Wound Treatment That’s More Than Skin Deep: Focusing on Pain Management

Who would instruct any patient to take 20 daily doses of 800-mg ibuprofen for the unrelenting hip pain he had been experiencing as a result of a recent car accident? It is incredulous to even consider such a scenario. But here was Tom, 34, a patient who recently presented to this author’s facility, a facility that specializes in the management of chronic pain, looking even more pain stricken after learning of the associated risks — namely gastrointestinal bleeding, renal insufficiency, and death — of following the prescribed regimen every day for three years. Could it have been that the primary physician was so worried about prescribing opiates that, even when considering that opiates would have been medically appropriate, he took the far more dangerous path of increasing the NSAID dosage instead? 

Apparently, Tom’s orthopedic surgeon had a similar opiate phobia. After performing a hip arthroscopy that brought with it the customary subsequent pain, the surgeon prescribed one Vicodin tablet to “control” that pain, according to Tom. Perhaps the most distressing element to all of this is that not only had Tom’s physicians mismanaged his acute pain, they didn’t refer him to a pain specialist when it was obvious that his pain was uncontrolled. By the time Tom made his way to this author through his own research, the pain from the avascular necrosis in his hip was chronic and severe, and he could barely function in his job as a deliveryman for a home appliance company. He was prescribed a low-dose, extended-release opioid medication and a low-dose diclofenac, an NSAID with a reduced cyclooxygenase (COX-1) inhibition, which reduces gastrointestinal and renal side effects, to prevent a rebound inflammatory response from abruptly stopping the ibuprofen. Had Tom been referred to a pain specialist earlier, his need for high-dose NSAIDS and opioid therapy may have been far lower and discontinued earlier, not to mention that his acute pain may have never progressed to chronic pain. He also may have been a candidate for regenerative medicine — perhaps adipose-derived autologous stem cells or particulate umbilical cord and amniotic membrane — which has the potential to heal nerve endings and tissues on a microscopic level while reducing pain to a tolerable level.

Because pain is so often inadequately managed, many Americans live with chronic pain.¹ Pain associated with chronic, nonhealing wounds is no exception. When considering that many types of medical practitioners from various disciplines are likely to come into contact with patients who live with chronic wounds (and hence chronic pain), including outpatient care staff, primary care physicians, plastic surgeons, infectious disease specialists, nurses and nurse practitioners, podiatrists, and physical therapists (to name a few), there are going to be some providers with limited experience in managing pain when compared to their peers. For those providers with more experience, however, there’s not always a correlation between that experience and quality, effective pain management. Treating pain can also be exceedingly challenging and time-consuming, even for providers in outpatient wound clinics — where essentially every patient can be considered to be living with chronic pain. Many wound care clinicians don’t have the logistical bandwidth to comprehensively evaluate their patients for their levels of pain and pain tolerance, let alone to determine the correct types of medications or interventions to employ, potential side effects to consider, or to properly assess whether pain medications are working and/or if the patient maybe abusing them. This article will help to educate providers in the outpatient setting on when to seek referral to a pain specialist. 

BIAS AGAINST TREATING PAIN?

When it comes to managing pain, physicians may not be eager to prescribe anything stronger than over-the-counter analgesics. There tends to be a prevailing attitude today among those practitioners who are not pain specialists that a high percentage of patients who experience pain, for whatever the diagnosis may be, will become addicted to prescription opiates. This simply is not true. Studies show that up to 96% of people who receive opioid prescriptions never develop opioid addiction.^2-4 According to the National Institutes of Health’s (NIH’s) Interagency Pain Research Coordinating Committee, “when opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, postoperative, and procedural pain, as well as for patients near the end of life who desire more pain relief.”¹ This in no way implies that we should go back to the prescribing habits that have led us to the opioid epidemic; rather, we should properly assess, manage, prescribe, and treat our patients.

It is inadequate treatment of pain that results in greater morbidity and mortality when compared to proper pain management, which includes procedures and medications (and may include opioids).⁵ Early intervention can prevent acute pain from transitioning into chronic pain, which becomes its own serious disease when neuroplasticity causes central nervous system changes that lead to an even greater perception of pain severity. The longer pain persists, the more sensitive the brain becomes to the negative stimuli. Opioids may also cause increased central sensitization, and this relationship seems to be both dose-dependent and molecule-dependent. In this author’s experience, oxycodone appears to cause more central sensitization relative to other opioid molecules. So, while it is advisable to advocate for proper pain management, which may include opioids, advocating for reduced use of opioids as much as possible is also a good idea.

It is true that opiates may not be the best first-line therapy to manage a patient’s chronic wound pain. Proper use of anti-inflammatories, nerve-pain medications, nerve blocks, or even cannabinoids may also control pain experienced as a result of wounds and wound care. Like any other disease, understanding the diagnosis and the pathogenesis of the wound is key to creating a multimodal pain-management algorithm for controlling the patient’s pain. 

PROPER MANAGEMENT OF WOUND PAIN, MAKING REFERRALS 

The World Health Organization’s analgesics ladder is a useful, stepwise approach to treating acute and chronic pain, starting with NSAIDS and ending with various types of opioid medications.⁶ But the devil is in the details: it’s also important to look for the safest drug in each analgesic category. That analysis includes a careful evaluation of the molecule and the technology (or lack thereof) that delivers the molecule. Complementary medicine, such as massage or acupuncture, should also be considered as a first- or second-line treatment option for controlling wound pain. These therapies have limited downside risks other than their financial costs to patients. 

Additionally, wound care physicians must be honest with themselves and their patients about whether they have the resources to manage pain associated with chronic wounds. If pain management isn’t one’s forte, or if a patient’s pain is legitimately not improving, it’s crucial for the provider to refer their patient to a true pain specialist (one who has proper training and intentions) who can concentrate on managing pain, just as wound care providers can focus on wound treatments that other providers and facilities can not offer. As healthcare providers, we all have a responsibility to ensure wholistic treatments, even if that requires us to refer our patients to others in order to achieve this goal. Much like wound care clinics can and do collaborate with primary care providers and long-term care/rehabilitation centers to coordinate care, so too can pain centers and wound clinics collaborate. According to the NIH, “all people with pain should receive adequate care.”¹ And while it’s imperative that wound care clinicians be comfortable with and educated on treating pain to a certain extent, they should also seek relationships with quality pain specialists in their region to help prevent patients from suffering unnecessarily. 

Referring patients to a pain specialist in private practice is admittedly challenging. Many pain management practices are limiting medication management because of the financial and legal burdens. In addition to the wound, many of these patients may also live with hypertension, active infection, and diabetes, as wound care providers well know. They may also require multiple medications. There is little financial incentive for the pain specialist to treat a complex wound patient, especially those who are covered by Medicare or Medicaid. An interventional pain specialist’s overhead easily runs many hundreds of dollars per hour to more than $1,000 per hour, depending on the setting. Reimbursement for pain management of a Medicare patient may be less than $100, and a typical office visit may take 20-30 minutes. There is only so much financial loss a private practice can bear. The answer is for wound care physicians to cultivate relationships with these pain specialists. A pain physician may be willing to treat that complex wound for patients who are covered by Medicaid or Medicare at a loss if the clinic is referring multiple patients with insurance plans that allow for a profit. If the patient is complex and his/her pain is not well controlled, or if the provider is not comfortable with the current state of pain management, the patient should be referred to a legitimate pain specialist promptly. Early intervention is the best way to prevent further morbidity associated with pain. 

Jay Joshi is a double board-certified and fellowship-trained anesthesiology and interventional spine and pain-management physician. He is chief executive officer and medical director of the National Pain Centers in Hoffman Estates and Vernon Hills, IL. He discloses no financial conflicts of interest. 

References

1. National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. Department of Health and Human Services. 2016. Accessed online: https://iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf

2. Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? a structured evidence-based review. Pain Med. 2008;9(4):444-59.

3. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573-82.

4. Hojsted J, Ekholm O, Kurita GP, Juel K, Sjogren P. Addictive behaviors related to opioid use for chronic pain: a population-based study. Pain. 2013;154(12):2677-83. 

5.  CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Centers for Disease Control and Prevention. Accessed online: www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

6. Vargas-Schaffer G. Is the WHO analgesic ladder still valid? twenty-four years of experience. Can Fam Physician. 2010;56(6):514-7.