Many of us found our corners in the healthcare industry (I’m a scribbler) because we were attracted to the heroics of medicine. For me it was a story about a little girl with leukemia. I was, I think, about 6 or 7 years old when I saw the drama on TV.
Medicine certainly has its heroic discoveries and disruptive drugs and surgeries.
Penicillin and other antibiotics, polio vaccines, open heart surgery, organ transplants, cancer cures, heart attacks stopped, hip and knee replacements, Tommy John surgery…emergency rooms virtually every weekend.
Sometimes problems call for a hero. But sometimes they don’t.
Case in point: chronic pain.
For patients with severe chronic pain, a heroic treatment model looks increasingly like a flawed and dangerous approach.
How a Heroic Painkiller Created the Opioid Epidemic
Connecticut-based Purdue Pharma L.P. is the company that developed and brought to market the opioid painkiller, OxyContin.
That was in 1995. The company decided at the time to market OxyContin as a breakthrough therapy that could ameliorate the scourge of chronic, debilitating pain.
Purdue’s playbook for marketing OxyContin was based on the practice of physician to physician training. Purdue set up a physician speaker’s bureau and paid participating doctors to attend medical conferences and testify that, in their practice and opinion, OxyContin was a breakthrough painkiller.
Doctors were also offered all-expense paid trips to pain management educational seminars.
Supporting the campaign were thousands of ads in medical journals, web sites and all kinds of paraphernalia from hats to toys to tags.
The launch of OxyContin was, at the time in the late 1990s, one of the biggest pharmaceutical product launches in history.
According to the sales training materials used by Purdue, OxyContin’s indications for use were as a treatment for post-operative pain, cancer pain as well as less acute but more chronic forms of pain like arthritis, back pain, sports injuries, or fibromyalgia.
What most doctors weren’t aware of was that OxyContin, an opioid, was more potent than morphine. So, while it had a pain ameliorating effect on patients, it also came with serious life-threatening side effects and complications.
Over the years, Purdue sold more than $35 billion worth of OxyContin—which means thousands of doctors wrote millions of OxyContin scrips.
Between 1999 and 2015, more than 200,000 people died from overdoses of prescribed opioids including, according to one heart breaking account, half of a Kentucky high school football team who’d been prescribed opioids to treat sports pain.
A Different Approach to Bad, Terrible Chronic Pain
One of the most interesting and hopeful trends in medicine today is the wave of pain management innovation. Companies like Flexion Therapeutics, Inc. or Pacira Pharmaceuticals, Inc. are changing the game in pre-and post-operative large joint pain management—without opioids—but at lower doses of well-known analgesics and with fewer side effects.
There is, however, one, non-heroic approach to severe, chronic pain that recently caught our attention.
It was featured in a January 2017 article by Atul Gawande, M.D., M.P.H., a general surgeon at Brigham and Women’s Hospital and prolific author on a wide range of medical and healthcare issues.
In his article Gawande described a counter-intuitive treatment protocol used by a pain clinic in Massachusetts to treat (successfully) the most severe chronic migraine pain patients.
We’re talking 15 on a scale of 1 to 10. Bad, terrible awful pain. The kind of incapacitating pain that causes patients to vomit every half hour.
The clinic’s name is The John Graham Headache Center and it consults with about 8,000 patients annually at several locations. It was founded in the 1950s.
Dr. Gawande joined one of the center’s doctors for a day of patient visits to see how the system worked.
Here, from his article, is what Dr. Gawande observed.
The initial patient consultation was “attentive and unhurried”. The examination room’s lights were turned down. “She [the clinics doctor] told me how she begins with new patients: ‘You ask them to tell the story of their headache and then you stay very quiet for a long time.’ She did not interrupt or comment, except to say, ‘Tell me more,’ until the full story emerged.”
The clinic’s physician “reviewed the woman’s records—all the medications she’d taken, all the tests she’d undergone—and did a brief examination. Then we came to the moment I’d been waiting for.”
Dr. Gawande was prepared for the hero’s solution. The novel diagnosis. The clever treatment.
It didn’t happen.
Rather, the clinic’s doctor “started, disappointingly, by lowering expectations. A complete cure was unlikely. Success meant that the headaches became less frequent and less intense, and that the patients grew more confident in handling them.”
No single remedy. No breakthrough. No magic pill.
No OxyContin.
The clinic’s doctor “…asked the woman to keep a headache diary using a form she gave her to rate the peak level and hours of headache each day. She explained that together they would make small changes in treatments and review the diary every few months. If a regimen produced a greater than fifty-per-cent reduction in the number and severity of the headaches, they’d call that a victory.”
For most of John Graham’s patients the process lasts years and over those months and years the patient and the doctor, together, tweak medications, try this, try that—always writing in the diary—and incrementally, slowly, the incidence and severity of pain fades.
One of the patient’s Dr. Gawande followed at John Graham was a gentleman named Haynes.
“When I met Haynes in 2015, he’d gone more than a year without a severe migraine. ‘I haven’t had a dreadful attack since March 13, 2014,’ he said triumphantly. It had taken four years of effort. But the clinic’s systematic incrementalism had done what nothing else had. ‘I’m a changed person, Haynes said, ‘I’ve a bubbliness in my life now. I don’t feel at threat. I’m not the social cripple that I was.’”
Not surprisingly, considering our immediate gratification culture, that the John Graham Center attracts the most severe cases—patients for whom all of medicine’s breakthrough painkiller promises have failed.
It’s hard to imagine anyone other than the most iconoclastic patient starting treatment with the John Graham Center.
Yet, John Graham offers patients one of the most successful pain treatment protocols in the United States.
Distracted Pain Therapy
Another fascinating innovation can best be described as distracted pain therapy. Indeed, many dental offices have jumped on this new pain management bandwagon.
We’re talking, of course, of virtual reality (VR) gaming.
Several recent studies have tested the hypothesis that VR systems could cut chronic pain.
Here’s one (there are several) recent study which appeared in the online journal Plos in December 2016, titled: “The Impact of Virtual Reality on Chronic Pain.”
Authors were Ted Jones, Ph.D., C.P.E., Pain Consultants of East Tennessee, Knoxville, Tennessee, Todd Moore, Ph.D., Psychology Department, University of Tennessee and James Choo M.D., Pain Consultants of East Tennessee, Knoxville, Tennessee.
The investigators recruited 30 patients with various chronic pain conditions. Each patient was offered a five-minute session using a virtual reality application called Cool!
Quoting from the study report; “The study participants were then asked about their pain using a 0–10 visual analog scale rating before the VR session, during the session and immediately after the session.”
“They were also asked about immersion into the VR world and about possible side effects.”
“The study participants reported that their pain was reduced from pre-session to post-session by 33%. Pain was reduced from pre-session during the VR session by 60%. These changes were both statistically significant at the p < .001 level.”
“Three participants (10%) reported no change between pre- and post- pain ratings. Ten participants (33%) reported complete pain relief while doing the virtual reality session. All participants (100%) reported a decrease in pain to some degree between pre-session pain and during-session pain. The virtual reality experience was found here to provide a significant amount of pain relief. A head mounted display (HMD) was used with all subjects and no discomfort was experienced.”
Desperately Seeking a Single Remedy
Purdue Pharma remains committed to its painkiller OxyContin even as it also recognizes the crisis that prescription opioid abuse has engendered.
Opioids remain one of the most prescribed drug classes in America. Annually physicians are prescribing some 160 million opioid doses.
Recently the FDA has approved a series of abuse deterrent opioids including one from Purdue that make it particularly difficult to grind these pills into snort-able or injectable powder.
Purdue and all other opioid suppliers hope these powerful compounds will remain at the center of pain management in the United States.
Sometimes a problem calls for a magic pill. And sometimes it doesn’t.
