Pain management field now widely regarded
Millions live pain-free, thanks to variety of treatments & therapies
BY LIBBY MCMILLAN Special to Florida Weekly

DAITCH

Thirty years ago, if a person had chronic pain - defined as pain lasting longer than 4-6 months - his or her medical options were very limited. Narcotics. Surgery. "Live with it."

Sometimes, the first two failed and "Live with it" was all that was left. Doctors often treated the symptom of pain without being able to address its underlying cause. They weren't negligent; at that time, there was very little known about how to control or alleviate pain. There were no clinical studies on pain management, nor were there physicians who specialized in it.

Today, thankfully, the story has changed considerably, and Southwest Floridians

join the millions of Americans who no longer live with pain, thanks to the field of interventional pain management. Fort Myers physician Dr. Jonathan Daitch was one of

the earliest physicians in the field, and has since achieved the highest certification possible in pain management.

Daitch's early medical career was as an anesthesiologist in the U.S. Air Force. "We were very involved in doing various injections around the spine for surgical anesthesia," he says, "but we realized the same tools could be used to help people who had pain." Soon he and a partner opened an early pain management center, and, like other pioneers in the industry, began sharing success stories with fellow colleagues. The methods used for surgical anesthesia had other uses indeed. "We were using the same types of injections to treat patients with chronic back pain and sciatica," Daitch explains.

ACOSTA

Today, the practice he shares with two partners - Advanced Pain Management and Spine Specialists - uses state-of-the-art treatments and therapies for patients with back pain, neck pain and sciatica, as well as "many other types of pain that we're able to diagnose and treat as well," he says. It was the first medical practice in Southwest Florida devoted only to the care and treatment of patients who suffered from chronic pain. Physicians there are all Board-Certified by the American Board of Interventional Pain, in addition to their other board certifications in anesthesiology, Physical Medicine and Rehabilitation, and Addiction Medicine.

Medical technology and procedures are advancing so fast that it's difficult for consumers to keep up. This is part six of Florida Weekly's eight-part series examining what's new in medicine in Southwest Florida. NEXT WEEK: Audiology

Another prominent pain management practice, Pain Management Consultants of SW Florida, also sees a wide variety of people who have been suffering from chronic pain. "Maybe two thirds of what we see are people beyond their 50s," says Dr. Gilberto Acosta," but the other third is younger." Many of the younger patients have work-related injuries. Some have been in car crashes. Others have sciatica, the common name by which most people refer to a condition in which pain is radiating into the leg, but its origin is in the spine. It affects both men and women, of all ages.

"Sometimes with chronic pain conditions," explains Acosta, "there's pain that radiates into the extremities. And there are other esoteric conditions not related to the spine, but are also chronic conditions, such as headaches and other chronic pain issues" also drive people to seek help.

Interventional mission statement

The goal is to avoid the knife. "Well over 95 percent of patients with pain can be treated by us without surgery," says Daitch. For the small percentage who can't, "We work very closely with spine surgeons here in town," he says. "If we have a condition we're unable to treat, that we feel would be better treated with surgery, then we recommend them to a surgeon."

A common misconception about pain specialists is that all they do is write prescriptions. "We don't want people to think our main focus is prescribing oral medications for problems," says Daitch. "In order to treat pain, you have to diagnose the underlying condition, and not just give people oral medication to cover up the problem." Referencing the crux of his field, he explains, "One of the problems with just treating pain conditions with oral pain medications is that patients get resistant and tolerant to the oral pain medications, and then they stop working entirely. Then you have people on very high doses of pain medication," he says, "and the meds are not working. Prescriptions are only given as a last resort in his field, he says.

"Actually the scrips are just a minor portion of treatment," says Dr. Acosta. "We treat many of the chronic pain conditions with injections or therapies." Interventional pain management tries to "quiet down the swelling and inflammation that is associated with the underlying symptom," he says. He cites a herniated disc as an example, explaining the herniation itself leads to inflammation and swelling of the tissues in and around the spine, where the herniation took place. That compounds the problem and makes it worse. As the swelling and inflammation get better, the pain can improve," he says.

Hope in a needle

The injections that Acosta is referring to feel like life-savers to many. "The simplest one to explain is the epidural steroid injection," he says. "It's a way of getting medicine into the spine," he says.

One state-of-the-art injection therapy is also an injection treatment, but doesn't rely on steroids. "This is something called the radio-frequency injection treatment," says Dr. Acosta, "which is also a way of treating a number of chronic pain ailments affecting the spine, without the need of using high-dose steroids. There are certain problems that can be treated with this procedure," Acosta explains, "and the advantage is there's much lower need for the use of steroids," (which can have side effects) "and the outcomes are also potentially longer lasting."

It will initially surprise many readers to learn that Botox is also an effective agent against pain. Because it profoundly relaxes muscles (some would say 'temporarily paralyze' but pain doctors don't like that phrase), Botox is used to treat conditions in which a patient has painful muscle spasms. An injection of Botox into the affected muscles can treat not only the painful condition, but also its source.

Many pain specialists administer injections with the aid of fluoroscopy, essentially a portable x-ray machine that allows doctors to look at the target, get a better picture and place needles in a very precise fashion, making the treatment more accurate and effective.

People can get better for several weeks to many months at a time," says Dr. Acosta, of injection therapy. "As long as people can respond without significant complications, they can have more."

Some patients with osteoporosis will develop exquisitely painful fractures of the spine. In vertebroplasty, a needle is used to put medical-grade cement into the vertebrae. It goes in as a liquid and hardens in 10-14 minutes. The results are instantaneous. This procedure is done following x-rays and MRIs, to determine the actual fracture location. People who hobble in for treatment often have no pain when they leave. "That's one of the most rewarding aspects:" says Daitch, "treating people who have vertebral fractures."

Some vertebrae are stacked on part of the pelvis - the sacrum. If an older patient with osteoporosis falls onto the buttock, and develops a fracture of the sacrum, Daitch and his colleagues can opt for sacroplasty - placing medical cement directly into the fracture site. "Our group is the only place within probably 100 miles treating fractures of the sacrum," explains Daitch, "and we're involved in the largest study to date, of treating people with sacral fractures."

Discography is used for those rare patients with severe back pain that has failed all other types of treatment (including oral meds, physical therapy, and injections). Under x-ray guidance, x-ray dye is injected into several spinal discs, to discover which are abnormal and also which reproduce the patient's pain exactly. Once doctors have diagnosed which disc or discs are the underlying problem, they can do a procedure to repair the torn, painful disc, or they will recommend surgery if they feel it's a better option.

"There's a lot that we can do," says Dr. Acosta. "I encourage people to look into it and not be afraid. These injections are very safe. The are very unlikely to make the situation worse, and they have a lot of potential for improving the underlying problem." Most of the procedures are out-patient therapies, he explains. "We numb you up with local anesthetic," he says. And there are certain procedures that are done with a very light sedative, so the patient is not as anxious. "There's always some degree of discomfort," he admits, "like the dentist. But a lot of the time we can do a lot to help. We are trying to prevent patients from having to have surgery," he says, "or we are dealing with cases where surgery is no longer an option."

Seeking alternatives

Many Americans look outside the traditional medical system for help with pain. The holistic approach of chiropractic has become so accepted in the past few decades that insurance companies now pay for treatment.

Dr. Linda Stevens, of Stevens Family Chiropractic, uses a unique therapy, called the VAX-D table, to treat herniated discs in the lower back, and chronic degenerative discs, which cause lower back pain. "The table decompresses the disc," she says. "It will actually pull that disc back into its normal position." Stevens uses the VAX-D after first looking at x-rays and MRIs.

Traditional chiropractic treatments actually move a bone back into the proper position.

"You're relieving subluxations," Stevens explains. "A misalignment that's less than a dislocation."

"People suffer far too long," she says, "and sometimes it's just a matter of getting themselves checked. They've had years of pain that they could have done something about. There are alternatives." Chiropractors adjust not only the spine but the extremities, too. "A lot of people don't realize that," she says. "Some people have wrist pain or ankle pain, and you can make adjustments that get rid of it, if there's no fracture. You get pain relief."

Stevens recommends preventive chiropractic visits, what she calls wellness care. "It's always best to come before you hurt," she says, "because by the time you feel the pain, the problem's been going on for a while. Pain is always the last thing to occur. Every 4-6 weeks are what we find to give the best results."

"I've seen people who have tried so many different things, and they come in with a problem they've had for years, and have one treatment and it's gone." Sometimes it takes more, she explains, but the results are usually positive.

The nerve impingements that chiropractic adjustments relieve are caused by a myriad of reasons. "Stress, emotional trauma, bad posture, little microtraumas that happen every day, injuries . . ." Stevens ticks off the list of pain catalysts.

Stevens also practices the ancient art of acupuncture, for which she went to school. "It can help control pain," she says, "or it can help get rid of the pain if there is something going on with the energy blockages in the body. Acupuncture goes to the cause of the pain."

Stevens gets many of her patients by word-of-mouth referrals, but also from area doctors. In turn, she will also send patients to an interventional pain specialist if she feels they could benefit from therapies he provides.

The Latest in the Medical Field

"The newest technologies in pain management involve a number of implants that we put in the body," says Dr. Acosta. "These are specifically for the treatment of people who continue to have pain after multiple spinal surgeries and they don't get better, they don't improve." He explains that after one to three surgeries without improvement, the likelihood of the pain decreasing becomes very small.

"There are implantable technologies that are of potential advantage to people in those situations," says. The spinal cord stimulator is a gadget the size of a pacemaker - small - and it's implanted under the skin. From this pulse generator, there are a number of wires implanted into the spine, which provide an electrical stimulus to the spinal cord, which in turn blocks the transmission of some of the pain impulses." In effect, it helps the pain.

The intrathecal pump is another state-of-the-art implantable device. Its purpose is to deliver pain meds directly into the spine. By injecting directly into the spine, you're delivering the med really close to some of the spine receptors that are involved in the actual mechanisms that allow the meds to work. When you ingest, you swallow it, it goes to the digestion, then the bloodstream, and then it acts. This way, doctors are using much smaller amounts, and the effects are much more potent," he explains.

Message to sufferers and their families

"We recognize that pain impacts not only the patient but also their entire family," says Daitch, of his colleagues. "As pain physicians, we want to maintain open communication between the treating physician, the patient and their family. And I think patients and families need to understand that there may not be any one-time treatment which is going to cure the underlying condition, but if they find a competent interventional pain management physician, that person will work hard to diagnose and find a long-term treatment for their condition."

"If people are having pain," says Daitch, "they need to see a primary care physician. If they're not bringing up the subject, then they need to get more proactive. Do some research online. Be a little more inquisitive with the primary care physician." Patients who do so will be referred to a specialist sooner, he says. And when it comes to pain management, everyone agrees: sooner is better.