Q: Please tell me about yourself.

I am Dr. Marco Papaggallo, pain specialist, neurologist. My area of expertise and interest is the study of chronic pain and in the management of patients who suffer from pain.

Q: What are the costs of chronic pain to the United States?

The costs of chronic pain are huge. Chronic pain costs the US economy more than $100 billion per year. If you include cost of medication, treatments, loss of work, etc. the cost is ever higher.
For sure, 50% of that estimate is related to chronic back pain. Back pain is a highly prevalent problem. Nearly 90% of people will suffer from back pain in their lifetime.
Chronic pain is like having a nail in your head and somebody is hammering all the time. It is an ongoing, nagging, suffering complaint. Years ago, people with chronic pain were labeled as psychiatric patients, when there was no clear-cut reason for the pain such as inflammation and cancer.

Q: What is the typical standard of care for back pain patients?
What happens now is that back pain patients see their primary care physician who prescribes anti-inflammatory drugs. When the pain persists, they send the patients to an orthopedic surgeon for an evaluation.
Here you have the problem. The pain specialist is bypassed. The pain specialist would evaluate and understand the patient’s problem and triage him accordingly. Sometimes patients will see a neurologist. But most neurologists are not in-depth about pain mechanisms and do not have that kind of knowledge.
Sometimes the patient bypasses the primary care physician on his own and goes to the spine surgeon. What we see nowadays, is that the surgeon will send the patient for a series of three epidural injections with steroids. If the pain persists, the patient will come back to the surgeon to evaluate.
The field of chronic pain management is new and unfortunately there are only a few specialists suited to take care of those patients.

Q: What is the difference between acute and chronic pain?
Acute pain is defined by pain, which subsides within 3 months. I would say that if the pain persists after 3 months, we are talking about chronic pain.

Q: What kinds of patients to do treat?
I care for thousands of patients. I see 50 new patients per month and hundreds of follow-up patients as well. 50% of the patients of see suffer from chronic back pain.

Q: What causes back pain?
There are a number of potential causes and mechanisms for back pain. I believe, in 90% of patients with chronic back pain, the true cause is still unknown. In a small percentage of patients there is a clear-cut pathology, where we know what is causing the pain.
Poor habits, lack of exercise, even the wrong exercises are likely triggers that contribute to the problem, but the true mechanism of back pain is still unclear. I believe because of the trend in more sedentary habits, the prevalence of back pain is increasing. Also, because the population is aging and people are living longer.
In many cases we see osteoarthritis, disk disease, degeneration of the spine…but we cannot say for sure that these are the causes of pain. These are non-specific symptoms because many people have these conditions, but are not in pain.

Q: How does chronic pain effect people in their lives?
Chronic pain will impact a person in many ways. It will cause depression, an inability to cope and relate to other people. It will change their personality. We have to give chronic back pain patients a comprehensive, integrated approach. A good evaluation will take at least one and a half to two hours to put everything together.
As of now, there’s a lack of education in the medical schools. We are behind in the residency schools how to teach this problem. Primary care physicians try their best, but in most cases, do not have the knowledge how to properly treat chronic pain patients.

Q; Can you measure and assess pain?
Assessment of pain is essential. One of the most simple reliable tools is feedback from the patient, using the pain scale from 0 (no pain) – 10 (extreme pain) during the treatment.
Another is a questionnaire called the brief pain inventory. Still rating the answers from the 0-10 scale. Questions include ability to sleep, function, perform daily activities, etc. We rely of those answers to see if the treatments are successful in follow-up appointments.
Pain is a complex phenomenon. The spine is a complex structure. There are bones, nerves, ligaments, muscles, joints. etc. Some people have a neuropathy, others have a Vitamin D deficiency.
We do not have an objective way to measure pain. It does not exist. Pain is subjective. We have to believe the patient. EMG, blood tests and MRIs do not assess pain but helps us correlate the pain with the causes.
EMG nerve conduction study has very little to do with the pain nerves. The test has no specificity to assess small nerve fibers. It can only study the large nerves, that have to do with strength and sensations like touch.
Abnormalities in the spine, we see on MRI and EMG tests do not equate with pain because many people have abnormalities with no pain. We don’t treat MRI or EMG. We treat patients. This goes to the core of the problem when evaluating pain. There is a science and an art to treating pain. We use a collaboration of the tests, evaluation, response to treatment and other factors.

Q: What medications are available to provide pain relief?
Generally medications are of two classes. Opioid and non-opioid analgesics. Non-opioid drugs include medications like aspirin, ibuprofen, anti-inflammatory drugs, Tylenol, acetaminophen…most of these drugs are bought over the counter and are prescribed for mild pain. They are effective, but not strong enough when we’re dealing with intense pain that is disabling.
Then there are drugs that were originally used for epilepsy and seizures that were found to be effective in the treatment of pain. Some of these anti-depressive agents like duloxetine, and venlafaxine can help with neuropathic pain where the nerves are abnormal. There are other medications that help lower blood pressure, etc. that we do not know about yet.
Opioid medications like morphine are used for more intense pain such as cancer. The main fear is the misuse of these drugs. We need to be careful in our assessment of the patient to make sure they are behaving. But if the medication is effective and we see reduction in pain level, and better quality of life, we are doing a good thing.
Often, we often combine all these agents (anti-depressive, anti-inflammatory, opioid) to be more effective and improve the patients quality of life.

Q; I use Bio-freeze and Capzasin sometimes. How do topical agents work?
Topical agents work mainly by absorption through the skin. Some are meant to work throughout the body such as fentanyl patches, which is a powerful opioid medication.
Many topicals are fairly benign numbing agents. They may work by placebo effect, which a very real response. Capzasin is another interesting agent that causes a burning hot feeling initially, but later. a natural agent will deactivate the pain nerves.

Q: I once took Lyrica for nerve pain, which helped. But how does it work?
Gabapentin, Lyrica, Neurontin and similar drugs all work in the same way. Gabapentin was originally developed as a drug for seizures to inhibit activity in some neurons.
Later on, it was found to help in neuropathic pain. It is still unclear how it works, but it seems these drugs modulate or interfere with a channel in the nerves to help calm down activity in abnormal nerves.

Q: What is the role of pain-relieving injections?
Epidural injections are for patients who suffer from acute pain and to help the doctor gain an understanding of the mechanism of pain. If the patient feels better by blocking one area, a more accurate diagnosis can be achieved. But for patients with chronic pain, these injections are temporary measures.
Most of the procedures we do have a temporary effect. Local anasthetics will help for only a few hours. Steriods may help for days or weeks. If you use radio frequency to heat and kill the nerves, the relief might last several months. Often, the nerves grow back causing the same abnormalities and pain.

Q: How important is prevention?
Prevention is important. You have to keep yourself in good physical condition. Try to not overuse or strain that part of your body you are trying to preserve. Lifting heaving objects incorrectly, etc. If a person is obese or runs many miles over years you would expect knee problems. These are triggers to avoid.
Moderate activity is best. Make sure your muscles and ligaments are in good shape. Try to delay the degeneration of the joints. Diet and genetic factors are also important. But there is still research going on, we have more to learn.

Q: What is your opinion on back surgery?
Surgery can help, but some people are no better after surgery and others are worse. I see a lot of patients after surgery failed to help them. My overall impression is that there are too many back surgeries.
But I do refer some patients for surgery. Sometimes patients have severe neurological deficits and surgery will be performed to prevent further damage.
The key is selecting the right patients with the right procedure. In the past, people with disk herniations went right to surgery. We learned that with the right medications and conservative treatment, the pain improves.
The disk is 90% water, so the disk with eventually dry out and the compression on the nerve will decrease. The pain will subside over time. This is in most cases.

Q: What is the state of the pain management field?
Pain management is fairly new and an extremely fascinating field of medicine. As the population is growing and aging we will have more cases of chronic pain and painful conditions. We need to make sure patients are listened to seriously. We need more advances in medicine and more support at every level. The pain management field should not fall between the cracks.

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