Taking a Better Approach to Pain Management

Zevi Tilles has regained his competitive edge on the soccer field now that he is free of debilitating pain that once left him bedridden.

Few people watching Zevi Tilles, 43, sprint across the soccer field would suspect he could barely get out of bed a few months earlier due to severe back and leg pain.

The trouble began last December, when Tilles felt a sharp pain in his lower back and left leg. He brushed it off, figuring he had tweaked something during his weekly soccer game. But when he was unable to walk, Tilles headed to Greenwich Hospital’s Emergency Department, where an MRI scan revealed the source of his debilitating pain: a herniated disc between two vertebrae in his lower spine.

While Tilles was at the hospital, Richard Zhu, MD, an interventional pain physician, treated him with an epidural injection containing a steroid and local anesthetic. Tilles soon felt well enough to go home. He received instructions to take non-opioid pain medications such as acetaminophen and was asked to sign up for physical therapy. Two months later, Tilles had a second epidural to address lingering mild pain. That finally did the trick.

Today, Tilles is back to playing soccer every Sunday. “I went from not being able to walk to sprinting,” said the New Rochelle, NY, resident.

Tilles benefited from the multimodal approach used by Greenwich Hospital’s Center for Pain Management to address acute and chronic pain with methods that lessen the use of opioids, whether patients are hospitalized or seeking outpatient care. The approach uses pain-relief medications and non-opioid treatments, such as epidural injections, spinal cord stimulators, regenerative medicine, radiofrequency ablation, physical therapy and more. The treatments are managed by a team of specialists including board-certified pain physicians, anesthesiologists, surgeons, nurses, pharmacists, physical therapists, social workers and case managers.

“People think they need to live with pain, especially as they age, but that’s not the case,” said Rajat Sekhar, MD, an interventional pain physician. “It’s important to address pain early, especially if you’re beginning to lose function.”

Personalizing pain management

Rajat Sekhar, MD, and Richard Zhu, MD, are interventional pain physicians who use innovative, non-opioid techniques to treat chronic pain sufferers at Greenwich Hospital’s Center for Pain Management.

Managing pain – which is the body’s protective response to an injury or trauma – can be challenging because people have varying perceptions of pain, explained Mark Chrostowski, MD, an anesthesiologist at the forefront of the hospital’s multimodal approach. “There is no set formula for managing pain,” he said. “You need to create an individualized plan and involve the patient in the plan.”

Much has changed over the past two decades in the ways the medical community treats pain. In 2001, the Joint Commission – a nonprofit organization that accredits healthcare organizations in the U.S. – introduced standards for assessing and treating patients’ pain. Pain became the fifth vital sign, routinely measured on a scale from one to 10, with 10 being the worst. “The goal was to get pain down to zero,” Dr. Chrostowski said. This expectation promoted excessive use of opioid pain medications and increased the incidence of opioid-related side effects.

Fast-forward to 2019: The nation faces a crisis. A growing number of people abuse opioids, a class of drugs including prescription painkillers such as oxycodone, hydrocodone, fentanyl, morphine and tramadol, as well as illegal heroin. According to the U.S. Centers for Disease Control and Prevention, 130 people die of opioid-related overdoses every day and 11 million people a year misuse prescription opioids.

The multimodal approach

Anesthesiologist Mark Chrostowski, MD, has been at the forefront of Greenwich Hospital’s multimodal approach to manage pain.

Multimodal pain management was introduced at Greenwich Hospital nearly 10 years ago as a data-driven way to offer patients a comprehensive, proven array of treatment options. “We started with patients undergoing joint replacement or spinal fusion surgeries,” Dr. Chrostowski said. “Before then, these patients typically received a regimen that was 100 percent based on opioids.”

Now with the multimodal approach, prior to surgery patients receive peripheral nerve blocks to numb areas associated with surgical pain. Afterward, they may take various non-opioid medications such as acetaminophen, ibuprofen, gabapentin and celecoxib. The new approach has dramatically improved post-operative pain management. Instead of staying in bed for a day or two after a knee replacement, patients are now walking within hours after surgery.

“The results have been pretty remarkable,” Dr. Chrostowski stated. “We saw a 50 to 60 percent decrease in the use of opioids and limited side effects like nausea, vomiting and constipation. Patients were also less sedated, and recovered from their surgery much faster.” Although Greenwich Hospital’s decade-long multimodal pain management program wasn’t intentionally prompted by the opioid crisis, its implementation has directly addressed the problem by greatly reducing inpatient use, Dr. Chrostowski said. Today virtually all patients having total joint replacements, spinal fusions, bariatric surgery, reconstructive breast surgery and obstetric procedures are offered multimodal medications.

The new approach to addressing pain, coupled with public awareness of the dangers of opioids, has also changed patients’ expectations about dealing with pain. These expectations are discussed during preoperative consultations. “Patients know that opioids are a big problem nationally, so they’re okay with less use of them,” Dr. Chrostowski said. “The best part of the new regimens is that patients are more comfortable while taking fewer opioids.”

Maternity patients at Greenwich Hospital are also receptive. The Gynecology and Obstetrics department, which was one of the early adopters of multimodal pain medications, has experienced impressive results, particularly in decreasing opioid use.

“We have reduced the number of opioid prescriptions, from the national average of at least 20 pills down to 12,” said Romelle Maloney, MD, an obstetrician and chair of the department’s co-management executive committee. “Patients often want to deal with pain as naturally as possible and don’t want to take any opioids.” Although women can opt for an opioid prescription after their cesarean section, the vast majority do not and instead go home with only acetaminophen and ibuprofen, Dr. Maloney said.

“We recognize that it is our responsibility to the Greenwich community to participate in whatever way we can to stem the tide of opioid abuse,” said Patricia Calayag, MD, director of Obstetrics and Gynecology. “We have a disastrous epidemic on our hands, and the patients really understand this.”

Obstetricians Romelle Maloney, MD, and Patricia Calayag, MD, director of Obstetrics and Gynecology at Greenwich Hospital, have successfully reduced the use of opioids in obstetric cases.

Innovative Options

Chronic pain sufferers also have access to innovative techniques on an outpatient basis at the Center for Pain Management. “We’re seeing a big push in the use of regenerative medicine, which involves the use of platelet-rich plasma and stem cell injections. These are safe, non-surgical procedures that stimulate healing of injured tissue,” said Dr. Sekhar. Another treatment option, called radiofrequency ablation, “stops or lessons pain by selectively destroying nerve cells,” noted Dr. Zhu.

For Linda Ricci of Scarsdale, NY, the use of a spinal cord stimulator finally tamed her chronic pain. Ricci seriously damaged her spinal cord and right knee after taking a hard fall in a store. “The pain was intense and kept me from doing much of anything,” she said. Ricci was prescribed oxycodone and non-narcotic pregabalin to relieve her pain, and she received physical therapy.

When the severe pain didn’t subside, Ricci had two surgeries – one on her spine, the other on her knee. Both procedures were successful, but the pain remained constant, despite resuming physical therapy at home and occasionally taking low-dose oxycodone, she said.

Last year, Ricci met with Dr. Sekhar, who eliminated the opioids and treated her instead with non-narcotic epidural injections. When that didn’t help, he suggested using a spinal cord stimulator. This small device – implanted under the skin using a minimally invasive procedure – continuously delivers gentle electronic currents to the spine to block pain signals to the brain. “So instead of feeling pain, she perceives something more pleasant,” Dr. Sekhar explained.

“I am pleased with my pain relief, and my quality of life has indeed improved,” said Ricci. “It is amazing what you take for granted in your life until you are unable to do it anymore.”