Interventional pain
Dr. Willis Interview
Dr Willis is the Medical Director for the Alabama Pain Center located in Huntsville, Alabama. He has been a full time interventional pain management physician for the past 12 years. His multidisciplinary pain management approach has earned the Alabama Pain Center the respect of pain management colleagues nationwide. Following completion of a surgical internship and an anesthesiology residency, he completed his pain management training with Dr. Gabor Racz in Lubbock, Texas in 1985. Since then he has served not only as a full-time clinician but also as a well recognized educator internationally. His particular areas of interest have been with implantable pain therapies, catheter directed neuroplasty techniques (Racz procedure), and serving as chairman for the committee on development for pain treatment algorithms for the American Neuromodulation Society.
Pain.com: Dr. Willis, what qualifies you to be able to discuss interventional pain therapies?
Dr. Willis: I have been a full time pain management physician since 1987. Prior to that I had formalized training in general surgery, anesthesiology and pain management. My background education includes extensive training with Dr. Gabor Racz, one of the foremost pain management experts in the world. I am a member of all major national and international pain treatment and educational organizations and a founding member of the American Neuromodulation Society. My career has been devoted to the full time practice of pain management for the past 12 years. This has given me the opportunity to evaluate and treat in excess of 10,000 patients with difficult and intractable pain problems over that period of time. For the past 10 years I have been actively speaking at many of the most prestigious pain meetings in the United States. This gives me access to some of the greatest minds in pain medicine and an opportunity to keep updated with state-of-the-art therapies as they develop. These therapies are added to my practice, clinically evaluated over a period of time and become incorporated into my practice as they prove to be safe and effective treatment options. All of this gives me a unique and relevant clinical experience to discuss both the older pain therapies as well as recent developments.
Pain.com: What is meant by interventional pain treatment?
Dr. Willis: Simply put, interventional pain treatment includes any and all efforts to "intervene" in the production and/or transmission of a pain signal within the body. In most cases, this means identifying and treating the underlying cause of a particular pain or pain complex and by virtue of encouraging the healing process the pain is subsequently reduced or resolved. In other cases where the pain pathology has no ability to heal despite medical or surgical therapy, the intervention takes on the form of "pain control." This can be done by using medications aimed at reducing the ability of the body to transmit the pain signal to the brain or, in more advanced cases, by utilizing an implantable device to alter the ability of the body's nervous system to transmit that pain signal. Still other methods rely on the physician's ability to damage nervous tissue in a controlled manner to stop the pain signal.
Pain.com: What kind of medications can be used to control pain?
Dr. Willis: The most common medications used to control pain are opioids, also known by the more common term "narcotics". These were originally thought to be inappropriate for the treatment of any pain other than cancer pain because of their potential for abuse and addiction. Many studies performed in the late 1980's and early 1990's have revealed these to be exceptionally safe and effective for the treatment of certain chronic pain syndromes.
Pain.com: But aren't narcotics known to be addictive medications?
Dr. Willis: Yes, they can certainly be used inappropriately with the potential to do harm but it has been well established over the past ten years that the addictive potential of the drugs are far outweighed by their overall safety and effectiveness. Their ability to provide control of certain types of pain is well documented. While legal and political systems remain somewhat slow in evolving to recognize this therapeutic benefit, the wheels are turning and many state legislatures are adopting "pain treatment initiatives" allowing physicians to provide therapeutic doses of oral narcotic for long-term chronic disabling pain. This puts the responsibility in the hands of treating physicians to use these medications appropriately. This responsibility includes establishing a proper dosage schedule and appropriate oversight and documentation to restrict a patient's ability to abuse these medications. Under such conditions these drugs can be used effectively (sometimes in remarkably high doses) without the patient developing addictive behavior and without dangerous side effects. In many ways opioids are one of the safest medications known to man.
Pain.com: Can narcotics be used to treat any type of pain problem?
Dr. Willis: It has been well know for many years that narcotics are extremely effective for pain originating within the musculoskeletal system. This would include pain from arthritic conditions, painful muscle conditions, broken bones, torn ligaments and tendons and pain of spinal disc origin. Pain of nerve origin (neuropathic pain), unlike pain of musculoskeletal origin (nociceptive pain), is only modestly responsive to opioid medications. Narcotics are often used to treat neuropathic pain but much higher doses are used with dramatically less success. It would be wrong to say that pain of nerve origin does not respond to narcotic medication but it would be appropriate to say that it is fairly non-responsive to narcotic medications. Under such conditions, other medications are usually more appropriate and more successful in treating neuropathic pain.
Pain.com: What medications would best be used in treating pain of nerve origin?
Dr. Willis: These generally fall under the category of anticonvulsants such as Tegretol, Depakote, Dilantin and more recently, Neurontin. These have been traditionally developed and used as seizure drugs but by virtue of their mechanism of action of controlling abnormal electrical activity within the brain (seizures), abnormal electrical activity in the peripheral nervous system (pain) can, likewise, be reduced and controlled to some degree. While these drugs are quite effective, in many cases patients are unable to tolerate these medications in sufficient doses to provide significant pain relief. Nonetheless, this is appropriate therapy as long as the physician maintains a watchful eye for some of the more profound side effects of reduced blood cell counts, reduced platelet counts, bone marrow suppression and liver damage. While these side effects are somewhat rare, they can be devastating if left unrecognized and unchecked. Periodic blood samples should be drawn to determine if any individual on these drugs is suffering from any dangerous side effects. Treatment with these drugs can also be complicated by the fact that there is no standard dose and excessive dosing can produce signs and symptoms of toxicity, therefore, blood levels must be carefully monitored.
Pain.com: Do anticonvulsant drugs work as well as narcotics to control specific pain problems?
Dr. Willis: Anticonvulsants do not work like narcotics in that you cannot take a pill and within a few minutes find a significant degree of pain relief, rather, these drug dosages must be slowly increased achieving a consistent blood level taken on a regular basis every day to the point that pain slowly begins to diminish over a period of days-to-weeks. This can be somewhat frustrating to a patient in chronic, severe pain but can be extremely effective over a period of time.
Pain.com: Are there any other types of medications routinely used to treat chronic pain?
Dr. Willis: The list of potential drugs or drug classes used to treat chronic pain is almost infinite. When you take into consideration that chronic pain is not simply a physical state but both a physical and psychological condition, then many other drugs enter the treatment armamentarium. Antidepressants are a mainstay for most chronic pain physicians as depression is a common associate of chronic pain. Also, many antidepressants have been shown to have a beneficial effect in reducing the transmission of the pain signal. Whether antidepressants exert their influence on the chronic pain patient by virtue of improving their mood thereby enabling the patient to better cope with their pain or actually reducing the transmission of the pain signal is not well known. It is well documented, however, that antidepressants provided in combination with appropriate interventional pain therapies work hand-in-hand to optimize a patient's perception of their pain and subsequent return to function.
Pain.com: Can muscle relaxants be used to treat certain chronic pain problems?
Dr. Willis: This is also one of the more common medication classes used to treat chronic pain but should be reserved for those cases that have as a major component of muscular spasm without a known and treatable underlying cause. For instance, arthritis in the joints of the spine is well known to produce major muscular spasms in that area of the spine and could be treated with a muscle relaxer. However, a more appropriate approach would be to utilize interventional pain therapy to reduce the inflammatory change in the joint spaces and, thereby, reduce the body's natural tendency to produce muscle spasm in that area. By treating the underlying source, the secondary muscle spasms can resolve naturally. In some cases, however, the underlying cause cannot be treated and in these cases muscle relaxants can certainly be used on a long-term basis to effectively control this type of pain. They are very often used in combination with oral opioid to potentiate each other's beneficial effects. This class of drug, like narcotics, must be carefully monitored and well controlled in order to reduce the potential for long-term habituation, inappropriate physical dependence and to protect the patient from the development of tolerance to these drugs, which reduces their effectiveness.
Pain.com: What type of patients and pain problems respond best to interventional pain therapy?
Dr. Willis: The best answer would be to say that virtually any pain problem can potentially respond to interventional pain therapy. It is always important to remember that while interventional pain therapy is aimed at reducing the ability of the body to transmit a pain signal to the brain, alone, it does not take into account the psychological state of the chronic pain patient. Significant contributions to the pain experience arise form this psychological state and are not directly affected by a purely interventional pain treatment program. Helping a patient "cope" with a chronic pain problem requires a multidisciplinary approach to pain therapy and, in most expert opinions, should be coordinated with an interventional pain treatment program. Fifteen years ago most pain programs had very little interventional capabilities and simply taught patients how to "learn to live with their pain." Over the past two decades research on the way the body generates a pain signal, sustains that signal and then transfers it to the brain where it is experienced as pain has yielded incredibly effective interventional treatment techniques for virtually every pain problem that exists. The addition of an interventional pain program to the physical therapy and psychological treatment programs of the past gives pain physicians the ability to significantly reduce the amount of pain with generated and transmitted through the body. In other words, it is easier to "learn to live" with 25 percent of your pain than 100 percent of your pain.
Pain.com: So, in other words, all pain problems can be treated in part by an interventional pain therapy approach? Is that right?
Dr. Willis: There is no physical pain known that does not have the potential to respond to appropriate interventional therapy. Many patients are told by competent and qualified physicians that there is nothing further that can be done for their pain problem. That is both a true and false statement. It is true that within the knowledge of that physician's specialty field there is nothing that can be done. However, in the hands of a trained, qualified, well-experienced pain treatment professional, interventions have recently been developed that can treat even the most difficult and hopeless pain problems. This requires expertise, which crosses specialty lines regarding the problem of pain.
Pain.com: We are hearing a lot these days about reflex sympathetic dystrophy, or CRPS. Can interventional therapy help with this pain problem?
Dr. Willis: That is one of my favorite questions and it has certainly become a hot topic. Reflex sympathetic dystrophy is just as the name implies. It is a natural reflex of the body. Reflex meaning that it is only present due to some other stimulus. In most cases, physicians treat reflex sympathetic dystrophy (more recently known as CRPS or complex regional pain syndrome) by simply blocking the sympathetic nervous system with a local anesthetic injection. While this very often significantly reduces the pain temporarily, the block wears off and the pain recurs. The pain treatment physician will often simply block the nerve repeatedly hoping for the nerve to reduce its intensity and somehow stop reflexly returning to its hyperactive painful state. A more appropriate approach would be to identify the underlying stimulus for this sympathetic hyperactivity by utilizing a specialized "diagnostic" sympathetic block relieving only the sympathetic pain while leaving behind the pain that is causing the painful sympathetic reflex. By identifying the underlying cause of the sympathetic pain, both the underlying cause as well as the sympathetic reflex can be resolved and the body, for the first time, can be given the opportunity to heal. Since the early 1990's this concept of treating reflex sympathetic dystrophy has led to dramatic increases in the success rate for this dreaded disease.
Pain.com: How about patients who have had several back surgeries? Can interventional therapy help them?
Dr. Willis: You are referring to the descriptive diagnosis of the failed back surgery syndrome patients. This term is well known in pain management circles but is descriptive only, not diagnostic. To answer your question, a pain physician must first be able to identify the single specific areas of the spine responsible for the pain generation. Once this diagnosis is made a specific and highly effective treatment plan can be initiated. The failed back surgery syndrome patient could have as many as six or eight different pain pathologies producing the pain state. This complexity is what makes treating back pain so difficult for the physician and the patient. By identifying each discrete and individual pain problem, appropriate interventional therapy can be provided for each pain pathology through a coordinated therapeutic plan over a sustained period of time to promote the healing process and provide a consistent ability to control these various pain problems. Even failed back surgery syndrome patients can be effectively treated in this manner. In fact, a treatment plan for failed back surgery patients has been developed through the American Neuromodulation Society relying on current literature noting the degree of effectiveness of various interventional pain therapies. This stepwise approach, known as an algorithm, enables a pain physician to go from very conservative steps through a series of increasingly more aggressive and potentially more successful steps leading to the ultimate resolution of debilitating pain. This step approach to the treatment of failed back surgery syndrome has proven useful and effective in pain physician practices across this country for the past several years.
Pain.com: What are some of the steps used in this treatment algorithm?
Dr. Willis: As I stated, these steps go from conservative to aggressive and always begin with an appropriate history and physical examination. Based on the information that a patient can give to an experienced and well-trained pain practitioner, pain can be placed into several broad categories and therapy can begin. Usually, treatment begins with the initiation of particular medications depending on the type of pain suspected. The next step in interventional pain therapy would be the use of diagnostic blocks, which simply refer to the specific injection of local anesthetics and oftentimes steroids into well identified structures in hopes of stopping the pain transmission and, thereby, identifying the structures responsible for the production and subsequent transmission of that pain. This helps to confirm the diagnosis and makes way for more advanced interventional pain therapies if the body shows no significant degree of response to such an approach. Injections or "blocks" should not be continued if there is no evidence that a healing process is taking place after a few weeks of therapy.
Pain.com: What can be done when the body fails to heal?
Dr. Willis: The more advanced methods of interventional therapy generally separate into two modes of thinking. First are the implantable techniques such as spinal cord stimulation therapy and intraspinal infusion pump therapy. The other school of thought is know as neuroablative therapy where various injectable substances such as alcohol, phenol or a more sophisticated route of utilizing controlled heat or cold can render the nervous system unable to transmit a pain signal. I personally feel the implantable therapies are most reasonable today and, when appropriately used, should be successful. They also have the advantage of being completely reversible and over the past twenty years during which these therapies have evolved, they have proven to be safe as well. Most failures seem to involve poor patient selection where these expensive therapies are used without confirming the pain diagnosis or that patient's responsiveness to that therapy through an adequate "trial" of that therapy prior to permanent implantation. The difficulty should come in determining who and when a patient is an appropriate candidate for trial therapy. A successful trial should lead to a permanent implant while a failed trial should lead to another therapeutic approach. It is really quite simple. Such an alternative therapy might be neuroablation. Today this is usually radiofrequency thermocoagulation or RFTC. This technique utilizes a finely controlled thermal injury at the tip of a needle to render a painful joint, disc or nerve incapable of sending a pain signal. This technique has a growing number of physician advocates, however, the long-term effectiveness still remains somewhat unclear. These techniques routinely provide weeks and often months of pain relief. This is most appropriate for chronic pain of intermediate duration such as terminal cancer pain or an injury capable of restoring within that time frame. Unfortunately, there is no such thing as a "permanent nerve block" as nerves have an uncanny ability to regenerate and reestablish the pain transmission with that recovery. Nonetheless, great hope springs from such procedures and their ongoing development.
Pain.com: Is there ever a place for surgery for chronic pain patients?
Dr. Willis: Certainly, and in fact, any qualified pain professional should be well acquainted and keep an excellent relationship with his or her local spine surgeons and general surgeons alike. An appropriate step treatment protocol should always include the potential for surgical correction of surgically correctable problems. These days most qualified spine surgeons are well aware of the pathological states that have reasonable opportunities to respond to surgical intervention. Likewise, this carries an inherent knowledge of those pain problems that do not respond well to surgical intervention. Pain management physicians should work closely with their local surgeon in providing the best complement of care, whether it is coordinating pharmacological management with medications, block therapies by injectable procedures (usually preformed under fluoroscopic guidance for accuracy and safety), surgical intervention, or the ability to provide implantable or neuroablative interventional pain therapies. With all of these tools available to the well trained and compassionate pain management professional, virtually any patient with a significant pain problem can be helped. This is especially true when the interventional care is provided within the structure of a multidisciplinary pain program which includes physical rehabilitation and psychological support.
Pain.com: How can patients suffering from chronic pain educate themselves in regards to their treatment options and pain physicians available in their area?
Dr. Willis: There are several excellent organizations that provide the names of physicians across the country who specialize in the treatment of chronic pain. While these physicians are usually anesthesiologists, they might well be orthopedic spine surgeons, neurosurgeons, podiatrists, psychiatrists, psychologists, neurologists or any other primary specialty with special training in pain management. Their membership in organizations such as the American Pain Society, American Academy of Pain Medicine, International Association for the Study of Pain (IASP), and International Spinal Injection Society (ISIS) is a good indication of their commitment to the practice of pain medicine. Beyond this, checking into their background specialty training, years of experience, full or part time commitment as a pain specialist and perhaps most importantly, their pain program coordinated utilization of all three disciplines of pain medicines (psychology, physical therapy and interventional pain therapy). Each of these factors can help to identify a qualified pain program. Pain management is a relatively new specialty, however, and many well-qualified pain practitioners have limited experience but are well qualified in their ability to help chronic pain patients. It is also extremely difficult to develop a multidisciplinary pain practice given the current lack of reimbursement provided by most insurance companies for the psychological aspects of chronic pain. For this reason, many qualified pain specialists find it necessary to help support themselves with a part-time anesthesia or other specialty practice while attempting to provide pain management services. If all services are not available in your area, however, a tertiary referral from your pain physician to a multidisciplinary pain program may be needed to fully implement care. These programs can now be found throughout the United States within reasonable proximity to almost any area. I would encourage any chronic pain sufferer or individual concerned about someone who suffers from chronic pain to also utilize the Dannemiller Memorial Educational Foundation's web site (Pain.com). I have found it to be extremely informative in providing personal information to specific questions that chronic pain patients have as well as providing a virtual library of information to research specific pain problems and treatment options. In the end, however, patients must have trust and confidence in their pain physicians and the way they provide compassionate and empathetic care to the chronic pain sufferer. Sometimes the best pain medicine can be a good listening ear and the ray of hope that encouragement can bring to an otherwise hopeless and painful existence. It is my hope that all chronic pain sufferers develop a relationship with a qualified pain professional and find that there is hope for the disabling excruciating pain that impacts their daily living. In my mind there is no greater specialty than the one that can relieve the human suffering of chronic pain. As Albert Schweitzer was once quoted as saying "it is my greatest privilege to provide the relief of the painful suffering in man, which is an ever more frightful enemy than even death itself." One day we may be able to treat all the sufferings of mankind, but for now, it is indeed a great privilege to finally be able to successfully treat the chronic pain patient. Simply remember this, there is hope for the hopeless.
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