LOUISVILLE “Where does it hurt?” That’s the common question asked of someone in pain. Medical professionals naturally follow up with “Why does it hurt?” and “Is there a way to fix the problem?” But what about when the problem can’t be fixed? What about chronic pain that the patient must live with?
In the past, the specific questions about where and why it hurts have been treated with generalized pain medication. But opioids are quickly giving way to pain management that is as targeted and specific as the location of the pain itself.
That, says Kristal Wilson, MD, is the primary message she wants to share with the rest of the medical community.
“Pain medicine, in general, has a very bad misperception,” Wilson says. “When someone thinks about pain management, they think of a pain clinic that just passes out opioid medication. Government restrictions over the last five years have cut back on pill mills, but the misconception that all we do is opioid therapy remains.”
Wilson, who practices at Baptist Health Medical Group (BHMG) Pain Management in Louisville, graduated from the University of Louisville School of Medicine. She became interested in pain management during the anesthesia portion of her residency.
“There was a lot of need in the community that I saw,” Wilson says. “Cancer pain, chronic pain, people needing help. That really drove me toward trying to help with pain management.
Wilson describes the scope of the BHMG Pain Management practice as “anything from head pain to toe pain.” They treat both acute and chronic pain with the average age of the patients presenting being 70 years old. Large joint pain and migraines are also common presentations among patients both young and old.
Wilson works closely with the primary care physicians, as well as relevant specialists, to help identify the source of the pain and plan any available solutions, such as surgery. The most common surgical referrals are to neurosurgeons for back and neck pain or orthopedists for large joint pain, such as shoulders, knees and hips.
But the specialist Wilson most often refers her patients to has nothing to do with surgery or a physical solution.
The Psychological Component of Pain
“The number one referral overall is to psychology,” she says. “Almost every patient with chronic pain has some type of psychological component. We refer almost every patient who comes through with chronic pain to a pain psychologist.”
Pain psychology helps patients stay away from unhelpful thoughts about their pain or develop techniques to distract themselves from their pain. Relaxation techniques, building coping skills, and addressing anxiety or depression are all part of a pain psychologist’s approach.
Wilson’s approach depends on the source and location of the pain, but increasingly she turns to solutions other than opioids.
“The misconception that we’re all about medication is false,” she says. “We take a multimodal approach and treat the patient, not just the patient’s complaint. We do interventional treatment to target the pain generators and more precisely deliver the therapies. Whether it be a steroid injection into the epidural space or joint, or a Botox injection for migraines, we’re actually treating the source of the pain rather than leaning on medication.”
Wilson points to Botox as prime example of a better solution than opioids for patients suffering from migraines.
“It’s not that Botox is brand new, but it’s becoming more acceptable and gaining in popularity as a treatment for migraines,” Wilson says, noting that opioids have proven ineffective for migraines. Botox has a strong track record of success and comes with few, if any, side effects.
However, opioids remain a big part of Wilson’s daily practice. One, because they are still useful in some situations. Secondly, because many of her patients have been relying on them for decades. Patients who have been on opioid therapy for years develop a high tolerance and are on very high doses, leading to the side effects of misuse and abuse. Convincing these individuals that there are better options is often met with resistance. “Trying to show the patient that opioid therapy is not the best for them after they have been on it for 20 years is very challenging,” Wilson says.
Better Options than Opioids
Among the treatments that are often better solutions than opioids are spinal cord stimulation, nerve blocks, and injections. Spinal cord stimulation involves the placement of stimulating leads into the epidural space. New technology has enabled physicians not only to be more precise in the placement of the leads, but also to adjust the wave lengths and frequency.
Precision is also the driving force behind a new type of knee injection that Wilson says is a vast improvement over the more commonly administered steroid.
“In many cases, intra-articular joint steroid injections aren’t effective,” she says. “We offer a genicular nerve block. The genicular nerve is one of the main nerves that supplies the knee. We go in and block the nerve and see if the patient receives any pain relief. If they do, it is diagnostically positive that the source of their pain is coming from that nerve.”
Once the nerve is confirmed as the source of the pain, Wilson can perform a radiofrequency ablation, which involves applying thermal heat to the nerve. That heat causes the nerve to scar over and results in pain relief of six months to a year. “You can actually do that procedure on many nerves throughout the body, with arthritic back pain being the most common indication,” Wilson says.
Wilson notes that the impact of these procedures can be life-changing. For instance, some patients who need knee replacements can’t get them because they are overweight. Their knee pain prevents them from exercising. The genicular nerve block can treat the pain, allow them to exercise and lose weight, and subsequently get the knee replacement.
“I really like my job when somebody gets improvement in their quality of life,” Wilson says. “I have patients tell me that I gave them their life back. That’s why you become a doctor.”
“Almost every patient with chronic pain has some type of psychological component. We refer almost every patient who comes through with chronic pain to a pain psychologist.”— Kristal Wilson, MD