Winter 2016

Pain Relievers

When patients hurt, this team of specialists ends the anguish

By Jacqueline Mitchell and Helene Ragovin 

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Illustrations by Joanna Szachowska

Like a lot of the patients who come to the Tufts Craniofacial Pain Center, the 30-something Ph.D. student was at her wits’ end. Since high school, she’d suffered from three or four migraine headaches a year. Then she woke up one morning with a sharp pain in her cheek that never went away. She began having one or two migraine headaches a week and feared her condition might ruin her career in academia.

By the time she showed up at Tufts, the woman was anxious and depressed, says Egilius L.H. Spierings, a clinical professor in the department of diagnostic sciences at the School of Dental Medicine.

“Generally, people have come through a good number of physicians and dentists before they ultimately end up here at the clinic,” says Spierings, a neurologist who consults with the dentists on complex cases. “She had seen a lot of physicians and gotten a lot of different opinions. She was on a number of medications. That’s the kind of thing that would make anyone irritable.”

She underwent a complete work-up. Over the course of several months, the dentists ruled out any tooth-related problems, like abscesses, grinding and clenching of the teeth or jaw misalignments. The clinic psychologists helped determine which came first, the patient’s intractable pain or the depression and anxiety.

“Everybody here got involved with this patient,” Spierings says. That approach—a team of specialists from many disciplines working together to unravel the puzzle of seemingly intractable pain—is the guiding philosophy at the Craniofacial Pain Center. It was among the first pain programs to use this holistic approach and is now one of the largest university-based centers of its kind in the country, according to Noshir Mehta, DG73, DI77, who served as the pain center’s director from its founding in 1985 until 2012. The team includes dentists, physicians and psychologists and draws on the expertise of physical and occupational therapists. A current physiology fellow who spent six years as a Buddhist monk works with patients on mindfulness meditation.

Beyond Toothaches

Chronic pain affects 100 million American adults and costs the country roughly $600 billion annually, according to the U.S. Institute of Medicine. Orofacial pain—including headaches—may account for as much as 40 percent of that price tag, according to a study published in the Journal of the American Dental Association (JADA) in July 2014.

“I think most of what I know about headache and face pain, I learned
from patients.” —Egilius L.H. Spierings

The Tufts Craniofacial Pain Center treats patients suffering from headaches, sleep problems and facial pain. The vast majority of them are diagnosed with conditions like cervical or musculoskeletal problems or sleep apnea, Mehta says, and is indicative of some of the primary causes of pain in patients everywhere. A study in the October 2015 issue of JADA found that “pain in the muscles and temporomandibular joints was reported as frequently as that in the teeth and surrounding tissues in patients visiting general dentists.” That conclusion was based on a survey of dentists in the northwestern U.S. from 2006 to 2009. Overall, the JADA study concluded that 21.7 percent of the U.S. population suffers from orofacial pain—and, Mehta says, facial pain quite often is accompanied by pain in other parts of the body.

Approximately 1,500 new patients a year come through the doors of the Craniofacial Pain Center at One Kneeland Street, says Shuchi Dhadwal, DG10, DI14, its interim director. In addition to treating patients, the center’s other mission is education. Predoctoral students rotate through the clinic, and there is a postgraduate program that leads to either a certificate or a master’s degree in orofacial pain.

Because pain management transcends traditional boundaries in patient care, work in this field, both research and clinical, is among the most interprofessional of endeavors at the School of Dental Medicine—a noteworthy model as collaborative health-care practice moves toward becoming the norm for the 21st century. “It’s not just that I’m a dentist. We look at our patients from a global standpoint,” says Mehta.

“In this environment, not only do the students get exposure to treating pain, but [also] how to collaborate with specialists outside their own field,” Dhadwal says. And for patients, the advantage is that all the providers can be brought together when the patient is there.

For more than 15 years, the pain center has been sharing its expertise by hosting weekly rounds at the dental school to address specific cases or topics, such as managing pain in patients who have other physical or mental illnesses or using new technologies to measure and study pain. Academics and health-care providers can call into the sessions from anywhere, either to share their own knowledge or to seek opinions about their patients. Two experts from Saudi Arabia called in this fall, says Ronald Kulich, a professor of oral pathology in the dental school’s department of diagnostic sciences, who hosts the sessions.

At a recent call-in, Chao Lu, DG10, an assistant professor in the department of diagnostic sciences at the dental school, presented two cases that, at first glance, looked like temporomandibular joint disorder. Closer examination, however, revealed other possible causes. In one case, a woman claimed her jaw misalignment and bruised left cheek resulted from a bad fall. But an MRI showed an injury more consistent with being hit or punched, information that could help the team offer intervention for domestic violence. In the other, a young girl had jaw pain typical of nighttime tooth grinding. But when one of the pain center’s physicians noticed she had a slight rash, he ordered a blood test. The diagnosis turned out to be Lyme disease, caught early thanks to the interdisciplinary team at Tufts.

For more than 15 years, the pain center has been sharing its expertise by hosting weekly rounds at the dental school.

The pain center’s collaborative approach also helped identify the source of the doctoral student’s sudden, stabbing cheek pain. Spierings ordered a CT scan to see whether an ear, nose and throat problem could account for her discomfort. The scan revealed a tiny bone spur, “like a splinter in your nose,” he says. “Once you have that, it causes inflammation, and you’re stuck with it.” A simple surgery took care of the problem, a solution that no single health-care provider had arrived at.

A Sneaky Foe

“Face pain is an elusive area. Very few people or institutions really have a good understanding of it,” Spierings says. And if the pain continues without relief, it takes on a psychological dimension, too—and can affect other people in a patient’s life. Dhadwal says she became interested in pursuing pain as a specialty—she received advanced training at Tufts in craniomandibular disorders—because a close family member suffered from chronic pain. “It can be really stressful not just for the patient, but for the family members as well.”

“The good doctors in pain management will look at everything, but need to come into the conversation believing their patients are telling the truth.” —Noshir Mehta

What bedevils both health-care providers and patients is pain’s invisibility—you can’t see it on an X-ray or measure it with a blood test. That, along with its extraordinarily subjective nature, makes it a frustrating adversary.

“If you cut your arm, and you show it to someone, they will see the cut and they will believe you,” Mehta says. “If you have pain, it’s up to you to describe it. And it’s up to me to believe you.” The standard practice of asking patients to rate their pain on a scale of 0 to 10, for example, leaves a lot of leeway. “If you have a pain of 3, it might be the same as someone else’s 7,” Mehta says.

“That’s the problem with chronic pain—you have to believe the person who is giving you information, and how much you believe in your patient will lead you to treat the patient differently,” Mehta says. “The good doctors in pain management will look at everything, but need to come into the conversation believing their patients are telling the truth.”

Spierings, a physician, agrees. He holds a Ph.D. in pharmacology, but he is primarily a neurologist who specializes in migraine headaches. In the early 1980s, he did a fellowship in headache medicine under John Graham, a pioneer in the field, at Boston’s Faulkner Hospital. “If you asked me what is the single most important thing that he taught me, I would say to listen to patients and to take as valuable what they tell you,” says Spierings. “I think most of what I know about headache and face pain, I learned from patients.”

Contact Jacqueline Mitchell at jacqueline.mitchell@tufts.edu and Helene Ragovin at helene.ragovin@tufts.edu.

 

Rx for Prescribed Painkillers

 

Late on a Friday afternoon, a new patient comes into the dental office with a toothache. She’s in severe pain, she says, and her X-rays reveal a cavity. There isn’t time to start a procedure, so you book an appointment for first thing Monday morning. She asks you to prescribe her something for the pain, just to get her through the weekend.

“What would you do?” Ronald J. Kulich, a professor of diagnostic sciences, asks a roomful of second-year dental students. “Write her a script for 30 pills? What’s your gut reaction?”

Illustrations by Joanna Szachowska

Illustrations by Joanna Szachowska

Kulich, a psychologist who specializes in chronic pain, is using this hypothetical case to help his students understand the basics of addiction screening. It’s part of a continuing effort to stem the tsunami of prescription-painkiller addiction that has swamped the United States since the early 2000s.

Every day, 44 Americans die from an overdose of prescription painkillers, which includes opioids, hydrocodone, oxycodone and methadone, as well as benzodiazepines like Valium and Xanax, according to recent data from the Centers for Disease Control and Prevention. The next generation is also at risk. Every 25 minutes a baby is born suffering from opioid withdrawal, according to the National Institute on Drug Abuse. The alarming statistic represents a fivefold increase since 2000. That’s why it’s crucial for dentists to know the signs of and risk factors for addiction before taking out that prescription pad.

Drawing from a mosaic of real-life cases, Kulich offers students more detail about his hypothetical patient. She has a pleasant demeanor, but she’s unemployed and may be so permanently as a result of back surgery. She had a postsurgery prescription for Vicodin, but she says she didn’t refill it. She smokes a little less than a pack of cigarettes a day and takes an antianxiety medication to help her sleep. She takes some heavy-duty headache meds, and she has an allergy to the drug suboxone.

At least one student recognizes this last red flag—suboxone is used to treat opioid addiction.

“I encourage you to use the patient’s medicine list as a way to complete your evaluation,” Kulich advises the students. “Sometimes that will tell you more than a patient will. Knowing esoteric medications will give you a nice history.”

Since 2010 dentists and physicians practicing in Massachusetts are required to check the state’s prescription monitoring program (PMP) database, which is housed on a secure website and keeps track of all prescriptions filled by patients in the last year. The database, which is populated by data from pharmacists and health-care providers, is designed to prevent patients from doctor shopping to obtain multiple painkiller prescriptions from multiple providers. All 50 states plus the District of Columbia and Guam employ PMP technology. Massachusetts was among the first to mandate its use and to work aggressively toward training physicians and dentists in identifying patients at high risk for substance abuse, says Kulich, who is working with state agencies in Massachusetts to determine how health-care practitioners and law enforcement can work together to address addiction.

The PMP can also help dentists make better clinical decisions, avoid drug interactions and foster better collaboration with their patients’ other health-care providers, he says. “It’s going to give you an opportunity to have a conversation with the patient,” says Kulich, who acknowledges some dentists are reluctant to broach the topic of addiction with their patients. “Assessment doesn’t have to ruin your relationship with the patient, but may improve it and give you a chance to have a frank discussion.”

In Kulich’s hypothetical case, the PMP reveals the patient filled not one, but two prescriptions for opioid painkillers recently, one from a dentist, the other from a physician. Whether she lied about it or forgot, says Kulich, doesn’t really matter. Dentists still need to treat their patients’ pain.

A cautious dentist might opt to prescribe this patient a very small number of pain pills and require her to come back on Monday for follow-up. An over-the-counter analgesic such as acetaminophen or ibuprofen could also work, although these drugs also carry risks, such as stomach and cardiovascular side effects. For some patients, prescription opioids remain the safest and most effective strategy for pain control, providing the dentist conducts an adequate assessment of risk, says Kulich.

“It’s not about shifting away from opioids,” he says. “The buzzword is ‘rational prescribing.’” –Jacqueline Mitchell

 

Moving the Needle

 

When George Maloney sees a patient in pain, he first determines whether the ache emanates from the nerves or the muscles. For nerve-based pain, he often prescribes medications. For muscle pain, he reaches for his needles.

Maloney, a clinical professor at the Tufts Craniofacial Pain Center, is a longtime advocate of using acupuncture over painkillers to treat muscle pain more effectively. In addition to his D.M.D., he has a master’s degree in acupuncture from the New England School of Acupuncture.

Painkillers, Maloney says, provide only generalized relief and can lead to drug dependence and addiction. “Opioid pain relievers can be effective for a short-term treatment of a day or two,” he says. By contrast, acupuncture can provide lasting relief from the pain.

Illustrations by Joanna Szachowska

Illustrations by Joanna Szachowska

Maloney begins acupuncture treatment by stabilizing the points of contact, or occlusion, between the teeth with a mouthguard or oral splint. “If you create a stable occlusion, which can reduce muscle activity in the jaw muscles, then you will find it much more effective when you treat the muscles more directly with needling,” he says. He treats muscle pain with traditional acupuncture needles or electro-acupuncture, which sends a low, pulsating electric current to the muscles.

In traditional Chinese medicine, inserting acupuncture needles into specific locations balances the flow of qi, or vital energy, throughout the body. More modern explanations typically point to acupuncture’s ability to stimulate peptides and other biochemical signals that cause physiological effects, such as increasing blood flow, reducing inflammation and easing muscle tension.

Maloney first got involved with the alternative medicine technique after repeatedly surveying patients on what reduced their pain and finding that a high percentage of them mentioned acupuncture. He took a distance-learning course through UCLA Medical School in 1998, following it up with the program at New England School of Acupuncture in 2002. Acupuncture works, he says, because chronic pain puts the face and jaw muscles into an altered state. Acupuncture can gradually get the muscles to relax.

While acupuncture is not widely used by dental pain practitioners, several clinical studies have shown it to be effective in treating craniofacial pain, especially when combined with stable occlusion. As far back as 1997, the National Institutes of Health issued a consensus statement affirming evidence that acupuncture is effective in relieving postoperative dental pain.

Maloney wants to add to the body of evidence. He is beginning a review of studies about the effectiveness of acupuncture in treating temporomandibular joint disorder and craniofacial pain. “I think that this review and other controlled clinical trials can produce the kind of evidence that may lead to wide-scale acceptance,” he says. –Michael Blanding

 

Migraines and Muscles

 

One of the things Egilius L.H. Spierings has learned over nearly 40 years of practice remains controversial in headache medicine—but it seems intuitive to anyone who has found that shoulder massage can ease a headache.

“People’s mouths drop open when I tell them that in the headache world, there is no attention being paid to the muscles,” says Spierings, a neurologist on the staff at the Tufts Craniofacial Pain Center.

Illustrations by Joanna Szachowska

Illustrations by Joanna Szachowska

About 5 percent of people suffer from daily headaches, according to a study Spierings published in the journal Headache in 2013. Among those, about half have migraine, the often-severe headache that can be accompanied by light sensitivity or seeing lights, increased sensitivity to sounds or smelling odors. The rest suffer from tension-type headache, characterized by milder, diffuse pain in the head and sometimes in the face.

While migraine may get more attention from headache experts, both types of headaches have perplexing origins. Tension headache is thought to be caused by a lack of sleep, stress, hunger, thirst, eye strain or strain on the muscles of the shoulders, head and neck, usually due to bad posture. (Think sitting at your desk all day.)

Migraine is a more baffling condition. What is known is that it occurs when blood vessels in the head dilate. Spierings doesn’t dispute that. But he’s certain that just as with tension headache, stress on the muscles in the neck, jaw and shoulders may also play a role, especially in people who have frequent or long-lasting migraine headaches. The more pain the person endures, the more likely she—and women suffer from migraine at about twice the rate as men do—is to store tension in those muscles.

It’s the musculature, he points out, that dentists treat when they fit patients with an appliance to ease jaw pain caused by nighttime clenching and grinding. Headaches often accompany these habits, and sometimes they are the first, if not only, daytime symptom.

The paralytic Botox, a long-acting muscle relaxant, is now used to treat chronic migraines—Spierings, a pharmacologist, participated as an investigator in one of the clinical trials that led to FDA approval of Botox as a headache remedy. “The pain is ultimately caused by the blood vessels widening,” he says. “But what drives the frequency, I think, is a muscular mechanism.” He says his findings that Botox alleviates migraine only among chronic sufferers support that conclusion.

In the quest for a more universal treatment for migraine, Spierings is among the researchers looking at targeting a chemical in the body called calcitonin gene-related peptide (CGRP) that is known to dilate blood vessels. Scientists have been able to block CGRP’s effects with a new class of drugs called anti-CGRP antibodies. The early results are promising. “It seems like a tremendous step forward,” he says. –Jacqueline Mitchell

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