​Coming Changes in Chronic Pain Management

Posted by Tim Gilmer in Life After Paralysis on September 30, 2022 # SCI Awareness

chronic painSeptember is both Spinal Cord Injury Awareness month and Pain Awareness month, and it’s fitting that they are happening at the same time. I can’t think of a person I know with SCI who does not have pain problems. If it’s not shoulder pain or some other neuromuscular pain, it’s a neuropathic pain, which studies have firmly established as “intractable” — a word that is hard to take since it offers no hope of successful treatment. With this in mind, I continue my quest for helpful information.

In my latest search for promising clinical studies or for any news that offers hope for relief from chronic neuropathic pain, I came across a few items that could make improved neuropathic pain relief a real possibility. The first item is a news release from CMS (Centers for Medicare and Medicaid Services) that establishes a new “rule” that will change the way Medicare authorizes and pays for pain treatment (either for people 65 and older or those with disabilities who are younger than 65). While the rule is overloaded with info relating to all kinds of codes and procedures, the current takeaway is that CMS, beginning in January 2023, will allow patients with chronic pain to have a pain treatment team. This is especially important for those of us who find it nearly impossible to find a primary care physician who knows much at all about neuropathic pain. Many doctors, lacking personal experience with this type of pain, too often dismiss it as either “psychosomatic” or exaggerated.

The team approach, as I understand it (further clarification by CMS will hopefully shed more light on this), would allow a patient to see different specialists, who would then collaborate on establishing a treatment plan. With neuropathic pain, studies show that many disparate meds may have some effect on pain reduction, but none is an effective treatment by itself. Imagine having a treatment plan with input from a physiatrist or physical therapist who specializes in treating SCI, an acupuncturist, a neurosurgeon, and a pharmaceutical specialist. It might be that one method of treatment is monthly while other methods could be weekly or even daily. No longer would “we” be expected to come up with our own treatment plan. That model alone, while it may not entirely eliminate pain, would have a much better chance of treating it more effectively.

Now let’s pair that model with some recent clinical trials that are promising. A March 2022 study analysis compared eleven different pharmaceutical treatments for neuropathic pain in 1,198 SCI patients. The study analyzed 20 random-controlled trials and found that Botox was most effective in terms of NP treatment; Botox, gabapentin and pregabalin were most helpful in relieving mental or sleep-related symptoms due to NP. The clear winner seems to be Botox, a treatment that many of us routinely use for bladder management. What distinguishes Botox from other drug treatments is that it lasts for up to 6 months. Also, according to the study, “guidelines published by the American Academy of Neurology recommend the use of BTX-A, illustrating its effectiveness (Level A) in SCI-induced NP.” This, by itself, could possibly provide support for having a neurologist on a team.

What about potential drawbacks? Botox has a paralyzing effect (good for NP relief) when injected in the bladder wall (as many as 40 locations during one treatment), so pinpointing a specific nerve or tract in order to “knock out the pain” or lessen it — without inadvertently losing some important function, will be critical. Also, as far as I know, there are not many clinical trials involving Botox that have been mounted with human subjects for the treatment of NP. So, this promising possibility may be just that — a possibility. Hopefully, future human trials will provide important information needed to guide the Botox procedure safely and effectively.

Looking even further into the future, a June 2022 study entitled “Future Treatment of Neuropathic Pain in Spinal Cord Injury: The Challenges of Nanomedicine, Supplements or Opportunities?” gives rise to speculation about a new and exciting type of scientifically formulated option for treating NP. With this new way of delivering medicines, smaller means better. Nanomedicines can be more accurate and specific in the way they deliver medicines to interact within our bodies. According to this study’s researchers, nano meds may be able “to address potentially dangerous side effects, allowing for more precise and targeted treatments.” With neuropathic pain, researchers have learned that the most effective treatments are combined treatments involving two or three different meds. With nanotechnology, controlling side effects could be addressed simultaneously.

Think of it as “smart” medicine: “Nano drug delivery systems may enhance therapeutic efficacy by regulating dosage, location, and side effects.” Neuropathic pain is precisely the kind of complex, often intractable pain that can benefit most from future advances with nanomedicines. But, as it is with so much involving SCI, more research is needed. Put it on your wish list.

Tim Gilmer graduated from UCLA in the late-1960’s, added an M.A. from the Southern Oregon University in 1977, taught writing classes in Portland for 12 years, then embarked on a writing career. After becoming an Oregon Literary Fellow, he went on to join New Mobility magazine in 2000 and edited the magazine for 18 years. He has published upwards of 100 articles, 200 columns, occasional movie reviews and essays. He and Sam, his wife and companion of 47 years, also own and operate an organic farm south of Portland, where they live with their daughter and son-in-law, four grandsons, and a resident barn owl. An excerpt from a memoir about his early post-SCI years, as part of a compendium of his writing over the past 30 years, can be read at his website — All You Need

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.