Pain Management From An Anesthesiologist’s Perspective
An Interview with Dr. Dwight Ligham
Dr. Dwight Ligham graduated from the State University of New York (Syracuse) medical school cum laude in 1992 and completed his anesthesiology and pain medicine subspecialty training at Yale University. He is board certified in anesthesiology and board certified in pain management. Dr. Ligham has earned numerous awards including the prestigious Merck Award for academic excellence. Dr. Ligham has staff privileges at the Hospital of Saint Raphael and the Yale New Haven Hospital and is a member of the Medical Board at the Hamden Surgery Center. He is on staff at the Yale New Haven Surgery Center at the Temple Medical Center in New Haven, CT and the Shoreline Medical Center in Guilford, CT.
Interviewed by Michael R. Kerin, Esq.
CQ: Pain management means many things to different people. How do you define “pain management”?
Dr. Ligham: Pain management as a description of the specialty is misleading because really what we are trying to do is optimize function and only indirectly manage pain. Pain is subjective. Your pain may be through the roof, 10 out of 10, and the next fellow’s pain may be 5 out of 10 and you might have the same level of function. I try to focus on functional abilities, both in workers’ compensation and non-workers’ compensation patients. It’s not pain management. It’s the facilitation of function that has been impaired by a state of pain. Unfortunately, that’s a mouthful.
CQ: What do you mean by “function”?
Dr. Ligham: On our initial evaluation we try to determine function in several key areas. At a very basic level, we ask if patients can perform their own self-care. Are you able to dress, bathe, and care for yourself? Can you maintain your activity level during all of the daytime hours, or are chunks of time taken out in order to rest or step away from activities because of pain. I try to understand the ability to be up and around as a percentage of the day.
I like to get a sense of work capacity. Is the patient missing any work time because of pain? Are they able to work full duty? Are they able to work light duty? What are their specific work restrictions?
Another important functional indicator includes the ability to obtain restful sleep. This is tied into daytime function, because people who don’t sleep well don’t function well during the daytime.
CQ: What types of physicians are included within the term “pain management” doctors?
Dr. Ligham: There is no one pathway to the subspecialty of pain management. Both training and credentialing have not been standardized. Depending upon the root specialty, the methods of pain management treatment can be very different and vary from psychological techniques, physical techniques, medication, injections, surgery, implants and others. Having said that, pain management is practiced by multiple specialties including anesthesiology, neurology, physiatry, psychiatry and even internal medicine. Recently there has been progress made in standardizing the credentialing of pain management specialists. Post doctoral fellowships are available to anesthesiologists, neurologists and physiatrists that, once completed, enable the diplomats to sit for an Added Credential examination by the American Board of Anesthesiology.
CQ: When assessing a workers’ compensation patient, are you cognizant of the distinction between curative versus palliative care?
Dr. Ligham: My understanding about the workers’ compensation definition is that curative treatment is anything that will get somebody back to work, and restore some degree of work capacity. Palliative treatment might make a patient feel better, but won’t necessarily restore work capacity or return them to work. This is different from the medical definition where curative implies healing.
As a physician, I seek to heal and my perspective and bias is to look for missed opportunity to do so. I say missed opportunity because many times the worker comes to me after failing treatments.
My first priority is to see if there is something curative which has been missed, and then try to follow the steps down that pathway. There are multiple pain problems that are potentially curable that can be missed or left untreated.
If a cure is not possible, then I go down the route of trying to mask the pain in order to restore functional capacity. This can be a complicated decision matrix and involves a balance of factors at multiple levels. A complete discussion is more detailed than can be explained here.
An example, though, of one such factor, involves the degree of pain relief to attempt to achieve. Rarely is complete pain relief achievable and even if achievable, it may not be a responsible or reasonable objective. There is a price to pay. You can predispose your patients to further injury if they cannot feel pain elicited by their activities. So if you have, for instance, a laborer, who is used to moving sacks of concrete or sand around and they have a back problem, they can’t go back to laboring because if you mask that problem, they have the potential to get worse in the performance of this activity.
Pain management usually requires on-going or episodic treatments. Work capacity is dependent upon continuing the medication program or periodic treatments. The beneficial effect of medication stops when treatment is withdrawn. Other treatments are not usually perfect and their therapeutic effects wear off with time. Withdrawal eliminates whatever work capacity was restored by them.
CQ: What is the ideal time frame for a patient to present him or herself to you for improvement of function, or, as we call it, pain management?
Dr. Ligham: Patients who present earlier to pain management usually respond better than those who present later. This is especially true of workers who have failed surgery. Treatment offered pre-surgery is much more efficacious than if offered post-surgery.
Very often, patients are labeled with the diagnosis “lumbar strain”. Lumbar strain is really not an acceptable diagnosis in a patient with low back pain lasting over a month. It’s not acceptable because it’s a dead end diagnosis since there is really no treatment pathway to cure. Our goal is to make the most specific diagnosis possible. Successful treatment depends upon his specificity.
Think about this is another way: Doctors are like tradesmen or auto mechanics in their approach to medical ailments. We have a certain number of tools that are at our disposal for treatment. However, before we can propose a treatment, we have to understand what specifically is “broken”. When you go to a mechanic, if the diagnostics are not properly done, you’re not going to get your car fixed properly. The same thing is true of people with medical problems.
Many times surgery is indicated, but the surgical decision is made by holding up an x-ray and making a diagnosis and then treating the x-ray. Only with the most overt pathology is this technique consistently successful. We can provide a very useful diagnostic service to surgeons so that those patients who do not respond to pain management treatment can undergo workup to help improve surgical outcome. Successful partnership through pain management diagnostic techniques can guide and shape the surgical intervention to improve outcome.
As a pain management doctor, I look at myself as a very careful diagnostician. Once you understand what the problem is, then you have a much better chance of fixing it.
CQ: Is it correct to say that you can provide a better result the earlier a patient gets to you, especially before surgery?
Dr. Ligham: Yes, we have a much better track record of successful treatment with patients returning to work when we are able to see them before surgery.
CQ: Are there any professional conversations between anesthesiologists and orthopedists or neurosurgeons in terms of getting patients diverted to you earlier, rather than as a last resort following a failed surgery?
Dr. Ligham: I think that this conversation should take place at the level of the occupational medicine specialist within 4-6 weeks of the injury. This is early on in the treatment paradigm.
Obtaining a pain management evaluation and starting that diagnostic process early is critical. If you can salvage these injured workers and get them back into the workforce early, you can ultimately save the system a fortune.
CQ: What does the ideal pain management candidate look like when they present themselves to you?
Dr. Ligham: It’s not what, it’s when. Early referral when the worker believes that they can return to work is critical.
The ideal candidate doesn’t have a lot of secondary gain issues, is straightforward emotionally, and is able to cope with the process. Individuals with this profile are usually seen early on. As time goes on, the injured worker becomes “institutionalized” for lack of a better word. They lose control of the process, become despondent and depressed and see no hope for resolution.
The less ideal patients have suffered for a longer period of time, and start to develop dependent behaviors. They no longer feel like they are in control of their own lives. They live for the mail, awaiting their compensation checks. They become depressed. They develop relationship problems. They lose the very people that they depend upon for emotional support. A lot of them lose their spouses. It becomes a downward spiral. This is all related to a failure of the system to provide for authorization of timely care and supportive services like vocational counseling and availability of return to work options.
These system problems include few resources for vocational counseling, retraining, the lack of permanent light duty jobs for return to work and poor coordination of achievable vocational goals with the adjusters and insurance companies. Usually, once we release patients back to full duty, they lose their jobs!
CQ: Do you find that the workers’ compensation patients are less likely to improve with the modalities of treatments that you offer them versus patients who are not in the workers’ compensation system?
Dr. Ligham: No, I don’t see that. I think that if somebody wants to return to work, whether they are in the workers’ compensation system or not, they will be motivated to return to work once they are able.
I think there is a lot of therapeutic power in work. Work directs one’s focus outwards, distracts from pain and personal issues and encourages relationship building. It allows workers to engage in social interactions and constructive activity which are important distractions for workers with residual pain. I encourage outside activities including volunteer activity in all of my patients with pain.
CQ: A perception exists among the workers’ compensation bar that when a patient fails surgery, the surgeon ships them off to this netherworld called “pain management,” which is basically the functional equivalent of a Russian gulag from which they are never to return to gainful employment. What is your response to this perception?
Dr. Ligham: I think that the compensation system really doesn’t like to get pain doctors involved because pain treatment is seen as prolonged. I think that the carriers see pain doctors as never-ending bottomless pits. To be fair, pain management is really a process and requires ongoing treatment in order to restore and maintain work capacity. Sometimes, the medical management of pain is the best course of treatment. I think that more often than not, the compensation carriers would rather see a fusion surgery or other surgical procedure and then be done with the case than authorize pain management evaluation and treatment.
Apart from ongoing pain management services, there are the diagnostic services that we offer that I mentioned earlier. Adjusters don’t seem to realize that if we can get injured workers through the diagnostic algorithm, we can get them to MMI and identify their work capacity. What I find, though, is that when I get somebody in from compensation, with rare exceptions, it is like pulling teeth trying to get the diagnostic procedures authorized so that I can see which way is best to treat this worker. It would be nice to have a partnership because we are all trying to achieve the same common goal which is to return to work.
CQ: You have referred to “diagnostic algorithm.” What is that?
Dr. Ligham: It’s a plan to figure out what’s wrong. It’s the workup to allow us to know as specifically as possible where the pain generator resides. This algorithm varies and depends upon the specific pain problem.
CQ: That leads into another one of the “hot button” topics in the conundrum of pain management. What role should the use of narcotics play in the treatment of someone suffering from chronic pain?
Dr. Ligham: Narcotics are very controversial. Doctors don’t like to prescribe them. I don’t really like to prescribe them. I don’t think anybody does. This is because of their addictive potential.
Narcotics are a tool for the treatment of pain. Just like any other tool, they have their place. There are stages in their use. Initially, the narcotics are designed as a transient bridge to improve pain and function during the diagnostic and treatment phases. Once successful treatment is implemented, the narcotics are weaned.
If treatment is unsuccessful then a careful risk/benefit decision must be made: if the pain is opiate responsive and function improved with low to moderate dose narcotic therapy, then it may be reasonable to commit to a carefully monitored medication program. This medication program might include opiates in a balanced, opiate sparing treatment regimen. Opiate sparing regimens often include an opiate along with medications of other classes that are synergistic in the treatment of pain and reduce the opiate dose required for functional restoration.
Narcotic medication, as a class, must be very closely supervised. Patients are monitored regularly for efficacy, degree of functional restoration, addiction, side effects, appropriate use, etc. It is important to insure that prescribed medication is beneficial, continues to be required, and is taken appropriately.
CQ: How do you define addiction?
Dr. Ligham: Addiction, very simply, is loss of control, and use despite harm. One of the ways to think of that is to think of the alcoholic you have known. An alcoholic doesn’t know when to stop drinking. The substance is used in spite of the harm it causes. They lose their health. They lose their relationships. They lose their jobs.
Our visits include addiction screening. We look for specific behavior that is consistent with addiction and misuse of medication. We do periodic and random urine drug screening for substances of abuse, as well as for medications that we are prescribing, to make sure that patients are taking what we are prescribing. We schedule pill counts to monitor compliance.
CQ: What is the occurrence of addiction in the patient population, as you have defined it?
Dr. Ligham: Well, addiction has been well studied and the incidence in the population is 10% to 15%. So, out of 15 people, the chances are that 1 or 2 of those people will either have substance abuse problems or will have a predisposition to addiction. There are various screening tools for addiction. We try to identify addiction risk and stratify people into low, moderate or high risk. Addiction correlates include family history of addiction; psychiatric disorders like bipolar disorder; and prior history of substance abuse amongst a host of others.
There are no guidelines that state that you cannot prescribe medication to patients who may use marijuana or cocaine. We have decided that in our practice the use of cocaine and illicit substances, for the most part, with some provider discretion, will result in us not prescribing opiates and controlled substances. We work closely with addition specialists to identify addiction risk and to offer treatment as required. The appropriate response in the case of addiction is to refer for treatment.
CQ: There was an article published in the June 2007 New York Times magazine about the prosecution of pain management physicians for over-prescribing narcotics. Does this concern you?
Dr. Ligham: Yes, very much so. In this practice, we’ve spoken to the DEA and we’ve had our own attorneys look into what the laws are with regard to prescribing narcotics and controlled substances. The bottom line is that the DEA has very clear regulations that state we cannot prescribe to people who are addicted to a substance.
There must be a physician/patient relationship between the prescribing physician and the patient. There must be clear documentation with regard to what is being treated and how the treatment is monitored. There must be reasonable attempts to monitor medication use and minimize the opportunity for diversion.
CQ: Is there a saturation point at which more pain medication is not helpful?
Dr. Ligham: We do see patients that have come to us from other practices on enormous doses of Oxycontin or whatever. It’s a variation in practice of pain medicine. It’s not the way I think pain medicine should be practiced, in my opinion.
If you look at a graph of pain relief over time at various dosing curves, you will see that you get the most pain relief from the first 10 milligrams. If you double that 10 milligram dose, you will get an incremental improvement in response, but it will be less than the response from the first 10 milligram dose.
So with every doubling of dose, you obtain less and less incremental pain relief. There comes a time when you can double a dose and really get very little additional pain relief. That’s because all of the narcotic receptors are occupied by drug. It’s just like a light switch. When the light switch is on, it’s on. You really can’t make the light brighter without changing the light. You really can’t change the light in people that is a function of their genetics. I try to identify a maximal dose that I will go to with any of the narcotics. Once I reach that dose, it doesn’t make sense to go higher. Then, I have to do something else.
It’s only the rare patient who is satisfied with partial pain relief. We dose to achieve improvement in functional status. That is our consistent objective in pain management.
CQ: What other tools do you use in pain management?
Dr. Ligham: As an anesthesiologist, I have a lot of tools to use outside of medication. There are specialized injections, radio frequency and cryo-ablative procedures, peripheral and spinal cord stimulation, implantable pumps and physical modalities. Each has its own specific indication and each can be very effective for pain relief.
CQ: Do you find that epidurals can be helpful in relieving back pain?
Dr. Ligham: Epidurals can be very helpful from a diagnostic and from a treatment standpoint. There are many different ways to perform an epidural injection. Each of these epidurals can be used in a way to optimize therapeutic response.
An epidural contrast dye study can show a radiographic picture of inflammation. Additionally, filling defects in the nerve root sleeves can demonstrate the source of the patient’s sciatica. That’s the diagnostic part of it.
The treatment places potent anti inflammatory steroids at the spinal pain generator. They work by decreasing inflammation and stabilizing neural membranes. If you can get the steroid to where the problem is, many times you can make a difference in the neuropathic pain component.
CQ: By contrast study, do you mean with fluoroscopic guidance?
Dr. Ligham: Yes, all of our epidurals, with few exceptions, are done under x-ray guidance.
CQ: Why do you require fluoroscopic guidance with epidurals?
Dr. Ligham: You really need to prove that the medication is getting into the epidural space. Additionally, you can use the contrast study as a further diagnostic tool to understand the pathology and define the treatment algorithm.
CQ: Often, we hear that a series of epidurals should not exceed three within a year. Is that a misconception?
Dr. Ligham: Well, I think that goes back to some very early studies of epidural steroid injections that showed three epidural steroid injections tended to build on each other for improved therapeutic effect.
The limit to the number of epidural treatments is the overall cortisone dose. This varies with each practitioner. I use a dose that allows for up to three epidural treatments in a six month period.
CQ: Is there a number of epidural injections beyond which a physician should not go?
Dr. Ligham: Typically, it’s not related to the number of epidurals, it’s related to milligrams of the cortisone given. The limiting factor for epidurals is the steroids.
Now the real question is not how many can be given, but how many should be given. I believe that this depends upon the response to treatment. Once a plateau is reached, there is no further benefit in giving more epidurals in the series. That’s not to say that an exacerbation of sciatica in the future would not be responsive to an epidural injection.
CQ: You also referred to one of the arrows in your quiver as being radio frequency ablation. What is this technique?
Dr. Ligham: Many times people have pain generators that are either abnormal functioning neural tissue or structures served by end branch sensory nerves that can be interrupted using extreme cold (cryo-ablation) or using heat (radiofrequency) energy. For example, after knee replacement surgery it is not uncommon to develop a sensory neuropathy in the superficial sensory arcade serving the knee. This problem can be cured using these techniques.
Mechanical back pain can be responsive to this type of treatment.
CQ: How does a radio frequency procedure work?
Dr. Ligham: After numbing the skin with local anesthetic, a very thin needed is placed. The tip of the insulated needed is used to stimulate for a response. This feels like a pressure or a tingling. Once positioned, radiofrequency energy is used to produce heat at the tip of the needle for 60-90 seconds. Treatment response can take up to three weeks to be seen.
These procedures can be temporary, lasting up to 2 years, or they can be permanent. They can be repeated as required.
CQ: Can you tell me in layman’s terms what a spinal stimulator does to eliminate pain?
Dr. Ligham: First of all, stimulators aren’t just for spine anymore. We use them for a lot of different neuropathic pain states. But let’s go to the spinal question.
The spinal stimulators work on the gate control theory of pain. The gate control theory of pain states that the spinal cord acts as a relay. If you can overwhelm this relay with a more pleasant stimulus, then less pain is perceived. The easiest way to conceptualize that is thinking about the last time you slammed your knee into the corner of your desk. If you rubbed your knee, it probably felt better. The stimulator overwhelms the pain relay at the spinal cord level, so that you feel less pain.
CQ: How is the stimulation introduced into the spine?
Dr. Ligham: We place two wires into the epidural space, usually using needles, although they can be place surgically. Then they are connected to a pulse generator. The system is completed implanted.
The patient has a remote control. They can turn the system on and off and vary the stimulation parameters to improve system response.
CQ: What is the efficacy of neural stimulator?
Dr. Ligham: For nerve pain we can expect to achieve 70-90% relief, and usually about 50-60% relief of the axial neck or low back pain.
CQ: You indicated that the spectrum of pain management specialists included physiatrists, internists, psychiatrists, and anesthesiologists. Does the training in pain management vary from specialty to specialty?
Dr. Ligham: It’s very variable. In anesthesiology, we are trained in the injection techniques since these are outgrowths of our anesthetic technique for surgical cases. Anesthesiologists have post doctoral fellowships available to them. All of our attending pain doctors here at Advanced Diagnostic are fellowship trained. There are really no unifying credentials for pain management. Pretty much anybody can hang out a shingle from their primary specialty and practice it.
CQ: Is there any national consensus or accepted consensus for the treatment of chronic pain?
Dr. Ligham: The American Association of Interventional Pain Physicians is one of the professional organizations that serve to unify the specialty of Pain Management. They coordinate research and have developed consensus and research based on practice guidelines. You can download these from their web site as a PDF. I think for the most part, they are pretty good.