, medical marijuana, procedures, medication management and more. This one-stop approach to care really does make the patient's life easier and ensures more coordinated, effective treatment. For patients who want to utilize the program's services but lack transportation, we recently received a grant which provides transportation free of charge.

Emily Laubham: How does someone get referred into the program?

Dr. Jack Kabazie: Most patients are referred by surgeons, PCPs, or rheumatologists. But they can self-refer, too. They can contact the call center and say, "I'd like to see a pain specialist because of this chronic issue," and they'll be scheduled for an appointment with one of our pain doctors. We accept a range of insurance types, as well as workers' compensation cases, so the program is accessible to most.

Emily Laubham: I know the program helps many different patients, but can you talk about how you measure success?

Dr. Jack Kabazie: The first priority is to set reasonable goals — if you don't do that early, the patient and physician will both be dissatisfied. The goal isn't always to eliminate pain completely. In fact, I often tell patients that pain is inevitable, but suffering is optional. So success might mean you still have some pain but you’re not suffering — you're functioning better, and we're managing the pain in ways that minimize other risks. Harm reduction is also important — if we can reduce someone's pain in a way that allows us to lower their opioid load or eliminate it entirely, that's a success.

There are clear results or measures of success with certain procedures, such as reduction of pain, reduction of medication used, and improved quality of life. After a procedure, if the patient's feedback is that it worked and they feel great, then we ask them to return as needed and typically everyone feels good about that. It's often more complicated though. Success may mean we reduced pain from an eight on the pain scale to a three. That isn't zero, but it's much better, and it may mean they're able to get better sleep or do some things they just couldn't do before. We look at function and enjoyment of life as important indicators of success.