A BATTLE OF NERVES

HEALTHCARE A Battle of Nerves

Alaska clinics research new pain management methods

By Rachael Kvapil

Pain management requires patience, as pain is inherently subjective, its sources often superimposing and shifting. So says Dr. Luke Liu, founder and CEO of the Neuroversion clinic in Anchorage. Battling pain is his mission, yet he knows the enemy cannot be cured or conquered, only tamed. Calling the field “management” recognizes the limitations of medicine in the face of life’s oldest sensation. Physicians distinguish between acute and chronic pain. According to the US Centers for Disease Control, acute pain is often defined as pain lasting four weeks or less, experienced by patients of all ages due to various conditions, including post-surgical recovery. In comparison, chronic pain lasts three months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or even an unknown reason. According to Liu, pain management starts with identifying sources. Chronic pain, he says, is a summation of physical, psychological, and social factors that can potentially produce associated complications such as depression, anxiety, chronic fatigue, decreased physical function or disability, poor quality sleep, excessive use of medication or alcohol, general dependent behaviors, adverse reactions from extended medication usage, and social isolation. Liu says his team's highest priority is identifying any specific treatable pain generators and providing palliative therapies. "We aim to break the vicious cycle of chronic pain and improve their physical and psychosocial well-being," says Liu. "We focus on improving the patient's function and quality of life instead of just masking the pain symptoms."

Dr. Claire Stoltz, medical director at Tanana Valley Clinic (part of Foundation Health Partners), adds that the functional goals of pain management are often individual to the patient. She says some patients want to attend family events, others want to live independently for as long as possible, while other patients want to maintain active lifestyles. "This is going to look different for each patient," says Stoltz. "Very rarely does pain management mean a life completely free of pain, but we continue to work towards limiting the impact that pain has on the patient."

As a family physician, Stoltz sees people for both acute and chronic pain. Chronic forms include orthopedic causes, central sensitization syndrome, fibromyalgia, chronic migraines, and neuropathic pain. At Neuroversion, Liu says staff treat conditions ranging from sports- or work-related injuries to cancer pain, musculoskeletal pain, and visceral organ pain. The most common pains are headaches, neck pain, and low back pain. More rarely, the clinic encounters complex regional pain syndrome or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Frequently, they treat conditions not typically classified as pain issues, such as post-traumatic stress disorder and long-haul COVID.

Once physical examination and imaging identify specific pain generators, Liu says his staff uses imaging-guided injections or minimally invasive surgery to target the anatomic sources. Procedures include musculoskeletal injections, trigger point injections, joint injections, Botox injections, intravenous and infusion therapies, peripheral nerve blocks, sympathetic nerve blocks, radiofrequency neuromodulation, radiofrequency ablation, peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and vertebral augmentations. Likewise, his team can prescribe medications, such as gabapentin, which makes the nerves a little less sensitive to irritation. "These interventions are designed to normalize the human body’s overwrought nervous system so that the body can instead focus on healing," says Liu.

Stoltz says Foundation Health Partners uses a multi-disciplinary approach to chronic pain that addresses root causes along with lifestyle modification to help with the self-management of pain. This includes physical therapy, osteopathic manipulation, behavioral health support, injections, sleep medicine referrals, or orthopedic referrals to help gradually regain function. When necessary, her team also uses medications. "It's critical to acknowledge the mental health toll as a result of chronic

"It's critical to acknowledge the mental health toll as a result of chronic pain, so we rely on a holistic approach to management.”

Dr. Claire Stoltz, Medical Director Tanana Valley Clinic

pain, so we rely on a holistic approach to management,” says Stoltz.

Stoltz adds that the pain management method must work for the patient while minimizing the risk of harm.

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Innovations in pain management over the last two decades mean that opioid medication is no longer the first-line choice.

ureradiancephoto | iStock

physicians have tried to decrease reliance on pharmaceutical options, given the risks. For instance, prescription opioids have attracted public attention because of their potentially addictive nature. Opioids are a wide range of substances, including the illegal drug heroin, legal synthetic opioids such as fentanyl, and prescription pain relievers such as oxycodone (sold as OxyContin), hydrocodone (Vicodin), codeine, morphine, and many others. Stoltz says opioids carry risks of addiction, respiratory depression, and death. She says patients at risk of respiratory depression should also have a prescription for naloxone, which can quickly reverse the effects of accidental opioid overdose. "Opioid use and misuse remain a major driver of adverse health outcomes in Alaska," says Stoltz. "As a medical community, we continue to have conversations with patients, work to decrease the risk of adverse events, and refer to support services as needed. Please don’t hesitate to contact your provider if you have concerns."

In general, Stoltz says opioids are not considered a first-line response except in very rare circumstances. Instead, Foundation Health Partners prefers other tools.

Liu agrees that pain management is more sophisticated than prescribing painkillers and injecting steroids. He feels the role of pain medication is declining because better diagnostic and therapeutic tools are available. In addition to the multitude of non-opioid analgesic medications, he says there are many supplements that patients can discuss with a physician, such as turmeric and magnesium. "One of the primary goals of an interventional pain management specialist is to reduce medication use, opioid and otherwise, in all patients," says Liu. "Of course, this is generally more feasible in patients with acute or chronic benign pain, as opposed to terminal or cancer pain. However, even in terminal cancer pain, there are often interventional and other strategies that can reduce medication use and, more importantly, the side effects accompanying medications."

Liu says people who have used opioids consistently for a long time may require increasing doses and might start seeking illicit drugs if they are cut off suddenly. He says many Neuroversion patients who come after years of using high doses of opioids weren’t offered effective non-opioid and non-pharmacological alternatives elsewhere. At that point, his team introduces viable options to wean these patients from opioid dependence.

Patients diagnosed with opioid use disorder work with mental health providers and substance counseling services. Besides providing effective pain management, Liu says they must enforce responsible prescription of controlled medications to keep their patients safe. He says Neuroversion is doing its part to reverse the tide of opioid use and misuse by actively monitoring opioid prescriptions through the Prescription Drug Monitoring Program and transitioning patients to better forms of care. "Given the horrifying consequences of 'sky’s the limit' opioid prescribing over the past two decades, we now know that long-term high-dose opioid prescription has significant limitations and dangers," says Liu. "Fortunately, the last two decades

have also seen great scientific and technological advancements. We now have an increasing number of tools as an alternative to opioids. These are becoming safer, more comfortable, and more effective."

Patients First

The road to pain management starts with a primary care provider, says Stoltz. Pain management specialists can augment care, but they often need an initial workup, typically through general practice or orthopedics. Liu adds that verifying a provider’s credentials is easily done online and vital to avoid charlatans using marketing ploys to exploit patients' desperation. Liu says there is a moral commitment to be insurance blind and not cherry-pick patients because of potentially better reimbursement or turn down patients based on their coverage. "We work with patients and insurance companies," says Liu. "We advocate for our patients as much as humanly possible. In many cases, we go out of our way to take care of our patients first and the bottom line second. Many medical conditions we deal with daily in our clinic are not elective like plastic surgery. Patient care always comes first."

Stoltz says trusting relationships are important, especially when facing the challenges of long-term pain management. Sometimes the existing pain management approach is no longer working, and patients become fearful when a provider suggests a change in protocol. She says fear of change and fear of worsening pain make developing a new approach complicated.

Liu agrees: "Ultimately, trust is paramount. Patients need to trust their provider, and the provider needs to be able to trust the patient to do their part. Respect and trust are earned, and this takes time in a relationship."

Liu adds that each treatment plan must be individualized and adjusted during treatment. Pain management is considered a fluid specialty, unlike cardiology, which has specific protocols based on the most up-todate large randomized control studies. Liu says the nature of pain makes "Different specialists have their unique perspectives and skill sets… Patients will benefit from a collaborative and synergistic medical ecosystem. At the end of the day, we are all here for our patients, helping to make our community healthier and better."

Dr. Luke Liu, CEO, Neuroversion

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HEALTHCARE "There are plenty of ‘off-label’ treatments out there being used routinely by physicians that aren’t covered by insurance, partly because sufficiently rigorous clinical trial data has not been generated… Only through objective clinical research can we obtain new therapies accepted by the medical establishment and insurance payers."

Deborah Duricka Clinical Research Scientist Neuroversion extensive randomized controlled studies challenging to perform and far more complex than treating medical conditions such as appendicitis, fractures, and heart failure. Because of this, it is hard to standardize pain management treatment.

Privademic Practice

Neuroversion is a “privademic” clinic—a private practice with an academic side. Besides taking care of patients and advancing the field of neuroscience, Liu and his team work with, educate, and cultivate students pursuing careers in medicine. Since Neuroversion opened in 2016, seven staff members have transitioned to medical school, and many more have gone on to careers in nursing and physician assistant programs. "It is my vision that Neuroversion will continue to offer students secondto-none clinical exposure to chronic musculoskeletal and neurological ailments," says Liu, "providing them the opportunity to develop and confirm their professional interest in medicine and pain management."

Deborah Duricka, a clinical research scientist at Neuroversion, collaborates with top researchers around the world. She says Neuroversion currently has two kinds of ongoing clinical trials. They are part of several multi-site Phase 5 clinical trials for neuromodulation devices. Duricka says this clinical trial will determine whether this device only works with a very select patient population in controlled conditions (efficacy) or if it works in the real world with all of its complications (effectiveness). They are also in the process of setting up a single-site Neuroversion-based clinical trial to test the effectiveness of stellate ganglion block for ME/CFS, funded by a grant from Solve M.E., a nonprofit dedicated to researching the condition. A similar trial for long-haul COVID is also planned in collaboration with international research groups. Duricka says they may consider applying for federal grants if it proves beneficial.

Research into new pain management methods helps patients who fall into difficult diagnostic and treatment categories, says Duricka. She feels clinical research is pivotal to exploring innovative treatments and validating their safety and efficacy. She adds that independent clinical research (grant-funded rather than industry-sponsored) is critical because it's not profit-driven. Clinical trials are labor intensive and expensive, so if a new therapy has the potential to make a profit, then there is a financial incentive for manufacturers to sponsor clinical trials. In the absence of industry interest, Duricka says research departments depend on grant funding, which is fiercely competitive. "There are plenty of ‘off-label’ treatments out there being used routinely by physicians that aren’t covered by insurance, partly because sufficiently rigorous clinical trial data has not been generated," says Duricka. "Only through objective clinical research can we obtain new therapies accepted by the medical establishment and insurance payers."

With remote communications becoming more convenient, conducting clinical trials in Alaska isn’t as difficult as expected, Duricka says. Traveling to the clinic from outside Anchorage is still a challenge, she admits, but that’s true for clinical care as well. Fortunately, many parts of a clinical trial don’t require the patient to be physically present.

Liu thinks Alaska is uniquely positioned to contribute to the everevolving fields of neuroscience and interventional pain management. At Neuroversion, Dr. Ben Ekstrom and Dr. Wendy Gaultney are spearheading a multidisciplinary pediatric pain management program, which Liu says hasn't been accomplished outside academic settings anywhere in the world. "Different specialists have their unique perspectives and skill sets," says Liu. “Patients will benefit from a collaborative and synergistic medical ecosystem. At the end of the day, we are all here for our patients, helping to make our community healthier and better."

Great pain management providers, Liu believes, are those willing to think outside the box since many pain and neurological conditions don't have cookie-cutter treatment recipes. He recalls advice from an attending physician during his residency: “Be a cowboy—but not an outlaw.”