IR can play a critical healing role for patients as the United States battles an opioid epidemic and pain crisis.
By Melanie Padgett Powers Winter 2019 (preview)
Gene Johnson was eating biscuits and gravy on a Monday night with his wife, Jeannie, and his elderly mother. “That was the last thing I remember until they were tubing me in my driveway and taking me to the hospital,” he says. In the middle of dinner at his home in Rome, Georgia, Johnson suddenly stopped chewing and put both arms on the kitchen table. He stared blankly straight ahead and didn’t respond to his wife repeatedly asking what was wrong. She called 911. He stayed unresponsive in the chair until paramedics arrived. He had suffered an accidental opioid overdose at age 70.
Johnson began taking painkillers for chronic pain after neurosurgery for multiple myeloma and associated spine fractures in 2013. It was later discovered that the neurosurgeon had accidentally cut a nerve that led to excruciating ongoing pain. In addition, Johnson had four rods in his back and one in his left arm. He eventually went to a pain clinic, where they tried several pain medications, including hydrocodone and Lyrica. “They kept giving me opioids and nothing would help,” he says. Then they gave him OxyContin, which, it turns out, would be the last opioid he would ever take.
In 2017, Johnson took one OxyContin pill on a Saturday, then one on Sunday and another on Monday. Just three pills before he collapsed with an overdose. However, he was continuing to take various other prescription painkillers he had been given, not realizing the danger. After surviving his overdose, Johnson swore off opioids. “We just threw away all the opioids in the house. I just hurt instead,” he says.
A pain epidemic
About 25.3 million U.S. adults like Johnson, or 11.2 percent of the population, suffer from chronic pain—defined as pain that lasts three months or more—according to a 2012 National Health Interview Survey.
The opioid epidemic has received a lot of attention in the past decade. But it goes hand in hand with a pain epidemic in this country. Many people who have become addicted to painkillers or even overdosed or died started by trying to find relief for their chronic pain. The first wave of opioid overdose deaths began after physicians increased their prescribing of opioids in the 1990s, according to the Centers for Disease Control and Prevention (CDC). In 2016, CDC released stricter guidelines on how to prescribe opioids for chronic pain, leading to fewer and shorter prescriptions.
Interventional radiology experts say IR didn’t play a significant role in the initial opioid crisis because the nature of the specialty means IRs don’t tend to write prescriptions for chronic pain. However, IRs can now play a critical role in fighting both the opioid epidemic and the pain crisis. In 2017, the U.S. Department of Health and Human Services (HHS) launched a five-point opioid strategy that includes better addiction services and research, as well as better pain management. The federal government has several ongoing initiatives examining enhanced pain management. IR pain treatment procedures could be an important component of the HHS plan.
“The application of the interventional radiology skill sets to pain has created a new reservoir for alternatives to opioids,” says J. David Prologo, MD, associate professor at Emory University School of Medicine and an interventional radiologist at Emory University Hospital in Atlanta. “There are brand-new options that didn’t exist 10 years ago to treat patients with pain.”
Even when opioids work to relieve sufferers’ pain, tolerance can become a problem. “We hear a lot about the addiction, but we have to take a step back and talk about the tolerance,” says Theresa Caridi, MD, assistant professor in the division of vascular and interventional radiology at MedStar Georgetown University Hospital in Washington. “Sometimes patients have a disease or injury that needs chronic pain relief. The problem is they need more and more opioids to get the same relief they were getting initially.”
And opioids come with unwelcome side effects, including sedation and constipation, which diminishes quality of life. “Constipation sounds minor, but you take away one pain and you give them another discomfort,” Dr. Caridi says.
Patient Gene Johnson describes how IR eliminated his pain and changed his life.
Even when Johnson was taking painkillers, they didn’t eliminate his pain. He needed a walker or cane to get around. His wife did all the driving. He quit his church choir because he could not stand for long periods of time. At first, he continued to work. But after about three years, his wife convinced him to quit the job he loved as an assistant principal at Rome High School. Then, one day, at a routine cancer checkup, a physician’s assistant they hadn’t met before recommended they meet with Dr. Prologo after hearing about Johnson’s pain.
After evaluating Johnson’s case, Dr. Prologo determined he was a candidate for treatment. To reduce Johnson’s pain, Dr. Prologo maneuvered around the four rods in his patient’s back to stabilize the old fractures with a newer technique called a percutaneous vertebral radiofrequency ablation and stabilization. Then he performed an intercostal nerve cryoablation.
“Historically these patients didn’t have a lot of options,” Dr. Prologo says. “Most of them are not candidates for neurosurgery, so they come to the ER in intractable pain.” They might be given painkillers and/or radiation to try to stop the pain, but that doesn’t address the underlying fractures, and, in Johnson’s case, the additional nerve damage.
But an IR can ablate cancer cells and then use vertebroplasty and kyphoplasty techniques to cement the fractures together (see sidebar). “The patient can have pain relief the same day,” Dr. Prologo said.
These pain therapies started with ablation, as IRs used the technique to treat liver and kidney cancer. Physicians discovered that ablation procedures also reduced patients’ pain so IRs started using the technique specifically to treat pain and improve quality of life.
IRs now use a wide variety of techniques that can reduce or eliminate pain, such as nerve blocks, ablation and embolization. Promising new research is examining the effectiveness of these and other techniques in patients with pain from more common conditions, such as chronic back pain or osteoarthritis (OA).
“One area of interest for a lot of people is the potential treatment of arthritic pain through the use of embolization and/or ablative therapy,” says Alexander Kim, MD, division chief of interventional radiology and an associate professor of radiology at MedStar Georgetown University Hospital. “There are more and more areas in terms of pain that are being looked at that could potentially be treated by interventional radiologists.”
In 2018, results from the first U.S. clinical trial on geniculate artery embolization (GAE) showed that GAE reduced knee pain caused by osteoarthritis. The prospective, multicenter clinical trial evaluated 13 patients with severe OA pain. One month after undergoing GAE, eight patients were followed up with. They had decreased pain, reduced stiffness and increased mobility.
Interventional musculoskeletal radiologist Douglas P. Beall, MD, chief of services at Clinical Radiology of Oklahoma, is taking part in the VAST Study, which is using allogeneic stem cells from a tissue bank to treat patients with low back pain. Preliminary results have shown that back pain was cut in half in 82 percent of patients, according to Dr. Beall. Three years later, 92 percent of these patients still had the same positive result.
Results from the SMART Trial offer another potential solution for chronic back pain. In a study of 225 participants, basivertebral nerve ablation via radiofrequency was performed on patients with chronic low back pain for at least six months in whom conservative treatment had failed. Three months post-procedure, 75 percent of patients in the treatment arm showed improvement compared to 55 percent in the sham control arm.
While new treatments are being studied, many minimally invasive pain therapies are available now. The problem is that few outside IR know about them. Patients often only discover these therapies when they are referred to an IR for another procedure.
Dr. Kim encourages IRs to take the time to ask patients about their pain. “I’ll talk to my patients about their pain level and see if they’re having significant pain or if they’re really overdependent on opioids,” he says. “I’ll talk to them about potentially incorporating nerve blocks to their care to try to alleviate some of that pain. Make that a standard part of the discussion.”
He also thinks training programs need to add segments or rotations on pain management. “That would be a very useful skill for interventional radiologists to have, not just in terms of delivering treatments to alleviate pain, but in terms of discussing pain with patients, learning about different types of pain and what types of pain may be best managed by the different treatment modalities that we have.”
It’s also up to the IR specialty to get the word out about these pain therapies, by talking to referring doctors, hosting continuing education programs and talking to local news media. (For tips, see the sidebar.)
Getting back to normal
Johnson had his procedure in August 2018. Afterward, he was surprised when he didn’t need a nurse’s help getting out of bed. The pain was gone—and it hasn’t returned. A month after surgery, at age 71, he and his wife drove to Washington, to tell their story at a Capitol Hill briefing organized and hosted by SIR. They love taking road trips together in the summer but hadn’t been able to do that for about five years. After spending only a couple of nights in D.C., they drove to Colorado and then Las Vegas before driving home to Georgia.
When he was in pain, Johnson says, he never meant to be “ugly” to people, but “I didn’t enjoy anything. I didn’t enjoy being around people because you had to put on a good face. Now I’m getting back to normal.
“I wake up every morning, and the first thing I do is check to see if the pain’s back,” he says. He thinks eventually that impulse will go away. Seven weeks after the surgery, he had taken a total of two Tylenol for soreness. Ideally, he would love to return to his education job.
Johnson still can’t believe the pain just disappeared all at once. “I wasn’t expecting to get rid of all my pain,” he says. “I said, ‘Just get it to 5.’ It’s been a different world. Dr. Prologo treated the problem; he didn’t just cover it up.”
Dr. Beall says IR is primed to potentially help millions of people in pain. “We’re talking about approaches that are demonstrably effective at treating some of the things that are the scourge of our society,” he says. “This is just the start of the revolution.”
Spread the word
Interventional radiology is in a unique position to potentially help millions of people in the United States suffering from chronic pain. But most people don’t know what IR can offer. Here are a few ways you can help increase awareness:
- Build relationships with referring doctors, especially oncologists and pain management specialists. This can include organic conversations, hosting educational seminars and partnering on research projects. Assure colleagues that you want to partner to help their patients, not take over their care entirely.
- Meet with hospital administrators. IR procedures are generally safer than more invasive surgeries and have shorter recovery times that allow patients to return to their normal lives faster. Talk to hospital leaders about the cost savings your specialty brings, while minimizing risks to patients and shortening hospital stays.
- Reach out to local media. Local television news shows often have health segments and/or invite special guests for Q&As. Create a bulleted list of easy-to-understand talking points about how people in your community can find potential solutions to their pain.
Look for resources to help you build alliances with referring physicians as SIR launches the Vision to Heal, Together national communications campaign.
New SIR–Thieme book on vertebral augmentation coming soon
Several procedures can stabilize broken vertebra in an effort to alleviate patients’ pain. A new book on these vertebral augmentation (VA) treatments is being developed by Thieme, SIR’s book publishing partner, and interventional musculoskeletal radiologist Douglas P. Beall, MD, chief of services at Clinical Radiology of Oklahoma.
The book, which is expected to be available in 2019, will be the first VA book in 10 years. It will include updates on the science and techniques of VA, as well as present case studies. Dr. Beall is soliciting subchapters from “masters” of VA treatment around the world to provide their expertise and experience, which will include their own innovative techniques and unusual cases. “It’s a very exciting time and a very exciting topic,” Dr. Beall says.
Look for more information on the book in 2019 from SIR.