Chronic or persistent pain affects more than 100 million Americans to the extent that they can't work, participate in physical activity or generally enjoy day-to-day activities. Chronic pain is often associated with depression, decreased productivity and can lead to an overall poor quality of life. Furthermore, more than half of cancer patients in the U.S. report uncontrolled pain in their last months.
Here Christine Chang, M.D., assistant clinical professor of psychiatry in City of Hope’s Department of Supportive Care Medicine, explains how interventional pain medicine can provide relief to chronic pain suffers, as well as the new pain-relief methods in use today.
What is interventional pain medicine and what role does it have in cancer care?
Interventional pain medicine is a subspecialty of medicine that is a “hybrid” and derivative of various other specialties, including anesthesiology, neurology, psychiatry and rehab medicine. In addition to medications for pain, interventions can and also should be utilized to directly deliver an anesthetic to an affected area. This generally results in a much smaller overall drug dosage than with oral medications. The procedures are guided by X-ray and include nerve blocks, plexus blocks, joint injections, neurolysis, implantable intrathecal drug delivery and neuromodulation techniques to disrupt transmission of pain signals.
What are some examples of interventional treatments?
In cancer-related pain, the pain is often abdominal, pelvic, bony or a sharp shooting nerve pain. Interventions include celiac plexus blocks for abdominal pain, hypogastric and ganglion impar plexus blocks for pelvic or rectal pain, epidural or selective nerve root injections for spinal and radicular nerve pain, and intrathecal pain pumps that deliver a tiny but potent dose of anesthetic directly into the spinal fluid for pain control. Spinal cord stimulation and peripheral nerve field stimulation are excellent treatments for low back and extremity pain, as well as for facial pain and headache. These same interventions also are suitable for chronic pain that is not related to cancer, but a result of aging, degenerative joint disease, and trauma or chronic postsurgical pain.
What are emerging developments in interventional pain medicine?
Interventional pain medicine, as a specialty, is a relatively new one that's goal is to properly diagnose and treat chronic pain and overall suffering with a multidisciplinary approach. This entails a responsible prescribing of pain medications, safe practice of procedures, and help for the patient coping with the impact that chronic pain has had on their lives and relationships. Cognitive behavioral therapy, group therapy, hypnosis and acupuncture also are available through our service to improve a patient’s quality of life.
More and more practices are using this multidisciplinary approach, with input from physical therapists, psychologists, case managers and social workers, to help the patient.
Where is the field of interventional pain going, and what do you think will be accomplished in the next five to 10 years?
In less than five years, I think our service will be joining with presurgical regional anesthesia to prevent and reduce chronic postsurgical pain from developing here at City of Hope. I’d like to see in five years a conversion from intravenous patient controlled analgesia to intrathecal pumps, particularly earlier in the course of illness, thereby reducing hospital admissions for pain and reducing the major side effects of systemic opioids.
I’d also like to find a better option for patients with severe graft-versus-host skin disease, with resultant horrible pain and sclerosing of their skin, and if spinal cord stimulation may be an option for them.
In 10 years, I think we will be seeing more deep brain stimulation being done here for chronic pain, in collaboration with neurosurgery.
Why did you choose this specialty? What inspires you to do the work that you do?
I chose this specialty after first completing a residency in psychiatry, then an interventional pain fellowship. There are not many psychiatrists that do procedures, but the fields have the same purpose: to hear a patient’s narrative, respect and be there for them, and provide relief of their pain and emotional suffering.
I’m very lucky to be able to do both aspects of my job, and seeing patients get better brings me joy.