Nerve Blocks :(

Anytime people talk about “pain clinic” this issue keeps coming up. For a reason unbeknownst to me, patients are expected to submit themselves to needling. Often these injections are performed on a weekly basis yet providing either zero or a very short-term pain relief. For the sake of argument, placebo effect will not be discussed here, although, certainly there is a lot to do with the so-called expected effect.

Physiologically, injected local anesthetics (hopefully, without corticosteroids) produce some pleasant warming numbness and muscle relaxation. Rarely, they produce long-lasting pain relief, but the mechanism is not clear yet. We can speculate that when these drugs are injected very close to the target nerve, or into the nerve, they cause neurotoxicity (poisoning) and slow conduction of electric impulses through this nerve. There is another hypothesis of a so-called “pain reset,” some magical Microsoft-like solution: if something doesn’t work and you don’t know what to do, just click "restart". There is also a strong belief that with repeated nerve blocks thepain will be diminishing. All these hypotheses have never been experimentally confirmed. On the other hand, tissue toxicity was documented in laboratory studies, and conscientious ethical pain physicians published their experience disproving nerve injections (Arne Johansson and Bengt Sjolund. J Pain Symptom Manage 1996).

Thus, we barely have something good, possibly have something bad, but sure enough, there is an ugly there. There is an inconvenient truth related to the fee for services system where doctors are paid per injection. Because, a single injection is not paid well, they do 6-12 needle punctures, injecting stuff into various unrelated and not united by sound diagnosis anatomical structures. I hope some of my colleagues do this because they believe in this ritual. They were educated by older and imminent needle jockeys and genuinely consider “drill-mill” to be an equivalent of Pain Medicine. Maybe they are just blessed with ignorance? Regrettably, I doubt they are blessed, I gather they are cursed by one of the worst sins, the greed. I refuse to believe they would apply “My Mom's Principle” but rather they push a fundamental principle, “Do No Harm” into the deepest drawer of their mind. The excuse is:  “it is common practice, and everyone is doing it.” This is true, but is it right?

Surprisingly, the regulations are very forgiving, and in the absence of evidence against this, the multiple no sense nerve blocks are considered the standard of care. All that is needed is to obtain a permit specifically allowing clinics to implement these injections in their practice. Interestingly, no special permission is required for other injections, such as joint aspirations. Perhaps, if someone comes with a swollen knee, offering an injection in the shoulder would be odd. However, when the low back hurts, no one asks why 10-12 injections are being performed.

We always say our Canadian system is not ideal, but at least we don’t do unnecessary treatments as Americans do. Well, in this case, our system is much worse. Certainly, some American doctors may also turn patients into pincushions to fill their bank accounts, but the American Society of Anesthesiologists recommended against nerve blocks for chronic pain other than for diagnostic purposes a long time ago. In the absence of the similar position here, and when nonsense declared as an appropriate and medically necessary method, patients should ask their doctor: “will you do it to your Mom?” and watch their facial expression.  

Medicolegal Expert

Let’s face an inconvenient truth: there are no independent medicolegal experts. We, physicians, are paid by either the plaintiff or defense to produce our medical evaluations. We are called to remain impartial and nonpartisan. This is obvious nonsense. People respond to incentives, and doctors are not immune to this. Even in seemingly transparent academic endeavors, financial incentives play a significant role. Numerous studies and literature reviews show a significant influence of industry, with a correlation between funding by the manufacturers and findings that show positive results for efficacy and safety of the benefactor’s products.

Why lawyers have an opportunity to take a side, but experts can’t? It’s okay to take a side, either in daily life or even in court. A judge may implicitly sympathize with an accused perpetrator. It’s human nature because we are social creatures. Thus, if we were programmed to like someone and dislike another based on certain synaptic connections in our cortex, how we are supposed to act when the main reward center in our brain is involved? When a doctor is paid, the amygdala is pleased. Moreover, it will work hard to receive the same reward all over again and make everything possible to eliminate obstacles in this process.

The ethical standards should stand safeguards and suppress the rewarding circuit. However, when ethics are shaken in politics, society, culture and even religion, why doctors are expected to remain immune, especially when a biased report does not threaten anyone’s life?

The solution is a simple and logical. Doctors, like attorneys, should be allowed to defend their clients. In the absence of any other superior judgment, courts and mediators should unravel medical casuistic the same way deal with other legal matters.

Peripheral Nerve Stimulation for Nerve Injuries

Peripheral Nerve Stimulation (PNS) method is older than any other neuromodulation technique. Pioneers of PNS experimented on themselves stimulating their infraorbital nerves, and achieving pleasant numbness in the face. Here is how they described the first treatment: "On October 9, 1965, Dr. Wall and one of us (Dr. W.H. Sweet) implanted a pair of silastic ring platinum electrodes around the ulnar and another pair around the median nerve in the arm carrying the wires out of the skin at the mid-forearm. On the median nerve 0.1- ms pulses at 100/s and 0.6 V provoked a pleasant tingling in the lateral three fingers and corresponding hand and stopped the pain in the medial three fingers and hand as well as tenderness in the third finger and palm."
White JC, Sweet WH: Pain and the Neurosurgeon:  A Forty-Year Experience. Springfield, Thomas, 1969, pp 894–899.

I started using PNS to treat intractable pain 15 years ago. Since I moved back to Canada in 2013, I have done only R&D work to develop new devices. Three of them are already FDA approved, and Health Canada approval is pending. 

I'm excited to have this modality here to make patients' lives better.

One of my patients from Seattle sent me this note a couple of weeks ago: Hello Dr. Gofeld. I'm the patient that you implanted the IPG into the calf of my leg to alleviate nerve pain in my left ankle. The nerve damage occurred during an ankle replacement. You SAVED my life!! Remembering how desperate I was for some solution, remembering being sent to you after a couple different appointments at the U of W, remembering the day that you told me, "I think I can help you". You don't know the impact your care of me had on my life and those around me! At this time, yes, I still use my IPG on a regular basis. My ankle tells me when to turn it on/off..........I find that so interesting. I just really want you to know that you're thought of and I am an eternally grateful former patient of yours. Sincerely, Sue Q"

Pain Specialist, eh?

A pain specialist, a specialist in chronic pain management, an algologist - all these and other definitions of a doctor who deals with individuals suffering from chronic pain do not make sense for the public. Does a family physician treat chronic pain? Yes, of course, as well as orthopedic surgeons, neurologists, oncologists, and the rest of medical specialties. Even dermatologists and ophthalmologists. So what makes this Pain Medicine special? Why can't each and everyone manage the pain of her/his patients? Perhaps, my view is unconventional, but I believe in accountability and commitment to patient well-being. If my esteemed colleagues did the same, many chronic pain conditions would be extinguished. For example, if spine surgeons would commit to staying with their patients, no surgeries for low back pain would ever happen. The reality is different: patients are promised miracles and cure, and then are thrown away back to their family doctors loaded with narcotics and more pain issues than before the surgery. But, let me come back to definitions. Thus, Chronic Pain Specialist is the one who should be finally able to make a correct anatomically sound diagnosis and treat the problem. Unfortunately, patients get to us after months and often years of physical and, subsequently, emotional suffering. When a clear bio-anatomical cause is not addressed, Pain is transformed brain of the sufferer, starting off a vicious cycle of pain-depression-social isolation-drug dependency-pain. Therefore, we, Pain Specialists, should see patients with sciatica, acute back and neck pain, and other conditions, way before orthopedic and other surgeons; we should consult patients with shingles and traumatic nerve injuries way before they are desperate. Pain Specialists should be seen as a new Palliative Care. Just until recently, only dying cancer patients would be referred to Palliative team. With the paradigm shift, these patients are be routinely assessed by palliative care doctors to address their symptoms - pain, fatigue, constipation, etc. It resulted not only in better care, but in significant improvements in the quality of life and, often, survival.