Patient Care: The Pain Frontier

Chronic pain is a quiet epidemic that has yet to grab the attention it deserves.  That’s not the case at URMC’s Neuromedicine Pain Management Center, which is being lauded for its pioneering work.

Everyone has laughed, at least a little, at the old joke:

Patient, waving arm: “Doctor, my arm hurts when I do this.”

Doctor: “Then don’t do that.”

That punch line, however, is the closest millions of Americans ever come to finding a cure for their pain. They simply do their best to work around it, letting pain govern their lives like a malevolent dictator. According to an Institute of Medicine (IOM) report, more than 116 million Americans suffer from persistent pain — yet it remains one of the most enigmatic conditions doctors face. It’s no laughing matter.

“We are decades behind other medical disciplines, like cardiology and infectious disease, when it comes to deciding who gets what treatment,” says John Markman, M.D., director of URMC’s Neuromedicine Pain Management Center. “Real innovation needs to take place around chronic pain.”

Markman isn’t sitting around waiting for others to lead the charge. He is somewhat revolutionary in his field, though that’s not immediately apparent upon introduction. He’s just finished getting a patient’s advice on how to stymie the bugs eating his backyard honeysuckle. Now he’s in his office, sparring with a cranky coffee machine that is (oddly enough) too small to fit an ordinary cup. There’s a smattering of wall art, and an Ian McEwan novel about a neurosurgeon is tucked into a pile of books. The only conspicuous evidence of Markman’s transformative work in pain management is nestled with a few odds and ends on the windowsill. It’s a 2013 Clinical Center of Excellence award from the American Pain Society (APS).

“We never envisioned we would come this far in six years,” he says, offering me an M&M.

URMC was the only academic medical center to be named an APS Center of Clinical Excellence this year; fewer than two dozen exist altogether. Considering chronic pain costs the nation somewhere close to $600 billion annually in medical expenses and lost wages, the APS designation holds a lot of weight. The award’s lack of prominence in Markman’s office is indicative of the epidemic itself. UR alumnus Philip A. Pizzo (MD ’70), who co-chaired the IOM report committee, calls chronic pain a “significant, overlooked problem” in America.

That’s not the case here, however. Back in 2007, Markman and Webster H. Pilcher, M.D.,Ph.D., chair of Neurosurgery, were meeting with other members of the department to talk about their chronic pain patients. The origins of their patients’ pain were numerous: shingles, diabetic neuropathy, chemotherapy treatment, a car accident, surgery, spinal stenosis, fibromyalgia, and much more. There was no single route in for treatment, and coordinating interventional, medical, rehabilitative and psychological care was clunky at best.

“We were working at a distance and working in parallel, rather than working together to deliver care. We wanted to try to find a way to deal with that problem,” Markman explains.

Multidisciplinary care models existed in many areas of health care, but neurological disease-related pain was rarely one of them. When specialties did collaborate, it was on the diagnostic end. As the science around pain evolved, however, so did treatments targeting the nervous system. The time was ripe for an integrated approach to care.

“The modern notion of pain is that it’s in the nervous system. Whatever the cause of pain, we see enormous commonalities in the symptoms patients have, the persistence of their problems, and the devastating impact on their lives,” Markman says. "We also see commonality in the treatment of pain. And a single modality or approach rarely brings about its resolution.”

Markman and Pilcher started piecing together the Neuromedicine Pain Management Center, which opened in 2008. Today, neurologists, anesthesiologists, neurosurgeons, nurse practitioners, radiologists, therapists and nurses flow in and out of the center’s exam rooms, procedure areas, and clinical trial labs. Colleagues put their heads together in hallways or sit in office chairs to toss about ideas, compare notes, view images, and make treatment plans. Patients, who sometimes travel miles to get here, might see two or three different caregivers in a single afternoon. It is a flourishing ecosystem designed to push pain to the bottom of the food chain, thus removing its ability to control peoples’ lives.

Pain management at the center starts with a measurement.

“The gold standard for pain has always been self-report, what the patient says it is. Unlike infectious disease, diabetes or coronary disease, we don’t have bacterial cultures, blood draws or stress tests to objectively match treatment to patient,” says Markman. “So the center developed, and continues to enhance, ways to measure the functional limitations of our patients. How well can they walk through Wegmans, or how long can they stand in front of the mirror to shave?”

Using a model similar to a stress test, Markman and his team document their patients’ functional impairment and pain intensity levels before and after new medications, injections, surgery, and other therapies.

By embedding clinical trials into clinical practice, the center is building evidence to standardize the use of certain treatment methods for certain types of patients. Along the way, doctors here are also discovering new pain treatment therapies.

“The center’s focus on the application of scientific advances in neuromedicine to the treatment of chronic pain is unparalleled in the nation,” says Pilcher.

The American Pain Society agrees.

“This program seems to nail it in translational research,” the society wrote in its review of the center. “This is something rare.”