Erin Kelly's problems started after her cesarean section.
Then 20, Kelly delivered a healthy baby boy, but was subsequently diagnosed with endometriosis and pelvic adhesive disease, which causes a buildup of scar tissue in the abdomen and pelvis. The abdominal pain that accompanied her condition was debilitating, and lasted 15 years. She missed work, underwent 10 surgeries—including a hysterectomy at the age of 30—and was downing 120 milligrams of OxyContin a day in a futile attempt to lessen the excruciating pain.
"I felt like my insides were going to fall out,'' says the 35-year-old Baltimore paralegal. "The pain was worse than labor.'' Kelly went from doctor to doctor in search of relief, but received little more than pain narcotics. "Nobody was coming up with a solution,'' she says. "I really wasn't happy with these doctors who kept prescribing me all this medicine.''
This past spring, in a last-ditch effort, Kelly tried the University of Maryland Pain Management Center at Kernan Hospital. Dr. Thelma Wright, the center's director, says Kelly is like a lot of pain patients who come through her doors.
"We get the more complicated cases. Most have been from doctor to doctor. This is their last stop. They come to us for the magic bullet,'' Wright says. "She [Kelly] had been through the wringer.''
Kelly was skeptical and said so. And Wright made no promises. The doctor suggested a new, high-tech implantable abdominal stimulator that delivers an electric current directly to the abdomen, masking the pain patients would normally feel. "It was a long shot,'' Wright admits.
The effects were immediate. "It changed my life,'' Kelly says. "I went in there feeling helpless and hopeless. Now I feel great.'' Instead of coming home from work and crashing on the couch, Kelly now can go on shopping excursions with her mom and enjoy concerts with her 15-year-old son. She and her husband go camping, deer hunting, and four-wheeling. She delights in a simple walk through the woods. "A lot of people think of pain management as pills,'' she says. "It does not have to be that way.''
In the past, pain management meant just that. Most patients wound up taking a cocktail of pills in hopes of getting some relief. But in recent years, technology in the pain field has exploded, creating myriad treatment options to calm even the most stubborn pain problems.
While many pain physicians have earned the nickname "needle jockeys'' or "block jockeys'' for the high volume of injections they perform, new drugs, devices, and alternative techniques continue to hit the market, many of which have shown promise in greatly easing persistent pain, if not eliminating it. Pain practitioners at the University of Maryland Pain Management Center use the highly touted "multidisciplinary approach'' in their pain treatment program, which can include medication, physical therapy, steroid injections, nerve root blocks, and the higher-tech implantable pain therapies. There's also a pain psychologist on staff to help patients learn to manage their pain, and to deal with the depression, anxiety, and irritability that can accompany pain. Many physical therapy clinics to which patients are refered by pain specialists are employing a technique called TENS—transcutaneous electrical nerve stimulation—in which pulses transmit signals to the brain that interfere with the pain signals. Other increasingly popular treatments at successful Baltimore-area pain practices include chiropractic and acupuncture, in addition to stress-reducing remedies like guided imagery, massage, meditation, relaxation therapy, biofeedback, and hypnosis.
"Pain medicine is not really a cure,'' Wright says. "It's more a management of pain. But you see results. We can reduce pain and help patients to function. We can get them off the couch and stop them from popping narcotics.''
Despite the evolving array of pain procedures, statistics continue to show that—more often than not—pain goes untreated or undertreated. According to a 2007 study by the American Pain Society, just 5 percent of chronic pain patients—those with debilitating pain from chronic illness, accidents, surgery, or advanced cancer—ever see a pain specialist. Industry experts blame primary care physicians who often do not take a patient's pain seriously or treat it adequately.
Studies show that nearly half of chronic-pain patients have changed doctors at least once, and more than a quarter have changed doctors at least three times.
"Most doctors prescribe a little Percocet and send them on their way,'' Wright says.
Take Julian Klaff. Several years ago, the 80-year-old Pikesville resident tumbled down his cellar steps and landed on his back. He had been accustomed to walking eight, sometimes 10 miles a day, and he was an avid gardener. But the pain in his back and neck as a result of the fall had brought all activity to a standstill.
"I went from one doctor to another,'' says the retired medical technologist. "They gave me pain killers, but that made me very sleepy. I finally gave up. I didn't want to hear anymore, 'You have to live with it.'"
Klaff eventually found himself at OrthoMaryland, one of the region's largest orthopedic and rehabilitation medical practices, where pain management specialist and psychiatrist Dr. Lisa Grant recommended a regimen of steroid injections, physical therapy, and home exercises. Klaff is now able to stroll to his garden on Rolling Road, where he happily hunches over for hours at a time, weeding and fertilizing to his heart's content. He also takes exercise classes at the nearby Jewish community center.
"The first thing she [Dr. Grant] said to me is, 'We're going to make you feel a lot better,'" Klaff says. "It was like looking up to heaven. There was hope instead of despair.''
As the population ages, and baby boomers are hitting their golden years, there are more and more folks in Klaff's shoes. Back aches and neck pain abound; hips are worn and complaining. But even when patients get the go-ahead from their primary-care physicians to see a pain specialist, pain docs are not always easy to find.
The American Pain Society study reported that the 2,500 board-certified pain specialists in the U.S. represent just four doctors per 100,000 patients with chronic pain—"woefully inadequate," the report concludes. Exact numbers for pain practitioners in Maryland are hard to come by: Just 24 pain specialists are listed in the directory of the American Academy of Pain Medicine, while the American Academy of Pain Management reports there are 90 pain practitioners statewide. "We don't have anywhere near the number of pain specialists to treat the number of those in pain," says Micke Brown, advocacy director for the Baltimore-based American Pain Foundation.
To make matters worse, a handful of hospital-based outpatient pain clinics in Maryland have been forced to scale back or shut down in recent years. Industry leaders blame stingy reimbursement practices on the part of insurance companies, which has made it virtually impossible for some pain centers to turn a profit.
Washington County Health Systems opened a pain services division in 1996, but by 2003, the hospital had shut it down, according to Brown, who was the former clinical coordinator of the pain clinic there. It currently employs just one pain nurse, Brown says. Howard County Hospital closed its pain clinic about two years ago. And a group of pain practitioners at Greater Baltimore Medical Center moved its business off the hospital campus.
"It's fair to say, as an industry-wide phenomenon, that with the growth in ambulatory surgery centers off hospital campuses, and related economic issues, including reimbursements, that pain-management practitioners generally have moved off campuses," says Michael Schwartzberg, GBMC's media relations manager.
"The successful pain services are the ones that provide multidisciplinary care, but insurance companies aren't paying for that. They're just paying for the injections and procedures,'' Brown says. "Pain management needs to allow for counseling and medical management, but there's very minimal reimbursement in those areas.''
Wright says the only way the University of Maryland Pain Management Center is staying afloat is due to financial support from the hospital, and the hospital's commitment to the program. Kernan Hospital continues to pour money into marketing the pain division in hopes of increasing its patient base. "The pain division doesn't make money for the group," she says. "You have to siphon funds to make it work. And you have to have the monetary support because you need the right equipment to do certain procedures. We are fortunate to have the support that we need."
In recent years, some private medical groups have hired pain physicians and other specialists in an effort to make their practices a one-stop shop for patients. OrthoMaryland, a 17-doctor group, last year consolidated operations in an expansive office at the Quarry Lake at Greenspring complex near Pikesville, and now offers orthopedics, sports rehab, neurology, acupunture, and pain management. Grant was the second pain physician to come on board at OrthoMaryland, and is in her third year of practice there.
"Within three months, we were completely booked up," she says of the pain division. "It's an aging population out there, and our spines weren't designed to live as long as we're living now. Pain management is definitely coming into the forefront.''
At Sinai Hospital's Department of Physical Medicine, five doctors see patients in pain. The department offers a long list of treatments, including epidurals, nerve blocks, and injections, generally combined with physical therapy, exercise, and medication. Dr. Ross Sugar, a Sinai pain specialist, says despite the allure for physicians of a 9-to-5 lifestyle and a results-oriented job, he sees an overall "underabundance of pain docs out there,'' perhaps due to a reluctance by some medical students to enter the field.
"Pain patients can be challenging,'' he admits. "I think it takes a doc with a lot of understanding and time to listen.'' Other doctors have been duped by drug abusers who fake their pain, while some say the fear of regulatory scrutiny—news reports have highlighted arrests of doctors on charges of overprescribing opioid drugs like OxyContin—may be keeping some medical students from jumping into the pain arena. Pain societies have since established guidelines to help doctors avoid such risks.
"One bad apple can ruin the barrel,'' says Pikesville pain management specialist Dr. Jason Brokaw of doctors who irresponsibly overprescribe, "and really get people jaded as to what pain management really means.''
Like it or not, opioids—which include morphine and morphine-like drugs—are part of the business, pain-management advocates contend. "There's a stigma,'' Brown says of pain physicians. "But if you're treating pain effectively, there are opioids involved. You have to know how to use them and you need to use them well.''
Industry experts say most doctors prescribe opioids cautiously, and that many patients and their families are just as wary of the addictive pain killers as their doctors. Diane Maloy, 62, of Towson, has suffered from chronic back pain for a couple of years. She likes to head out West to see her grandchildren in Denver, where they live in an historic house with steep steps. The constant lifting of children and climbing of steps takes a toll on Maloy's back each time she visits. "But I will not give into it,'' she says.
At OrthoMaryland, Dr. Grant has tried several different treatments on Maloy, including steroid injections and physical therapy. The pain still comes and goes, Maloy says, but is under control. "She is not a pill pusher,'' says Maloy. "And she is real open to alternative medicine. I'm in acupuncture right now.''
Grant says OrthoMaryland's pain practice is based on avoiding surgery and conservatively prescribing medication. While the success of pain treatment is difficult to measure, Grant says most of her patients "do get better,'' and 85 percent of her back-pain patients will never need surgery. "Eighty percent of acute back-pain sufferers are better within 12 weeks, whether we do anything or not,'' she says. "My goal is to help them get better more quickly.''
Her partner, Dr. Brokaw, says it's a progression of treatments that allows patients to heal. "It takes different tools for different problems,'' he says. "It's hard to measure, but most people experience improvement.'' He says he avoids prescribing narcotics unless necessary. "Some people think that pain management means narcotics management, which is very different from the way we approach it. My goal is to get people off medications that slow their thinking and slow them down.''
As pain management continues to gain acceptance in the world of medicine, and more primary-care physicians see it as a viable answer to their patients' suffering, industry leaders and specialists see a growing need for such services.
Just ask Thalia Resnick. The 75-year-old Owings Mills resident had chalked up years of swinging tennis racquets and golf clubs before her back started giving her trouble. Before she knew it, she couldn't even get out of a chair without difficulty. "I didn't want to do much,'' she says. "I certainly don't look my age, and I hated walking like I was 75.''
Resnick received a double shot in the spine from an area pain specialist, and the aches subsided. She now goes in for tune-up injections, and participates in exercise classes three days a week.
Resnick encourages friends who are hurting to give pain management a shot. Or two. "I'm a believer,'' she says. "I'm really not in pain any more, and I am back to living my life.''