痛症八大誤區（摘譯）

估計有116萬美國人患有慢性疼痛，正確的疼痛診治，可以減輕疼痛，但普遍存在的誤區可以阻礙痛症的準確診治，疼痛的控製，從而防礙功能的恢複和保持正確的生活質量。有人相信這些錯誤傳說, 有的流行於病人中，也有的則是由醫師延續下去。

斯科特格拉澤（Scott Glaser），醫學博士，DABIPP，美國介入疼痛醫師協會會長，大芝加哥疼痛專家和董事會成員，和疼痛管理部門在約翰霍普金斯大學醫學教育主任和疼痛主任史蒂芬P.科恩（Steven Cohen )，MD， ，在沃爾特裏德國家軍事醫療中心的研究，討論了痛症八大誤區。

誤區1。止痛藥是天生不好。

這個誤區源於各種錯誤新聞報道，例如在2008年近15000美國人死於處方止痛藥物過量而致，新聞報道中誤用上隱，成隱等造成民眾誤解。

科恩博士說：“止痛藥是沒有好壞之分，他們是一個需要被醫師完全掌握，病人理解，醫患有效溝通，並合理應用與嚴格觀察副作用及風險的痛症治療有效方法，”。

科恩博士說，最重要的是根據病人病痛處方止痛藥，因人而異。例如，癌症疼痛的老年患者可能反應良好阿片類藥物，但與年輕患者背部疼痛是一個風險較高的發展容忍甚至痛覺過敏，使人體對疼痛更敏感。

“這就像一切，這些事情都必須逐案的基礎上確定的，”他說。

誤區2。谘詢委員會和準則委員會的建議是黃金標準。

根據患者的保護和支付得起的醫療法，以降低醫療費用，不影響覆蓋或質量的情況下創建的獨立支付谘詢委員會及以醫療性介為中心的成果研究所製定了所謂黃金標準以指導保險公司限製醫療服務。許多痛症醫生，包括格拉澤博士和ASIPP的董事會和首席執行官，科恩博士說及介入痛症協會 Laxmaiah Manchikanti主席都認為應該廢除這些以協助保險公司為主，限製病人治療的黃金標準。

誤區3。所有背部疼痛是一樣的。

初級保健醫生和神經科醫師不具備足夠的知識或方法來治療腰背痛，導致他們對腰背痛的認識停留在較低的傳統認識上。
格拉澤博士說，有許多不同的結構，可導致椎間關節，骶髂關節和這些關節與神經的影響，如背部疼痛。其他原因包括手術失敗綜合征，包括相鄰的水平椎間盤突出症，不穩定和神經損傷的後遺症。每個處方治療腰痛的原因是不同的。

誤區4。核磁共振總是腰痛的診斷結果。

雖然核磁共振成像可以提供客觀圖像，如椎間盤退化性疾病和椎間盤膨脹，但圖像可能與疼痛不相關，研究結果發現在正常人群，隨著年齡的增加椎間盤退化和椎間盤膨脹均會發生。
“核磁共振診斷疼痛的敏感性，實際上具有非常低的的，”格拉澤博士說。 “椎間盤退化性疾病是人類老年退變，如果你對無症狀的50歲人進行檢查，90％的核磁共振都會有椎間盤退行性疾病。”

科恩博士，大型隨機試驗說明：核磁共振成像不改善的治療結果，不影響決策。核磁共振圖像有非常低的特殊性和缺乏相關疼痛和治療結果。

誤區5。疼痛治療隻是硬膜外注射。

格拉澤博士說，介入性疼痛醫師專家已經開發出了不同的治療方法 - 包括注射，神經阻滯和neurolytic程序 -來治療不同來源的疼痛。

誤區6。手術是背部疼痛容易修複
。
這個誤區來自一個＂希望＂：手術可以治愈背部疼痛的希望。但往往現實中手術是無法治愈腰背痛的。格拉澤博士說。“手術後可以短期無症狀，但你不能阻止椎間盤退化性疾病，”他說。 “手術隻能盡量減少症狀。”

科恩博士說，大多數的研究表明，延伸到腿部或頸部疼痛延伸到手臂與背部疼痛的患者，手術效果是暫時的。術後前6個月，患者會比沒有手術者更好，但有兩年後手術效果消失。
腰背部手術，同所有手術一樣，有其風險，格拉澤博士說。通常情況下，風險是不值得輕易選擇手術方法。
“腰背部手術是一個易失敗的風險很高的手術” 他說。 “腰痛手術應是最後的選擇，除非有壓迫脊髓或神經根，這實際上是極其罕見的。”

誤區7。可以每年隻有三個類固醇注射。

這個說法沒有科學依據，格拉澤和科恩倆位博士說。一些保守的疼痛醫生仍然相信和根據這個誤傳進行治療。注射類固醇不同於口服類固醇，格拉澤博士說。口服類固醇，會產生一大堆的健康問題，如形成白內障，青光眼和骨質疏鬆症的風險增加。他說，由於類固醇注射屬沉澱劑型，基本作用為注射局部，不存在口服類固醇全身副作用。

科恩博士說，做多次注射的決定應取決於患者治療反映。如果病人在一次注射治療後疼痛100％緩解，那就不必再注射。

誤區8。任何人都可以做痛症診治

去年，路易斯安那州最高法院裁定，疼痛診治需要由醫生進行。 ASIPP還試圖在伊利諾伊州通過類似法案。

格拉澤博士說。 “痛症注射治療是微創，其實是有風險的，因為注射部位非常接近脊椎及中樞神經係統。沒有適當培訓的護士或醫生助理或醫師，不應該允許執行這些治療。”

科恩博士說：“事實是，你可以教別人做硬膜外類固醇注射，你可以教他們將骨釘打入骨折部位，但這並不說明他們能行醫，”他說。 “最重要的是知道什麽是治療指征，任何人都可以取出闌尾，但你需要很多經驗，知道什麽狀況需要治療，以及如何識別和治療並發症。”

8 Myths About Pain Management
November 18, 2011

For the estimated 116 million Americans suffering from chronic pain, proper pain management can improve functionality and quality of life as well as reduce pain, but pervasive myths can hinder treatment. Some of these myths are believed by patients while others are perpetuated by physicians.

Scott Glaser, MD, DABIPP, president of Pain Specialists of Greater Chicago and a board member of American Society of Interventional Pain Physicians, and Steven P. Cohen, MD, director of medical education for the pain management division at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center, discuss eight myths surrounding pain management.

1. Narcotics are inherently bad. This myth has been supported by recent headlines after the release of the Center for Disease Control report that found almost 15,000 Americans died from prescription opioid overdose in 2008. The issue is not that cut-and-dried, Dr. Glaser says.

"Narcotics aren't good or bad; they're a treatment option with risks that need to be appreciated, communicated, and dealt with," he says. "They're not inherently evil, and doctors who prescribe them aren't evil. For some folks, they're life savers. It enhances their quality of life without adverse side effects. It's easy to lose sight of that fact in the pandemonium surrounding the epidemic of prescription drug abuse."

Dr. Cohen says the important thing is to prescribe drugs based on individual patients. For example, an older patient with cancer pain might respond well to opioids, but a young patient with back pain is at a higher risk for developing tolerance or even hyperalgesia, a condition that makes the body more sensitive to pain.

"It's like everything else; these things have to be determined on a case-by-case basis," he says.

2. Advisory board and guideline committee recommendations are the gold standard. Both the Independent Payment Advisory Board and the Patient-Centered Outcomes Research Institute were created under the Patient Protection and Affordable Care Act to reduce the cost of healthcare without affecting coverage or quality. Many interventional pain management physicians, including Dr. Glaser and ASIPP's chairman of the board and CEO, Laxmaiah Manchikanti, MD, think they should be repealed.

"I think it is a myth perpetuated by well-meaning folks at the highest levels of government that a group of epidemiologists and non-practicing physicians and statisticians can come up with appropriate recommendations for billions of people when the issue of best treatment isn't even settled in medical literature," Dr. Glaser says.

Dr. Cohen, who oversees numerous clinical trials, says advisory boards and guidelines committees are the "lowest level of acceptable evidence."

"Many reach different conclusions based on the same articles evaluated with different criteria," he says. "It depends a lot on the perspective [of the members]. The best guidelines consist of recommendations from a multidisciplinary group, including multiple specialties, private practice, military and government."

3. All back pain is the same. This myth is found among patients, some primary care physicians, and multiple specialists, Dr. Glaser says. Primary care physicians and specialists such as neurologists don't have the knowledge of the causes or the tools to treat back pain which leads them to lump lower back pain in to one broad category rather than attempt to understand the unique causes. Dr. Cohen calls this a naïve statement and says distinguishing different types of back pain is essential to determining treatment.

"Perhaps the broadest and most critical categorization is to differentiate between mechanical pain and nerve pain," he says. "This is a really important categorization because it affects treatment at all levels."

Dr. Glaser says there are many different structures that can cause back pain such as the intervertebral joints, the sacroiliac joints and effects on the nerves traversing these joints.  Other causes include failed back surgery syndrome and the sequelae including adjacent level disc disease, destabilization and nerve damage. The prescribed treatment for each cause of back pain is different.

4. MRI always results in a back pain diagnosis. While MRIs can provide objective information about back disorders, such as degenerative disc disease and bulging discs, they rarely point to the cause of the pain because of the incidence of these findings in the normal population increases with age. Dr. Glaser says many issues that show up in an MRI might have been present before the patient experienced any pain.

"MRIs actually have very low sensitivity for diagnosing pain," he says. "Degenerative disc disease is so common in human beings that if you do MRIs on asymptomatic 50-year-olds, 90 percent will have some findings consistent with a degenerative disc disorder."

Dr. Cohen, who will be releasing a large, randomized trial on MRI use next month, says MRIs don't improve outcomes and don't affect decisions. They have very low specificity and are poorly correlated with pain and treatment outcomes.

5. Pain management is only epidurals. Dr. Glaser says interventional pain management specialists have developed different treatments — including injections, nerve blocks and neurolytic procedures — for different sources of pain.

"Pain management has evolved as a subspecialty because of the advancement and knowledge of the causes of pain through advances in our knowledge in anatomy and the sensory innervation of the joints in the lumbar spine," Dr. Glaser says.

6. Surgery is an easy fix for back pain. This myth comes from a hope that surgery can cure back pain, but often there is no cure for back pain, Dr. Glaser says.

"It can be made asymptomatic, but you can't stop degenerative disc disease," he says. "You can only minimize the symptoms."

Dr. Cohen says most studies show that in patients with back pain extending to legs or neck pain extending into the arms, surgery works temporarily. For the first six months, patients are better off than they would have been without surgery, but that benefit wears off after two years.

"First of all, it doesn't work in everyone," he says. "Even if it works, it may not improve long-term outcomes."

Like all surgery, back surgery has its share of risks, Dr. Glaser says. Oftentimes, the risk is not worth the benefit for this elective procedure, he says.

"Back surgery is associated with a high risk of failure," he says. "Even a microdiscectomy can be associated with rapid onset of epidural fibrosis or scarring. Surgery for back pain is always an elective procedure unless there's compression of the spinal cord or nerve roots, which is actually extremely rare."

7. Only three steroid injections can be given per year. This myth has no foundation in science, say both Drs. Glaser and Cohen. Some conservative pain management physicians still believe and treat based on this myth. A steroid injection is not like taking an oral steroid, Dr. Glaser says. With an oral steroid, consistent dosing means increased risk for a whole host of health problems such as cataract formation, glaucoma and osteoporosis. Because the steroid is injected, the medicine more or less stays put, he says. The same risk isn't there.

Dr. Cohen says the decision to do multiple injections should depend on how the patient responds. If the patient gets 100 percent relief from one injection, there's no point in doing more, he says. If a patient fails to obtain relief from the first injection, it might make sense to do a second injection in a different manner, such as using a different approach or a higher volume of medication, he says.

8. Anybody can do pain management. There has been a movement to allow nurses and physician's assistants to perform some pain management procedures. Last year, the Supreme Court of Louisiana ruled that pain management is a medical practice and needs to be performed by physicians. ASIPP also tried to get a similar bill passed in Illinois.

"The fact is that there are risks," Dr. Glaser says. "These procedures are minimally invasive but maximally dangerous. We're working very close to the spine. A nurse or physician's assistant or a physician without appropriate training should not be allowed to perform these procedures."

Just because someone can be taught to perform pain management procedures, such as epidural steroid injections, doesn't mean they should, Dr. Cohen says.

"The truth is you can teach somebody to do an epidural steroid injection, you can teach them to put a screw into a bone, but that doesn't constitute the practice of medicine," he says. "The important thing is to know when something is indicated. Anyone can take an appendix out, but you need a lot of experience to know when the treatment is indicated, and how to identify and treat complications."