LEXINGTON – Current studies estimate that 26 percent of Americans suffer from chronic pain, a debilitating disease that can lead to a lifetime of discomfort and a myriad of treatments. At The Pain Treatment Center of the Bluegrass (PTC), the longevity of chronic pain is matched by the lifelong commitment of Dr. Ballard Wright, founder of PTC, established in 1991 and one of the oldest private pain management practices in Kentucky. In addition to the physician practice, Ballard Wright, MD, PSC, the Center has a second division, an ambulatory surgery center called The Stone Road Surgery Center. PTC’s professional staff includes 10 physicians, a psychologist, a physical therapist and physical therapy assistant, registered dietician, and four mid-level providers: three PA-Cs and one ARNP. While both divisions are headquartered in Lexington, the center’s geographic reach extends to satellite clinics in Mount Sterling, Hazard, and Albany, KY.
A pioneer in the field of pain management in the Bluegrass, Dr. Ballard Wright, now in his 70s, plays a more emeritus role, seeing clinic patients one or two days a week when he is in town and providing medical direction and guidance in business management. The Ballard Wright tradition of pain management follows a familial path, as his children are also in the practice: Peter Wright, MD, is the president and medical director of Ballard Wright, MD, PSC, the physician practice division of the center, and Ms. Heather Wright, Esq. is its CEO. As president and medical director of the physician practice, Dr. Peter Wright oversees the medical decision making of the clinical staff. According to Dr. Peter Wright, “Our mission is essentially to have a multidisciplinary approach, to tailor the treatment to the individual and their particular pain problem using a multidisciplinary model.” Dr. Peter Wright also works in conjunction with Ms. Wright to run the Center. Ms. Wright’s role is to oversee the administrative staff and functions. Ms. Wright also shoulders the aspect of social responsibility by taking a leadership role in educating the public regarding pain management, working with legislators, and advocating for pain management doctors and patients. [See “Headlines” this issue, p. 4.]
A Multidisciplinary Model
There is not a cookie cutter approach to treating acute or chronic pain. No two patients experience pain in the same way. By approaching pain management from a comprehensive perspective, using a variety of disciplines, PTC ensures that every patient has access to the most effective treatments for their individual condition. “We use essentially the modalities that are traditionally considered part of pain management but that are often not necessarily associated under a single roof or facility,” says Dr. Peter Wright. Those modalities include: “behavioral medicine; physical therapy and rehabilitation; interventional procedures such as epidurals, facet blocks, or even more aggressive therapy such as spinal cord stimulation or intrathecal pump placement; and of course, medication management, which can be as simple as anti-inflammatory medications or other adjuvant pain medications, but also up to and including chronic opioid therapy for chronic intractable pain.”
The PTC physician also use a variety of diagnostic tools housed at the Center, which include CT, x-ray, EMG/NCV and EKG, to examine and treat the pain patient. Moreover, the Center has recently added an ultrasound and laboratory to aid in the treatment. The ultrasound gives physicians the ability to perform same-day injections in the office for some cases that previously required localization through fluoroscopy or x-ray in the operating room. The new lab is a product of the center’s dedication to high ethical standards and compliance monitoring. The lab provides the access to rapid (same day) and accurate screening results, ultimately shortening the cycle of treatment and increasing compliance. PTC is considering adding an MRI in 2012.
Behavioral Medicine Focuses on Well-Being and Risk Assessment
According to Ken Kirsh, PhD, clinical psychologist and director of Behavioral Medicine at PTC, the department’s goal is to assess every patient that comes through the center. The reasoning is twofold: 1) for risk assessment to protect physicians, patients, and the community and 2) to evaluate for psychological distress.
“Risk assessment is the cornerstone of pain management,” says Dr. Kirsh. “We never want to inadvertently give medications to someone who is using them outside of pain management.” Not only does the center participate in risk assessment, but it is a national leader in the area through research and development of new tools. PTC was a beta site for the Kentucky All Schedule Prescription Electronic Reporting System (KASPER), which Dr. Peter Wright asserts is the best program in the country. “It’s been one of our best tools in following patients and ensuring patient compliance and also attempting to reduce and or eradicate the doctor shopping, which can occur with patients that are interested in drug diversion,” says Dr. Peter Wright. Each patient who comes into the center has an initial KASPER evaluation performed. Follow up KASPERS are performed depending on the patient’s circumstances. NASPER, a national version of the program, has never been fully developed, and one of the challenges for Kentucky physicians is working with other states that may not have efficient systems in place to get good quality information. At PTC, they put other safeguards into place to combat drug diversion, including random urine drug monitoring, pill and patch counts, opioid risk tools, and non-verbal behavior inventories.
In terms of psychological distress, the incidence rate of depression in the U.S. is between one and six percent of the population and more predominant among women. “When you put a chronic pain population in place, instead of that one to six percent, what you find is pain is the great equalizer. Men and women have equal rates of depression … and most studies show somewhere around a 25 to 45 percent rate of clinical depression, not including anxiety or other issues, in chronic pain patients,” says Kirsch. The Center provides across-the-board therapy services, and part of Dr. Kirsh’s role is also to recommend medications, as many are indicated for both pain and depression.
Nutrition Counseling Enhances Comprehensive Treatment
The concept is simple: poor diet is linked to weight gain and an increased incidence of diabetes, both of which lead to increased pain symptoms. Dr. Kirsh first began thinking about nutrition from a psychology perspective, considering how diet impacts the way medicines are absorbed, the effects of weight gain, and the correlations between eating habits and depression, anxiety, and addiction risk.
Now about a year and a half old, the nutrition counseling program at PTC focuses mainly on diabetes patients because it is one of the few areas of nutrition services covered by Medicare, Medicaid, and private insurers and because diabetes is one of the most prominent co-morbidity issues of weight gain in Kentucky. Dr. Kirsh estimates the national incidence of diabetes in the general population is seven to eight percent, and of those, 30 to 40 percent will end up with diabetic neuropathy. At PTC that percentage is much higher, 60 to 70 percent, due to the advanced disease state of their population.
Jennifer A. Kouns, MS, RD, LD, is PTC’s resident nutritionist. In addition to diabetes patients, she sees a small number of self-pay weight management patients. Ms. Kouns formulates customized weight loss plans based on in-depth background and data analysis. “What we try to do here at the Pain Treatment Center is to get those patients in here and get them started on a healthier lifestyle, a healthier diet, and hopefully prevent those complications that can happen later on, which in turn can cause more pain from nerve damage or excess pressure on the joints,” says Ms. Kouns.
Research that Rivals an Academic Center
Clinical research and achieving an academic-like environment are critical components of PTC’s comprehensive care approach. “We see it as an important part of our duty as one of the leaders and largest pain centers in the region, that we should be involved in furthering the field,” says Dr. Peter Wright. John Peppin, DO, is an internist and director of the Clinical Research Division at PTC. His role includes research, publishing papers, presenting posters, and giving lectures, as well as seeing patients.
Dr. Peppin recently presented three posters at an American Academy of Pain Medicine meeting in Palm Springs: one on nutrition, another on the Zung depression scale in chronic pain patients, and one on a consensus panel making recommendations on who, what, and how often to use urine drug screening, which Dr. Peppin concedes is weak evidence but is valuable because of the lack of literature on the topic.
The nutrition study surveyed the eating habits of approximately 200 patients and evaluated a six-minute walk test applied upon initial intake and after four months in the clinic. Results showed a diet worse than the average American. Additionally, “We found that there was a statistically significant increase in their ability to walk, but of great interest is that they didn’t even reach the low level of normal for 60 year olds,” says Dr. Peppin.
Some recent research projects Dr. Kirsh has developed include co-writing a paper that identified and ranked more than 25 risk assessment tools across the country, launching a non-verbal behavior interview that combines psychology and law enforcement techniques to interpret body language, and co-creating the Chemical Coping Index, a middle-of-the-road scale addressing drug misuse that does not qualify as addiction.
Challenges and Advancements
Unfortunately, addiction and drug diversion are part of pain management, especially in Kentucky, but advancements are being made. “There has certainly been improvement in the variety of medications available, in particular in the area of long-acting opioid preparations, and an attempt to make those more resistant to abuse,” says Dr. Peter Wright. He cites a reformulated OxyContin pill that is more difficult to break down, a Butrans® patch that has low addictive potential and higher resistance to tampering, and a new opioid called Nucynta®, which is “less active at the opioid center and helps control pain via avenues other than just acting on opioids receptors in the spine,” says Dr. Peter Wright. Although new drugs and refinements can offer increased benefits, they also tend to pose obstacles regarding cost and insurance coverage that affect not only Medicare and Medicaid patients, but also those with private insurance.
The landscape is slowly changing, as payers are beginning to accept preventive care models, such as nutrition services, that are more cost-effective in the long run. In the meantime, PTC continues to look for new ways to advance the knowledge, education, and treatment of pain medicine.