Inside This Issue
Tag-Teaming Chronic
Headache
p6
Improving Ablation
for SI Joint Pain
p8
Opioid Complications:
More than Just Abuse
p 12
Research Snapshots
and Clinical Trials
pp 14, 16
Pain Consult
D E PA R T M E N T O F PA I N M A N A G E M E N T | 2 0 1 3
mild
Procedure
Minimally Invasive Approach
to Lumbar Spinal Stenosis
p3
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
Dear Colleague,
At Cleveland Clinic, we recognize the central role that innovation plays in meeting our nation’s growing imperative to deliver greater healthcare value — that is,
better patient outcomes without higher overall costs.
I’m pleased that this issue of our Department of Pain Management’s Pain
Consult is full of examples of that kind of innovation. Take the story on page
8 featuring the work of Jianguo Cheng, MD, PhD, in developing a simple yet
ingenious tool to improve radiofrequency ablation (RFA) for sacroiliac joint pain.
Faced with the need to precisely place seven or eight needle electrodes for the
procedure, Dr. Cheng designed a small plastic template to quickly and reliably
guide placement of the electrodes. The result has been a two-thirds reduction in
procedure length, a 90 percent reduction in patients’ X-ray exposure and greater
patient comfort. In other words, markedly improved healthcare value.
Other stories spotlight additional examples of innovation in our department.
The cover story touches on Cleveland Clinic’s contributions to early clinical
testing of the minimally invasive mild® procedure for lumbar spinal stenosis
and the encouraging results we’ve achieved to date. And the “Research SnapVKRWVµVHFWLRQRQSDJHSURÀOHVVHYHUDORIRXUVWDII·VUHVHDUFKLQLWLDWLYHVLQ
areas ranging from cooled RFA for painful bone tumors to ultraprecise spinal
cord stimulation for lower extremity pain.
Our ethic of innovation extends beyond procedures, devices and research.
For example, the story on page 6 illustrates how patients with chronic headache
VWDQGWREHQHÀWIURP&OHYHODQG&OLQLF·VVLQJXODUPRGHORIFROODERUDWLRQEHWZHHQ
our department’s pain medicine experts and the headache specialists in
Cleveland Clinic’s Neurological Institute. And the story on page 10 examines
how a number of our pain specialists are bringing complementary and alternative medicine to bear for increasing numbers of patients with chronic pain.
The quest for value in our changing healthcare landscape depends increasingly
on this ethic of innovation. It also depends on a commitment to sharing successes in innovation with our colleagues across the nation in a multidisciplinary
fashion. That is the spirit in which we bring you this Pain Consult newsletter.
,KRSH\RXÀQGLWVWLPXODWLQJDQG,XUJH\RXWRFRQWDFWPHRUP\FROOHDJXHV
who are featured in these pages with your feedback and thoughts.
Richard W. Rosenquist, MD
Chairman, Department of Pain Management
rosenqr@ccf.org | 216.445.8388
2
On the Cover: Nagy Mekhail, MD, PhD (foreground), performs the mild procedure in a patient with lumbar spinal stenosis.
clevelandclinic.org/painmanagement
2013 | Pain Consult
Cleveland Clinic
Procedure,
Intense
Satisfaction
Minimally Invasive Approach to Lumbar Spinal Stenosis Relieves Pain and Increases Mobility
P
atients with moderate
to severe lumbar spinal
stenosis (LSS) often can’t
stand longer than a few
minutes or walk more than
a few hundred feet without
developing severe pain. This
VLJQLÀFDQWO\OLPLWVWKHLUDFWLYL
ties and quality of life. Until
a few years ago, the only
treatment options available
for patients with LSS were
conservative therapies or
open spine surgery.
Continued next page i
3
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
For patients who don’t respond to con-
Patients with moderate to severe LSS may
The mild procedure offers a new treat-
servative treatment and are unable or
be candidates for mild if they complain of
ment option for these patients. “With
unwilling to undergo open spine surgery,
neurogenic claudication and if MRI shows
more than 10,000 baby boomers turning
Cleveland Clinic’s Department of Pain
WKDWDWKLFNHQHGOLJDPHQWXPÁDYXPQRW
65 every day, more and more patients
Management now offers a novel X-ray-
a bulging disk, is the major cause of the
are seeking innovative treatments such
guided percutaneous outpatient treatment
spinal stenosis, Dr. Mekhail says.
as mild to stay active and maintain their
called mild®, which stands for minimally
invasive lumbar decompression.
C A N FA L L S H O R T
M I N I M A L LY I N V A S I V E ,
“The mild procedure decreases pain
Nonsurgical treatment for LSS includes
M A X I M A L LY Q U I C K R E C O V E R Y
and increases mobility while maintain-
NSAIDs, physical therapy and/or epidural
The mild procedure is performed under
ing the structural integrity of the spine,”
LQMHFWLRQVWRUHOLHYHLQÁDPPDWLRQDQG
deep sedation through a 1-cm incision. The
says Nagy Mekhail, MD, PhD, Director
swelling. These treatments are effective in
clinician uses a special sculpting tool that
of Evidence-Based Medicine in the
only a small percentage of patients, and
glides through a portal with a diameter of 5
Department of Pain Management.
WKHLUFKDQFHVRIHIÀFDF\GHFUHDVHZLWKWKH
mm, about the size of a pen cap, to go be-
The average age of patients presenting with
duration of LSS. If they do work, the effect
tween the bones, scrape out the ligaments
may not be sustained, and they need to
and widen the spinal canal to reduce nerve
the mild procedure in July 2012, and a
be repeated.
compression (see images below). X-ray
number of private insurers cover it as well.
“Epidural steroid injections tend to have
LSS is 73 years. Medicare began covering
W H O ’ S A C A N D I D AT E ?
LSS may be due to a bulging disk
and/or hypertrophy of the ligamentum
limited effectiveness because LSS pain
LVLVFKHPLFUDWKHUWKDQLQÁDPPDWRU\LQ
origin, as in radicular pain due to a herniated lumbar disk,” Dr. Mekhail explains.
ÁDYXPZKLFKOLQHVWKHEDFNRIWKH
spinal canal. Narrowing of the spinal
6RPHSDWLHQWVZKRKDYH/66FDQEHQHÀW
canal causes nerve compression. When
from open spine surgery, in which the
someone with LSS stands or walks, the
laminae are removed to relieve pressure on
spinal canal narrows even more, caus-
the spinal nerves. However, not all patients
ing neurogenic claudication, or low back
are candidates for open spine surgery,
and leg pain that is relieved with sitting
especially since surgery and anesthesia
or bending forward.
carry a higher risk in the older patients who
account for the bulk of LSS cases.
4
quality of life,” Dr. Mekhail says.
TRADITIONAL OPTIONS
ÁXRURVFRS\DQGUHSHDWHGLQMHFWLRQRIFRQ
trast material into the epidural space are
used to assess positioning and assist with
visualization throughout the procedure.
Because the architecture of the spine
remains intact, spinal mechanics are not
disrupted and patients typically recover
quickly. They are discharged home after
a couple of hours and are able to begin
ZDONLQJZLWKLQWKHÀUVWKRXUVDIWHU
the procedure. Patients are encouraged to
walk regularly and/or participate in physical therapy following the procedure.
Radiographic views of a spine before (left) and after (right) the mild procedure. Widening of the spinal canal decompresses nerves, relieving
chronic pain from lumbar spinal stenosis.
2013 | Pain Consult
clevelandclinic.org/painmanagement
Cleveland Clinic
ENCOURAGING AND
E N D U R I N G R E S U LT S
Results with mild to date have been
PATIENTS PLEASED WITH QUALITY-OF-LIFE PAYOFFS
encouraging. Dr. Mekhail and colleagues
recently published one-year outcomes
Enthusiastic testimonials are common among patients who have had the mild
among dozens of patients who under-
SURFHGXUHIRU/66+HUHDUHSURÀOHVRIVHYHUDOSDWLHQWVZKRXQGHUZHQWWKH
went the mild procedure (see Suggested
procedure in Cleveland Clinic’s Department of Pain Management.
Reading). Highlights include:
• No major device- or procedure-related
complications
•6LJQLÀFDQWUHGXFWLRQLQSDLQDW
one-year follow-up
• Improvement in physical functionality
and mobility as measured by change
(before vs. after procedure) in walking
distance and standing time
• Decreased disability secondary to
neurogenic claudication
Results are no less impressive at the individual patient level, as illustrated in the
sidebar. “Patients are able to get back to
more normal lives and the activities they
enjoy — everything from grocery shopSLQJWRJROÀQJµ'U0HNKDLOQRWHV
Frances Robinson, 70, had the procedure in January 2012. She had previously
received epidural injections to control her LSS-related pain, but the effectiveness
would eventually wear off. “I couldn’t walk too far or I would get pain down my
OHJDQGZRXOGKDYHWRVWRSµVKHVD\V6KHDOVRFRXOGQ·WVWDQGORQJHUWKDQÀYH
or six minutes without having to sit or lie down.
Since the procedure, Mrs. Robinson has been able to run errands and do
FKRUHVDURXQGWKHKRXVHWKDWKDGEHFRPHLQFUHDVLQJO\GLIÀFXOW2QDUHFHQW
WULSWR)ORULGDVKHZDVDEOHWRHQMR\ZDWHUDHURELFVVKRSDWÁHDPDUNHWVDQG
outlet stores, and comfortably walk on the beach with her husband for 40 to
50 minutes at a time.
“I call the mild procedure my miracle,” Mrs. Robinson says. “I would certainly advise others to consider this procedure, as it made such a big difference to my life.”
Michael O’Malley, 71, used to experience LSS-related pain that “felt like an
electric shock that started at the hip and went all the way down to the knee.”
That pain is a distant memory since he underwent the mild procedure in
November 2012. Despite unrelated hip pain for which he is seeking treatment,
Mr. O’Malley has been regularly walking a quarter of a mile a day for exercise.
He says he was impressed that mild was done on an outpatient basis and he
To refer an LSS patient for evaluation for
was able to get back to his normal activities so quickly. “The procedure was
the mild procedure, call 216.444.9114.
amazing, especially the fact that you could go to the hospital at 8 a.m. and be
back home by 4 p.m. The doctors and everyone there were excellent.
I walked the same day I had the procedure.”
Nagy Youssef, 67,DRQHWLPHLQWHUQDWLRQDOOHYHOWUDFNDQGÀHOGDWKOHWHIURP
(J\SWFRXOGZDONQRIDUWKHUWKDQIHHWDQGKDGWRVLWDIWHUÀYHPLQXWHVRI
VWDQGLQJZKHQKHÀUVWVDZ'U0HNKDLOIRU/66UHODWHGSDLQ7KHSDLQIRUFHG
0U<RXVVHIWRVLJQLÀFDQWO\VFDOHEDFNKLVZRUNFRDFKLQJ(J\SWLDQWUDFNDQG
ÀHOGWHDPV+HZDVDOVRXQDEOHWRPHQWRUKLVJUDQGFKLOGUHQLQWKHLUDWKOHWLF
SUGGESTED READING
pursuits or grocery shop with his wife.
Mekhail N, Costandi S, Abraham B,
´7KHEDFNSDLQGHFUHDVHGVLJQLÀFDQWO\DIWHUWKHmild procedure, and I can now
Samuel SW. Functional and patient-reported
outcomes in symptomatic lumbar spinal
stand for more than 30 minutes and walk four miles,” says Mr. Youssef, who
stenosis following percutaneous decompres-
was known as Nagui Assad when he competed in the Olympics in the 1970s
sion. Pain Pract. 2012;12(6):417-425.
and ’80s. He’s now back at work as a coach, active with his grandchildren and
Mekhail N, Vallejo R, Coleman M, Benya-
once again able to help his wife with shopping.
min RM. Long-term results of percutaneous
lumbar decompression mild® for spinal
stenosis. Pain Pract. 2012;12(3):184-193.
“I feel that my life clock has been wound back to before the year 2000, when
the pain started,” Mr. Youssef says.
5
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
Collaboration Brings a Full Spread
of Options for Chronic Headache
// FEATURING SUMIT KATYAL, MD, and STEWART TEPPER, MD //
For patients with refractory chronic headache, pain relief often is all about treatment options — having
enough of them and having access to the expertise to deploy them wisely.
Cleveland Clinic’s Department of Pain
nerve blocks — medial branch blocks,
Dr. Katyal for interventional procedures
Management includes several pain
atlantoaxial (or C1-2) blocks, spheno-
or for diagnostic support in especially
challenging cases.
specialists with expertise in headache
palatine ganglion (SPG) blocks, occipital
and atypical facial pain. They are a key
nerve blocks and others — depending
resource in an extensive and multidis-
on the source and type of headache.
ciplinary array of treatment options
Many can alleviate headaches in some
Cleveland Clinic offers to patients who
patients for six months or more.
suffer from refractory chronic headache,
sided headache, which Dr. Tepper says
usually signals one of three headache
types, one of which is cervicogenic head-
He also sometimes performs blocks in
ache. “The best way to diagnose cervi-
conjunction with radiofrequency abla-
cogenic headache is to do a block of the
tion. In some cases, good response to
C1-2 nerve roots,” he says. “So I may
D U A L H E A D A C H E / PA I N M E D I C I N E
a couple of diagnostic nerve blocks can
refer a patient with one-sided headache
EXPERTISE
predict long-term response to ablation
to Dr. Katyal for a diagnostic block. If the
or identify good candidates for stimula-
headache is stopped cold by the block
tor placement.
but then returns when the block wears
be it migraine, cluster headache or other
forms of primary or secondary headache.
“We provide a number of interventions
to give patients long-term relief from
headache pain they may have suffered
with for years,” says Sumit Katyal, MD,
a member of the Department of Pain Management who is one of a handful of U.S.
SK\VLFLDQVERDUGFHUWLÀHGLQERWKSDLQ
medicine and headache medicine.
Those interventions include:
• Specialized nerve blocks
• Injection of botulinum toxin
and other medications
• Radiofrequency ablation
C A L I B R AT I N G C A R E W I T H A
TEAM OF HEADACHE EXPERTS
In those types of cases, Dr. Katyal and
off, and if this process can be repeated,
we can then diagnose cervicogenic headache and manage it accordingly.”
his Department of Pain Management col-
S P E C I A L I Z AT I O N M AT T E R S
leagues work closely with the headache
This type of close cooperation between
specialists in the Headache and Facial
headache specialists and pain special-
Pain Clinic in Cleveland Clinic’s Neurological Center for Pain.
Stewart Tepper, MD, is one of those
headache specialists. “There’s a lot of
consultation and collaboration between
ists is not possible at most institutions.
“We’re fortunate to have the Headache
and Facial Pain Clinic,” says Dr. Katyal.
“Many hospitals don’t have a department
dedicated to headache medicine, so
the neurologists in our headache clinic
headache patients are seen by general
• Epidural blood patches
and the Department of Pain Manage-
QHXURORJLVWV+DYLQJERDUGFHUWLÀHG
• Stimulator implantation
ment,” he says. While Dr. Tepper and
Many additional options exist within
these categories. For instance, Dr.
6
Take the example of continuous one-
Katyal performs a host of different
his colleagues provide comprehensive
evaluative, diagnostic and medical
management services for headache
patients, they often refer patients to
headache specialists can make a big difference for patients by allowing for more
comprehensive and specialized care. Dr.
Tepper and his colleagues see headache
patients exclusively.”
2013 | Pain Consult
clevelandclinic.org/painmanagement
Cleveland Clinic
A M U LT I T U D E O F O P T I O N S F O R C H R O N I C H E A D A C H E S U F F E R E R S
Department of Pain Management
• Interventional management
– Radiofrequency ablation
– Epidural blood patches
– Specialized nerve blocks
Headache and Facial Pain Clinic
SPG, occipital nerve, others)
• Evaluation/diagnosis and medical
management by headache specialists
IMATCH Program
day-hospital program
•(YDOXDWLRQRIGLIÀFXOWFDVHVZLWK
– Medication injections
Chronic Pain
Rehab Program
• Interdisciplinary
– Stimulator implantation
(medial branch, atlantoaxial,
• Day-hospital program
Headache and Facial Pain Clinic)
Alcohol and Drug
Recovery Center
• Inpatient/outpatient
Center for
Neurological Restoration
• Deep brain stimulation
for patients with
for patients with head-
programs for patients
and other stimulation
medication overuse/
ache refractory to other
whose headache has an
modalities
habituation issues and/
interventions; uses
addictive component
or medical/psychiatric
UHKDELOLWDWLRQGHWR[LÀ
comorbidities
cation, mobilization
Dr. Tepper likewise notes that many pain
take care of the whole person by address-
medicine physicians do not provide the
ing comorbid psychiatric or medical issues
“We refer patients and solicit opinions
across these various areas all the time,”
headache interventions that the Depart-
along with the chronic headache,” Dr.
says Dr. Tepper. “There is a lot of cross-
ment of Pain Management does, because
Tepper explains. It is one of only two day-
fertilization.”
of the technically advanced procedures
hospital programs of its kind in the nation.
required. “Beyond that,” he adds, “for
headache patients in whom additional
medications, blocks, stimulators or other
procedures are not going to help, there is
a very rich smorgasbord of other options
at Cleveland Clinic.” As outlined in the
diagram above, these include:
• The IMATCH (Interdisciplinary Method
for Assessment and Treatment of Chronic
Headache) Program, a three-week dayhospital program in which patients receive
IV infusions and are seen by neurologists,
• The Chronic Pain Rehabilitation ProJUDPDWZRWRÀYHZHHNGD\KRVSLWDO
program that focuses on rehabilitation
WKHUDS\GHWR[LÀFDWLRQDQGPRELOL]DWLRQ
“There are very few intensive outpatient
pain rehab programs like this in the
country,” Dr. Tepper says.
• The Alcohol and Drug Recovery Center,
MORE OPTIONS THAN MANY REALIZE
This richness of available treatment
options is something Dr. Katyal hopes
physicians become more aware of.
“I’m not sure primary care specialists
know about the many interventional
approaches that can be effective for
chronic headache,” he says. “Their paWLHQWVZLWKFKURQLFKHDGDFKHFDQEHQHÀW
for patients whose headache has an ad-
from many options that might not be
diction component.
available in their local community.”
• The Center for Neurological Restoration,
psychologists, internists and physical
which offers deep brain stimulation or
therapists. “The aim is to wean patients
implantation of other stimulators requir-
off any overuse headache medications and
ing neurosurgery expertise.
Dr. Katyal can be contacted at
216.444.3134 or katyals@ccf.org.
7
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
Better Ablation for SI Joint Pain:
Template for Precise Needle Placement Shortens
Procedure, Reduces X-ray Exposure
// FEATURING JIANGUO CHENG, MD, PHD //
Sometimes the best innovations are the simplest. Consider the small plastic template that Jianguo
Cheng, MD, PhD, developed to guide the precise placement of needle electrodes during radiofrequency
ablation (RFA) procedures to treat sacroiliac (SI) joint pain.
The template, which is made of a
Over the years, four different RFA
SAVING TIME AND
material similar to the cover of a watch
modalities have been developed, with
ENSURING PRECISION
face, has resulted in:
varying levels of clinical complexity and
The template that Dr. Cheng developed is
• A two-thirds reduction in procedure
length, improving patient comfort
and saving time for the clinician
• A 90 percent decrease in patients’
X-ray exposure
´7KLVLVDPHGLFDOÀUVWµVD\V'U&KHQJ
Professor of Anesthesiology and Director of Cleveland Clinic’s Pain Medicine
designed with eight holes spaced exactly
1 cm apart, with two small radiopaque
the clinician to place seven or eight nee-
metal marks embedded in the template
dle electrodes that are exactly parallel
as guides (see images on page 9).
to one another, optimally spaced exactly
1 cm apart. This precise placement
causes a geographic lesion between the
electrodes, which can be very effective
in targeted SI nerve ablation.
This simple yet highly utilitarian
design ensures that once the clinician
numbs the patient’s skin and places
the template under X-ray guidance, all
the electrodes can be aligned perfectly
Fellowship Program in the Department
Traditionally, it takes a skilled clinician
parallel, ensuring that the geographic
of Pain Management. “The template
about 45 minutes, with continual X-ray
lesions will be made in the desired
is effective, practical, easy to use and
guidance, to precisely place the needles
spots.
inexpensive to produce.”
for this procedure.
R A D I O F R E Q U E N C Y A B L AT I O N
T O T R E AT S I J O I N T PA I N
Low back pain is a major clinical
problem, with up to one-third of cases
attributable to the SI joint. Over the past
decade, RFA of the nerves supplying the
SI joint has evolved as an effective treatment. Heat generated by radiofrequency
electrical pulses is delivered through
needles placed in the patient’s body to
ablate, in a controlled fashion, the SI
8
equipment needs. The bipolar RFA approach used at Cleveland Clinic requires
nerves that are conducting the pain.
2013 | Pain Consult
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Cleveland Clinic
Use of the template has shortened
the procedure from 45 to about 15 minutes.
“Once you determine the position of
the template, you can almost automatically determine the right position for
abdomen, which can be an uncomfortable
position for those with SI joint pain.
the needle electrodes, so you can place
PAT E N T P E N D I N G
them more precisely and more quickly,”
:KHQ'U&KHQJÀUVWKDGWKHLGHDIRU
says Dr. Cheng. Indeed, use of the tem-
the template, he drew a diagram with
evidence that there will be demand for
Meanwhile, Dr. Cheng has informal
plate has shortened the procedure from
measurements, from which designers
the template, which can be sterilized and
45 to about 15 minutes and allows just
in Cleveland Clinic’s Department of Bio-
reused. “We have 10 of the templates
DFRXSOHRI;UD\H[SRVXUHVWRVXIÀFH
medical Engineering created the model.
for use in our practice,” he says. “Our
instead of the continual X-ray exposures
Dr. Cheng is now working with Cleve-
attending physicians have found it an
required in the past.
land Clinic’s technology commercializa-
easy-to-learn and very useful tool — and
tion arm, Cleveland Clinic Innovations,
all our graduating fellows want to keep
on a patent application. Future research
one when they leave.”
With the template, even a less experienced clinician can complete the procedure in 20 minutes. The result: The patient spends less time lying on his or her
will focus on medical device outcomes
and comparative analyses of the four
Dr. Cheng can be reached at
RFA approaches.
216.445.9572 or chengj@ccf.org.
9
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
CAM Therapies for Chronic Pain: With Minimal Risk,
There’s Little Reason Not to Try Them Early
// FEATURING HONG SHEN, MD, and WILLIAM WELCHES, DO, PHD //
It’s no secret: Patients with chronic pain will return to physicians again and again in search of an inWHUYHQWLRQWKDWFRPEDWVWKHLUSDLQDQGVLJQLÀFDQWO\LPSURYHVWKHLUIXQFWLRQLQJ$IWHUPXOWLSOHVWUDWHJLHV
fail to provide that relief, more than a few patients and their providers will turn to complementary and
alternative medicine (CAM) therapies.
They’re not without reason to do so,
Dr. Shen concurs. “With opioids, you
studies demonstrate its effectiveness,
DVHYLGHQFHVXSSRUWVWKHHIÀFDF\RI
have to worry about addiction,” she says.
Dr. Shen notes. The NIH’s National
acupuncture, dietary changes and/or
“With NSAIDs, you have to worry about
Center for Complementary and Alterna-
osteopathic manipulation therapy for
cardiac, GI and kidney damage. With
tive Medicine features the most rigorous
many types of chronic pain. The ques-
other medications, you have to worry
VFLHQWLÀFÀQGLQJVRQLWV´*HWWKH)DFWVµ
tion may be why so many patients
about other side effects.”
website (nccam.nih.gov/health/acupunc-
and providers wait so long.
ture/acupuncture-for-pain.htm).
“Most of my patients have tried almost
COMPLEMENT FOR MANY
OVERCOMING SKEPTICISM —
everything when they come to my of-
A much safer alternative, she notes, is
A N D M A N A G I N G E X P E C TAT I O N S
ÀFHµREVHUYHV+RQJ6KHQ0'DSK\V
acupuncture, which can relieve muscu-
Dr. Shen initially was skeptical. “I was
iatrist in Cleveland Clinic’s Department
loskeletal pain, headaches, neck pain,
trained in China, and I didn’t believe it.
of Pain Management with an interest
low back pain, myofascial pain and joint
Stick a needle in someone to help their
in CAM therapies. She’s one of sev-
pain. For about 10 percent of patients,
pain? Initially I used acupuncture to treat
eral physicians in the department who
Dr. Shen combines acupuncture with
patients who failed all conventional treat-
integrate a wide range of traditional and
other therapies such as pain medication
ments. I didn’t have any other options,
alternative strategies, each employed
or trigger point injections.
so I tried acupuncture. Then I saw the
appropriately to optimize the chances
amazing results.”
RIVLJQLÀFDQWUHOLHIIURPFKURQLFSDLQ
Between 70 and 80 percent of patients
report initial results good enough to
Dr. Welches reports little reluctance
Another such physician is William
continue acupuncture, says Dr. Welches,
among physicians. “It’s remarkable —
Welches, DO, PhD, who encourages
DFHUWLÀHGPHGLFDODFXSXQFWXULVW)RU
even surgeons refer patients to me for
that reason, acupuncture should be
acupuncture. It’s widely accepted.”
referring physicians to consider CAM
strategies sooner to spare patients the
tried fairly early in almost all patients
adverse effects of some pain medica-
with chronic pain, he adds. “There are
tions. “It’s not that medications cannot
no side effects, it’s easy to do and it’s
be useful sometimes,” says Dr. Welches,
relatively inexpensive compared with
“but physicians are using them all the
medicine and procedures.”
time, and too often we fail to seriously
investigate the alternatives.”
10
ACUPUNCTURE: A SAFE, EFFECTIVE
Still, patients must have realistic expectations about insurance coverage — Dr.
Shen estimates only about 25 percent of
insurers in Ohio reimburse for acupuncture — and the number of treatment
Not only is acupuncture safer than most
sessions required. “Many people think
other interventions, but more and more
they can come for one or two sessions,”
2013 | Pain Consult
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Cleveland Clinic
she says, “but usually they need more
than 10, based on the national studies.”
Some patients require ongoing periodic
treatment as well.
A ROLE FOR DIET TOO
The Department of Pain Management
also offers dietary interventions and
supplementation. “It amazes me that
diet and exercise are considered complementary to mainstream medicine,” Dr.
:HOFKHVVD\V+HFLWHVWKHDQWLLQÁDPPD
tory diet — modeled after the Mediterranean diet and rich in vegetables, fruit and
seafood — as an example. “I’m not sure
how this got labeled as complementary.
,WKDVWKHDGGLWLRQDOEHQHÀWRIEHLQJWKH
healthiest diet there is — the one we all
should be following.”
But Dr. Welches cautions that patient
expectations are important here as well.
“I tell my patients that the diet I’m putting them on is rigorous and a hard one
to follow.”
For some patients, Dr. Shen recommends
nutritional supplements in conjunction
with physical exercise, such as gluFRVDPLQHDQGÀVKRLOSURGXFWVWRWUHDW
chronic osteoarthritis joint pain.
O S T E O PAT H I C
M A N I P U L AT I O N T H E R A P Y
Dr. Welches also practices osteopathic
manipulation therapy (OMT), which he
says is about alignment, with muscles
playing a central role. OMT aims to
“open up” interconnected muscles,
bones, nerves, blood and other systems
as part of a holistic approach to treating
the patient. OMT works by optimizing
KRZRQHV\VWHPÁRZVLQWRDQRWKHUXQ
encumbered by pain or misalignment.
do up above — it’s not going to last,”
It can be frustrating for patients, as they
Dr. Welches says, citing the intercon-
don’t always get the results they want. It
nectedness of the musculoskeletal system
is critical that we engage patients in their
between the neck and lower back.
own recovery. Usually we have to sit down
In rare instances, Dr. Welches cannot recommend OMT because he cannot identify
a musculoskeletal source of chronic pain.
But about 99 percent of patients make
appropriate candidates, he says.
A PAT H T O E M P O W E R M E N T
No matter what the intervention, patients
with chronic pain need to make a daily
commitment to lead a healthy lifestyle.
“For instance, I start out evaluating a pa-
“That’s the leading edge in pain manage-
tient with neck pain by looking at the lower
ment,” Dr. Welches observes. “We realize
back,” he explains. “If the patient’s stance
we’ve created a healthcare system that
is cockeyed, it doesn’t matter what I
encourages the patient to remain passive.
with patients to explain what is required
of them and what it is we are doing.”
Dr. Welches sees patients at Cleveland
Clinic’s Euclid and South Pointe hospitals;
he can be reached at 216.692.8813 or
welchew@ccf.org. Dr. Shen sees patients
at Cleveland Clinic’s Lutheran Hospital
and Westlake Medical Campus; she can be
reached at 440.312.7246 or shenh@ccf.org.
11
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
Complications of Opioid Therapy:
More to the Story than Abuse and Addiction
// BY BENJAMIN ABRAHAM, MD //
2QHRIP\SDLQPHGLFLQHPHQWRUVRQFHVDLG´7KHÁLJKWWLPHDQGODQGLQJDUHDVLPSRUWDQWDVWKHWDNHRIIµ
How true for opioid therapy. Too often, pain management specialists are seeing new patients who have
DOUHDG\´WDNHQRIIµRQRSLRLGWKHUDS\ZLWKRXWDÁLJKWSODQ7KH\KDYHQRHVWDEOLVKHGJRDOVVRWKH\GRQ·W
know how to determine if the therapy is working. They have no idea when the therapy should end or how
they will “land.” Some have no understanding of the challenges they may encounter along the way.
A M U LT I T U D E O F P O T E N T I A L E F F E C T S
the dosage or discontinue opioid therapy
Because these symptoms can be at-
Of course, one of the biggest challenges
when possible, such as for patients with
WULEXWHGWRYDULRXVFDXVHVLW·VGLIÀFXOW
with opioid therapy is risk of abuse
nonmalignant pain.
to pinpoint whether they are caused by
and addiction. In the past decade, the
$QGURJHQGHÀFLHQF\ One study of
number of deaths from painkillers,
including opioids, has quadrupled to
nearly 15,000 per year in the United
States. (See “Opioid Management: How
WR+DUQHVVWKH%HQHÀWVZLWK)HZHURI
the Harms” on page 8 of the 2012 issue
of Pain Consult at clevelandclinic.org/
painconsult2012.)
cancer survivors found that 90 percent
of men taking opioids had hypogonadism, compared with 40 percent of those
not taking opioids.1 But opioid-induced
DQGURJHQGHÀFLHQF\23,$'LVDQLVVXH
for both men and women. Symptoms
include erectile dysfunction, reduced
opioids and how soon they may follow
opioid initiation. However, we know it
can take about one month after stopping
opioid use for testosterone and estrogen
to reset and for changes such as weight
gain and erectile dysfunction to begin to
reverse. Reversing changes like reduced
bone density may take longer.
OLELGRIDWLJXHKRWÁDVKHVPHQVWUXDO
If discontinuing opioid use is not pre-
But abuse and addiction aren’t the only
irregularities, low energy, weight gain
ferred, treatment can include androgen
concerns. Opioid therapy can cause other
and depression. And OPIAD can lead
replacement therapy, although androgen
unwelcome side effects, some of which
to more serious complications, such
replacement in women sometimes brings
are detailed below.
as infertility and osteoporosis.
other medical concerns.
Immunosuppression. For more than
a century, studies have shown opioids’
ability to weaken the immune system.
OPIOID-INDUCED SIDE EFFECTS AND POTENTIAL TREATMENTS
SIDE EFFECT
POTENTIAL TREATMENT
Immunosuppression
Reduce opioid dose or discontinue
$QGURJHQGHÀFLHQF\
Testosterone replacement therapy
every opioid user.
Constipation
Stool softeners and laxatives;
methylnaltrexone for severe cases
With no tried-and-true method for
Hyperalgesia
Reduce opioid dose; rotate to methadone
Depression
Reduce opioid dose; antidepressants
The function and activity of antibodies
and T cells decrease immediately after
exposure to opioids. While it may not
EHFRPHFOLQLFDOO\VLJQLÀFDQWXQWLO\HDUV
later, immune function declines in
boosting immune function, the best way
12
to manage this side effect is to reduce
2013 | Pain Consult
clevelandclinic.org/painmanagement
Cleveland Clinic
dose. Centers for Disease Control and Prevention data show that prescription opioids
were involved in 14,800 overdose deaths
in 2008 — more than the deaths from
cocaine and heroin overdose combined.
That’s why Cleveland Clinic’s Department
of Pain Management prescribes opioids
Constipation. Constipation can set in
morphine and NMDA receptor antagonist
quickly, after only a day or two of opioid
that actually reverses opioid-induced
use. Prevalence varies by study, from 15
hyperalgesia. Methadone brings its own
to 90 percent of patients.2 Effects can
challenges, however. Its dosage is dif-
range from uncomfortable hemorrhoids
ÀFXOWWRDGMXVWDQGLWFRPHVZLWKVLJQLÀ
to life-threatening bowel obstruction.
cant side effects, including risk of heart
only when other treatments and analgesics have proven ineffective. At that time,
we establish expectations and set goals
for each patient and then actively monitor them. Post-discharge follow-ups are
standard procedure. Together with refer-
arrhythmia and respiratory depression.
ring physicians and colleagues through-
laxatives are effective management tools.
Depression. Studies show that about
side effects of opioid therapy before they
For more severe cases, most often in
10 percent of patients using opioids
cause major complications.
patients with long-term opioid use, there
develop some kind of depression. Again,
is methylnaltrexone. This mu-opioid
LWLVGLIÀFXOWWROLQNRSLRLGXVHGLUHFWO\WR
Dr. Abraham, a specialist in the Depart-
receptor antagonist acts locally in the GI
this effect because depression can occur
ment of Pain Management, sees patients
tract, selectively reversing opioid-induced
for other reasons. If a patient cannot be
at Marymount Hospital and Elyria Fam-
constipation without reversing pain relief.
transitioned off opioids, antidepressants
ily Health Center. His specialty interests
Methylnaltrexone is administered as a
are standard adjunctive therapy.
include interventional pain manage-
For the most part, stool softeners and
subcutaneous injection in two doses.
Once it relieves the severe constipation
and removes bowel obstruction, the
patient can resume using stool softeners
C O M P L I C AT I O N S N O T
L I M I T E D T O L O N G -T E R M U S E
Notably, these conditions are not limited
out Cleveland Clinic, we work to head off
ment for back and neck pain, pain from
failed back surgery, abdominal pain,
vertebral compression fracture and peripheral neuropathy. He can be reached
and laxatives.
to patients with long-term opioid use or
Hyperalgesia. Evidence of increased
even those who have been using opioids
pain resulting from opioid use has
for a short time. Many effects begin to
REFERENCES
been observed since the 19th century.
RFFXULPPHGLDWHO\³ZLWKLQÀYHPLQXWHV
1. Rajagopal A, Vassilopoulou-Sellin R,
for some instances of hyperalgesia. And
Palmer JL, Kaur G, Bruera E. Symptomatic
symptom is relatively unstudied, partly
they can occur even with properly man-
hypogonadism in male survivors of cancer
EHFDXVHSDLQLVGLIÀFXOWWRTXDQWLI\
aged therapeutic doses.
In general, the way to manage opioid-
The rate of drug overdose in the United
induced hyperalgesia is to reduce the
2. Panchal SJ, Muller-Schwefe P, Wurzelmann
States has more than tripled since 1990.
JI. Opioid-induced bowel dysfunction: preva-
dosage or rotate to another opioid, such
Current estimates suggest that more than
as methadone. Methadone is a synthetic
100 people per day die from drug over-
However, the onset and severity of the
overuse. They can occur in all patients,
at 216.587.8830 or abrahab@ccf.org.
with chronic exposure to opioids. Cancer.
2004;100:851-858.
lence, pathophysiology and burden. Int J Clin
Pract. 2007;61:1181-1187.
13
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
Research Snapshots
3URÀOHVRIQRWDEOHLQYHVWLJDWLRQVXQGHUZD\LQWKH'HSDUWPHQWRI3DLQ0DQDJHPHQW
Cooled RFA: New Option
for Painful Metastatic
Bone Tumors
A new radiofrequency ablation (RFA)
technique uses a
bipolar water-cooled
Nagy Mekhail, MD, PhD
analog scale as well as decreased dis-
heating. Internal cooling eliminates the
ability and improved function, with an 80
pain related to
tissue charring that is common with con-
percent improvement in Pain Disability
metastatic bone
ventional RFA. Transmission of RF waves
Index score. Improvements were main-
tumors when such
ceases in charred tissue, limiting the size
tained at two- and six-month follow-up.
pain is unresponsive to conventional
of the intervertebral lesion. The bipolar
methods. Clinical experience with cooled
tip on the OsteoCool device localizes
RFA (OsteoCool® RF Ablation System)
heating within cortical bone, eliminating
at Cleveland Clinic shows local disease
the need for a grounding pad and reduc-
control, marked pain reduction and
ing risk of damage to surrounding tissue.
quality-of-life improvements from a single
treatment, says Nagy Mekhail, MD, PhD.
Up to 30 percent of patients with
“The lesion created by water-cooled RFA
is spherical and extends beyond the probe
tip on both sides,” says Dr. Mekhail. “It
metastatic bone tumors do not respond
is eight times greater by volume than the
to palliative measures involving radiation
thermal RFA lesion produced by a similar-
therapy, chemotherapy, surgical excision
length probe. A large spherical lesion can
or conventional RFA. Most RFA systems
effectively ablate the metastatic tumor
were designed for use in soft tissue,
and the free nerve endings that are caus-
employing a monopolar technology. They
ing the pain.”
do not perform consistently in bone
because bone is not a good conductor of
electrical energy and heat. The current
from the single probe tip takes the path
of least resistance to a grounding pad on
the patient’s leg, explains Dr. Mekhail,
The treatment is performed on an outpatient basis. Patients who have vertebral
fracture as a tumor complication can
undergo kyphoplasty in conjunction with
cooled RFA.
Enrollment in a study to test the Osteo&RROV\VWHP·VHIÀFDF\DQGVDIHW\LQ
patients with spinal metastases will begin
at Cleveland Clinic soon, says Dr. Mekhail.
Precise Method of Spinal Cord
Stimulation Promises Better
Control of Lower Extremity Pain
Though spinal cord
stimulation has
been used to treat
chronic pain since
the 1970s, it often
fails to control lower
Samuel Samuel, MD
extremity pain
because of the dif-
ÀFXOW\RIWDUJHWLQJWKHVSHFLÀFDQDWRPLF
sites involved. Dorsal root ganglion (DRG)
stimulation is emerging as an option with
the ability to more precisely stimulate ana-
Director of Evidence-Based Medicine in
To date, 11 patients have been treated
the Department of Pain Management.
tomic targets implicated in chronic pain
with the OsteoCool system at Cleveland
— even in the lower extremities. So says
“Ideally, we’d like to produce a big lesion
by burning the tumor and the surrounding trabecular bone,” he says. “Ablating
WKHIUHHQHUYHÀEHUVFDQDOOHYLDWHSDLQ
caused by vertebral body metastases.”
Current RFA systems produce lesions
14
ance, increasing the radius of effective
RFA probe to treat
Clinic and the University of Washington
Samuel Samuel, MD, a pain specialist
in Seattle. Three patients who presented
leading a study of DRG stimulation in
with severe low back pain despite opioid
the Department of Pain Management.
therapy — two with metastatic breast
cancer to the L3 vertebral body, and one
with vertebral metastasis secondary to
prostate cancer — have been treated
FRQÀQHGWRWKHDFWLYHWLS$QLQWHUQDOO\
at Cleveland Clinic. All achieved a 75
cooled RFA probe lowers tissue imped-
percent reduction in pain on the visual
Patients with lower extremity pain,
such as neuropathy or postlaminectomy
syndrome (failed back surgery syndrome),
appear to be the best candidates for DRG
stimulation, which has been in clinical
2013 | Pain Consult
clevelandclinic.org/painmanagement
Cleveland Clinic
use in Europe for the past few years.
pain with or without back pain in the
The current DoD study in rats is testing
Single-center pilot studies and case stud-
multicenter clinical trial. The principal
safety, analgesic effects and anti-toler-
ies have been conducted in the United
investigators at Cleveland Clinic are Dr.
ance effects, as well as the longevity and
States, in preparation for a multicenter
Samuel and Nagy Mekhail, MD, PhD.
stability of the cells once transplanted.
trial for which Cleveland Clinic is enroll-
To refer a patient for enrollment, call
ing patients.
216.636.0103.
The DRG is located within the spinal
Analgesic Cell Therapy
Could Be a Game-Changer
in Chronic Pain
foramen and contains cell bodies of the
primary neurons. “We are just beginning to understand the DRG’s function
pain signal,” says Dr. Samuel. “The DRG
receives information from the extremities
or the trunk and conveys it to the brain,
complex structure.”
Discrete stimulation of one side or one
level of the spinal column is sometimes
hard to achieve with conventional spinal
patients with intractable neuropathic pain,
patients with cancer pain could someday
land Clinic could
If the stem cell therapy is found to be
way chronic pain
Jianguo Cheng, MD, PhD
promise,” says Dr. Cheng. In addition to
be good candidates for this therapy.
cally change the
diminishes the pain signal depending
can be tested in humans, initial results
from animal studies have shown great
underway at Clevesomeday dramati-
DFWLQJDVDJDWHNHHSHU,WPDJQLÀHVRU
on the information it gets. It’s a highly
over many years before this approach
Stem cell research
and its mechanism for modulating the
“While many more studies are needed
is treated and decrease the potential
for prescription drug abuse.
The research is in the early stages of testing
whether mesenchymal stem cells, after
safe and effective, potential advantages
include:
• Therapeutic alternative — This
approach promises the ability to treat
intractable neuropathic pain in patients
who don’t respond to prescription opioids.
• Fewer side effects — Patients who opt
cord stimulation, which may explain
being harvested from a patient’s bone mar-
for analgesic cell therapy could avoid the
some treatment failures with convention-
URZDQGUHSURJUDPPHGLQWRFKURPDIÀQ
side effects of exogenous opioids, such
al stimulation. Preferentially targeting the
primary sensory neurons responsible for
like cells, can provide relief from chronic
as respiratory depression, immunocom-
intractable pain when they are transplanted
promise, disruption or depression of en-
chronic pain in the lower extremities —
back into the same patient.
which DRG stimulation makes possible
The endogenous opioids that are gener-
— can improve the outcomes obtained
DWHGIURPWKHVHGLIIHUHQWLDWHGFKURPDIÀQ
docrine functions, constipation, vomiting
and itching.
• Decreased abuse — Endogenous
with neuromodulation.
like cells have powerful analgesic effects.
“For instance, we can precisely stimulate
In fact, they have the potential to treat
as an alternative to highly addictive
nerve injury-induced pain that usually
prescription opioids, which cause more
doesn’t respond to exogenous opioids
deaths than car accidents and are often
such as morphine and its derivatives,
diverted for illegal use.
the left thigh or the right foot if needed,”
explains Dr. Samuel. “The advantage is the
ability to stimulate one or two levels of the
spinal column, and one or both sides.”
Candidates for DRG stimulation undergo
a trial stimulation period of up to two
weeks. If they experience 50 percent or
greater improvement in pain, electrical
leads and contacts are placed permanently using a minimally invasive epidural approach, and the leads are attached
according to Jianguo Cheng, MD, PhD,
principal investigator of the Department
of Defense (DoD)-funded study and Professor and Director of Cleveland Clinic’s
embryonic stem cells, once the mesenchymal stem cells are differentiated into
FKURPDIÀQOLNHFHOOVWKH\FDQ·WJURZRU
divide, so tumor risk is not an issue.
Dr. Cheng and his collaborator, Tingyu
If found to be viable, analgesic cell
Qu, MD, PhD, from the University of
Illinois at Chicago, developed the patentpending technology to differentiate the
performed on an outpatient basis.
DXWRORJRXVVWHPFHOOVLQWRFKURPDIÀQOLNH
patients with chronic intractable leg
• Reprogrammed stem cells — Unlike
Pain Medicine Fellowship Program.
to a neurostimulator. The procedure is
Cleveland Clinic seeks to enroll 20
opioids from analgesic cell therapy serve
cells. Initial animal studies have already
demonstrated the feasibility of transplanting the cells for pain relief.
therapy has the potential to be a gamechanger. As stated in the DoD’s assessment of the grant application, “This
approach to pain management is very
innovative and, if successful, could have
a tremendous impact on the way that
chronic pain is treated.”
15
Cleveland Clinic
Pain Consult | 2013
216.444.PAIN (7246)
Ongoing Pain Management Trials:
Is Your Patient a Candidate?
Cleveland Clinic’s Department of Pain Management is enrolling patients in a range of ongoing clinical studies.
To refer a patient for possible enrollment, call 216.636.0103.
C U R R E N T C L I N I C A L T R I A L S I N T H E D E PA R T M E N T O F PA I N M A N A G E M E N T
Study Name
PI
Key Inclusion Criteria*
Major Exclusion Criteria*
Controlled, Two-Arm,
Parallel-Group, Randomized Withdrawal Study
to Assess the Safety and
(IÀFDF\RI+\GURPRU
phone HCl Delivered by
Intrathecal Administration
Using a Programmable
Implantable Pump
Nagy Mekhail, MD,
PhD
• Age 18-75
• History of dependence on opiates, stimulants,
alcohol or benzodiazepines in prior year
Prospective, Randomized,
Multicenter, Controlled
Clinical Trial to Assess
WKH6DIHW\DQG(IÀFDF\
of the Spinal Modulation
Axium™ Neurostimulator
System in the Treatment
of Chronic Pain (ACCURATE Trial)
Samuel Samuel,
MD, and Nagy
Mekhail, MD, PhD
‡&OLQLFDOGLDJQRVLVRIFKURQLFSDLQIRU•PR
• Presently on intrathecal pain medication and has
or is eligible for SynchroMed® II pump implantation
• Metastatic cancer to spinal canal or known
CNS contraindication to intrathecal therapy
• Active implanted device that would interfere
with intrathecal pump
• Pain in head/neck region, central pain synGURPHVRUDQ\RWKHUSDLQXQOLNHO\WREHQHÀW
from intrathecal administration
• Age 22-75
• Chronic intractable pain of lower extremity for
•PR
• Diagnosis of failed back surgery syndrome, complex
regional pain syndrome or peripheral neuropathy
• Any of the following in past 30 days: escalating or changing pain condition, corticosteroid
therapy at intended stimulation site, unstable
pain med dosages
• Previous failure of spinal cord stimulation
• Minimum average VAS > 60 mm in lower
extremity
• Pain only within a cervical distribution
• Inadequate pain relief from at least two drugs from
different classes
• Active implantable device, other indwelling
device, or need for MRI or diathermy
• Stable neurologic function for past 30 days
• Coagulation disorder
• Radiofrequency treatment within past 3 mo
• Cancer diagnosis in past 2 yr
Prospective, Multicenter,
Randomized, DoubleBlinded, Partial Crossover
Study to Assess the
6DIHW\DQG(IÀFDF\RI
the Bioness® Stimulator
Neuromodulation System
in Treatment for Patients
with Chronic Pain of
Peripheral Nerve Origin
Nagy Mekhail, MD,
PhD
Phase 4 Multicenter,
Open-Label Pilot Study
of Pregabalin and
Prediction of Treatment
Response in Patients with
Postherpetic Neuralgia
Daniel Leizman, MD
‡$JH•
• Severe intractable chronic pain of peripheral nerve
origin associated with post-traumatic/postsurgical
QHXUDOJLDIRU•PR
• Ability to tolerate skin surface stimulation (TENS)
‡:RUVWFKURQLFSDLQOHYHOLQSULRUKRXUV•
on NRS for Pain
• Implanted demand-type cardiac pacemaker/
GHÀEULOODWRURURWKHUPHWDOLPSODQWLQDUHDRI
planned implantation
• Bleeding disorder or active anticoagulation
that cannot be stopped for a few days for
implantation
‡7UHDWPHQWZLWKVWDEOHGRVHRISDLQPHGVIRU•
wk before screening and ability to maintain dosage
from randomization to 3-mo follow-up
‡$JH•
• Pain for > 3 mo after healing of herpes zoster
skin rash
• Other severe pain that may confound assessment of postherpetic neuralgia (PHN) pain
• Neurolytic or neurosurgical therapy for PHN
‡6FRUH•RQ156IRU3DLQDWVFUHHQLQJDQG
baseline
• Failure or intolerance of pregabalin or gabapentin therapy
• Completion of at least four pain diaries within past
GD\VZLWKDYHUDJHSDLQVFRUH•
• Any clinically unstable cardiovascular,
hematologic, autoimmune, endocrine, renal,
hepatic, retinal or GI disease
• Malignancy in past 5 yr
Functional Capacity
Evaluation of Patients Undergoing Lumbar Spinal
Cord Stimulation Therapy
16
Daniel Leizman, MD
‡$JH•
• Diagnosis of chronic back pain with radicular lower
limb pain extension and successful completion of a
spinal cord stimulator trial
*Complete inclusion and exclusion criteria to be covered at time of referral. Pregnancy, breastfeeding and potential to become pregnant are exclusion criteria for most of these trials.
2013 | Pain Consult
clevelandclinic.org/painmanagement
Cleveland Clinic
&OHYHODQG&OLQLF·V3DLQ0DQDJHPHQW6\PSRVLXP
Heads to Las Vegas in February 2014
More than 250 physicians and other providers from 40 states and 12 nations brought themselves
up to date on the full spectrum of pain medicine at Cleveland Clinic’s 15th Annual Pain Management
Symposium, held in Sarasota, Fla., this past February.
Now course organizers are busy planning
decisions,” says Richard Rosenquist,
While many attendees are specialists
for the 16th Annual Pain Management
MD, Chairman of Cleveland Clinic’s
in anesthesiology or pain management,
Symposium, to be held Feb. 15-19,
Department of Pain Management and
attendees this year came from nearly
one of the faculty members for the
20 different specialties, with sizable
2013 symposium.
contingents from rehabilitation medicine,
2014, at Caesars Palace in Las Vegas.
7KHFRPSUHKHQVLYHÀYHGD\FRXUVH
internal medicine and family practice.
provides in-depth reviews and analyses
Content is presented by approximately
of most major aspects of contemporary
40 renowned experts in pain manage-
pain medicine. This year’s topic catego-
ment. About half the faculty comes from
ries ranged from emerging technologies
Cleveland Clinic and half from other
to controversies in pain medicine and
leading U.S. and international medi-
ment Symposium to learn about the
from evidence-based spine pain care to
cal centers. The 2013 faculty included
latest advances in pain medicine and
risk management in pain medicine. Ad-
experts from Sweden and the United
how healthcare reform is changing our
ditional program sections were devoted
Kingdom. The agenda is a diverse mix of
practices,” advises Dr. Rosenquist.
to imaging techniques and updates on
traditional lectures with problem-based
headache management.
learning discussions, cadaver workshops
For 2014 symposium details and regis-
on novel interventional techniques, and
tration info, email cmeregistration@
live-model workshops for training in
ccf.org or visit ccfcme.org/pain14.
“This course tackles provocative issues in
pain medicine and challenges attendees
to examine the basis for their medical
The course is designated for CME credit
for physicians and CE credit for nurses.
“Plan to attend the 2014 Pain Manage-
ultrasonography-guided injections and
peripheral nerve blocks.
17
Pain Consult | 2013
Cleveland Clinic
216.444.PAIN (7246)
Department of Pain Management at a Glance
30
Physicians
127,303
Patient visits
(2012)
20
42,394
Locations in
NE Ohio
Procedures
(2012)
And we act fast when needed: 37% of our 2012 procedures were acute.
A N E D U C AT I O N P O W E R H O U S E
10
30-40
Fellows
per year
Residents
per year
Launched optional two-year pain medicine fellowship in 2012
A RESOURCE FOR RESE ARCH
$1.13 million in Department of
Defense research funding in 2012,
and $150,000 internal funding
for research
S O U G H T O U T F R O M A FA R
932 patients in 2012 came
from out of state or out of
the country
FILLING THE CARE G AP IN THE WAKE OF 2012 “ PILL MILL BILL”
2012 saw a 15% surge in our new-patient volume after passage of Ohio HB93, which tightened
standards for operation of pain clinics and opioid distribution. Scores of Ohio providers stopped
prescribing opioids, so many of their patients on opioids turned to Cleveland Clinic. Department
of Pain Management staff met with these patients to optimize their care plans.
REGIONAL GROW TH SPURT
18
Clinic expansions are underway in 2013 for our
locations at main campus and Fairview Hospital.
The volume of our Regional Pain
Management practice continues to grow:
• 74,408 total visits in 2010
• 75,865 in 2011
• 81,529 in 2012
2013 | Pain Consult
clevelandclinic.org/painmanagement
Cleveland Clinic
New Staff
The Department of Pain Management welcomes new specialists:
Daniel Callahan, MD
Adam Kramer, MD
Specialty interests:
Interventional pain management (injection therapy,
medication management),
electromyography, autonomic
disorders
Specialty interests:
Spine pain, complex regional
pain syndrome, chronic pain
in athletes, abdominal pain,
headaches
Location:
South Pointe Hospital
216.491.6433
callahd@ccf.org
Location:
Medina Hospital
330.721.5700
kramera@ccf.org
Our pain management specialists are available at 20 locations across Northeast Ohio.
For a complete list of physicians and their locations, visit clevelandclinic.org /painmanagement.
Same-Day Appointments
Cleveland Clinic now offers same-day appointments to help
your patients get the care they need, right away. If patients call
our same-day appointment line, 216.444.CARE (2273), they
can be seen, in most cases, by a physician that day.
When patients call before noon, we’ll offer them a same-day
appointment; when they call after noon, we’ll offer an appointment
for the next day.
5HFHLYH7KLV1HZVOHWWHU
Electronically
Want to receive future issues of Pain Consult electronically?
Just log on to clevelandclinic.org /chronicpainnews
to receive future issues in your email inbox.
DEPARTMENT OF
PAIN MANAGEMENT CHAIRMAN
Richard W. Rosenquist, MD
M A N A G ING EDITO R
Glenn Campbell
ART DIRECTOR
Michael Viars
MARKETING MANAGER
Laura Vasile
P H O TO G RAPH Y
Cleveland Clinic Center for
Medical Art & Photography
19
The Cleveland Clinic Foundation
9500 Euclid Ave./AC311
Cleveland, OH 44195
RESOURCES FOR PHYSICIANS
Referring Physician Hotline
855.REFER.123 (855.733.3712)
Hospital Transfers
800.553.5056
On the Web at:FOHYHODQGFOLQLFRUJUHIHU
6WD\FRQQHFWHGZLWKXVRQ«
$ERXW&OHYHODQG&OLQLF
Referring Physician Center and Hotline
Cleveland Clinic’s Referring Physician Center has established
a 24/7 hotline — 855.REFER.123 (855.733.3712) — to
streamline access to our array of medical services. Contact
the Referring Physician Hotline for information on our cliniFDOVSHFLDOWLHVDQGVHUYLFHVWRVFKHGXOHDQGFRQÀUPSDWLHQW
appointments, for assistance in resolving service-related
issues, and to connect with Cleveland Clinic specialists.
Physician Directory
View all Cleveland Clinic staff online
at clevelandclinic.org /staff.
Track Your Patient’s Care Online
DrConnect is a secure online service providing realtime information about the treatment your patients
receive at Cleveland Clinic. Establish a DrConnect
account at clevelandclinic.org/drconnect.
Critical Care Transport Worldwide
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of vehicles are available to serve patients across the globe.
Cleveland Clinic is an integrated healthcare delivery
system with local, national and international reach.
At Cleveland Clinic, more than 3,000 physicians and
researchers represent 120 medical specialties and subVSHFLDOWLHV:HDUHDQRQSURÀWDFDGHPLFPHGLFDOFHQWHU
with a main campus, eight community hospitals, more
than 75 northern Ohio outpatient locations (including
16 full-service family health centers), Cleveland Clinic
Florida, Cleveland Clinic Lou Ruvo Center for Brain
Health in Las Vegas, Cleveland Clinic Canada, Sheikh
Khalifa Medical City and Cleveland Clinic Abu Dhabi.
• To arrange for a critical care transfer, call
216.448.7000 or 866.547.1467
(see clevelandclinic.org /criticalcaretransport).
In 2013, Cleveland Clinic was ranked one of America’s
top 4 hospitals in U.S. News & World Report’s “America’s
Best Hospitals” survey. The survey ranks Cleveland Clinic
among the nation’s top 10 hospitals in 14 specialty areas,
and the top in heart care for the 19th consecutive year.
Clinical Trials
We offer thousands of clinical trials for qualifying patients.
Visit clevelandclinic.org /clinicaltrials.
• For STEMI (ST elevated myocardial infarction),
acute stroke, ICH (intracerebral hemorrhage), SAH
(subarachnoid hemorrhage) or aortic syndrome
transfers, call 877.379.CODE (2633).
Outcomes Data
View clinical Outcomes books from all Cleveland Clinic
institutes at clevelandclinic.org /outcomes.
CME Opportunities: Live and Online
The Cleveland Clinic Center for Continuing Education’s
website offers convenient, complimentary learning opportunities. Visit ccfcme.org to learn more, and use Cleveland
Clinic’s myCME portal (available on the site) to manage
your CME credits.
Executive Education
Cleveland Clinic has two education programs for healthcare
executive leaders — the Executive Visitors’ Program and
the two-week Samson Global Leadership Academy immersion program. Visit clevelandclinic.org /executiveeducation.
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