Martha’s Vineyard Hospital pioneers new path in pain management

Cheryl Kram, nurse manager at the Center for Pain Management, facilitates a telemedicine consult with Dr. Christopher Gilligan and a patient. — Heidi Wild

Opiates, the drugs designed to eliminate pain, have instead created pain and suffering for millions of addicted Americans and their loved ones. Again and again, a legal prescription for painkillers has been the rabbit hole to addiction. As the casualties from the national opiate crisis continue to mount, the medical community is working on ways to contain an epidemic that it largely helped to create.

At Martha’s Vineyard Hospital (MVH), a sea change in pain management has been quietly underway that is attracting national attention as a promising new approach.

The Martha’s Vineyard Hospital Center for Pain Management (CPM), started in September 2013, combines nonopioid injections and medications and telemedicine — video consultations with pain specialists from Massachusetts General Hospital (MGH) in Boston.

Nationwide, chronic pain affects over 100 million American adults and costs society between $500 billion and $635 billion annually, more than the cost of diabetes, heart disease, and cancer combined, according to the Institute of Medicine at the National Academy of Science. Back pain is now the leading cause of disability in Americans under 45 years old, according to the U.S. Department of Health and Human Services.

Remote areas like the Vineyard face a double whammy when it comes to treating chronic pain — they typically have some of the highest addiction rates and the fewest pain management specialists, who tend to practice in cities.

Promising signs

Dr. George Hanna, critical care and pain medicine specialist at MGH, and Cheryl Kram, nurse manager for the CPM, spoke with The Times last week about the success of the groundbreaking program at Martha’s Vineyard Hospital.

“For many decades there’s been a huge reliance on opioid analgesics, but here we’re offering other treatment strategies, injections, alternative medicines, physical therapy, even nerve stimulator devices,” Dr. Hanna said. “The number of patients we’re treating has grown threefold since we started. I think it’s a good sign that we’re doing the right thing. Patients see a big savings in time, energy, and cost of traveling to Boston. They felt confident about the confidentiality and the quality of the treatment they received.”

Dr. Hanna, dressed in scrubs and surgical booties, had just completed a lumbar epidural steroid injection. He would perform between 28 to 30 procedures over the next two days, which would include sacroiliac joint injection, ultrasound guided nerve block, facet joint injection, and radiofrequency treatment.

Initially, Dr. Hanna was the only MGH doctor making monthly trips to the Vineyard, but demand grew, and last year, Dr. Shiqian Shen from MGH began alternating monthly visits with Dr. Hanna.

When Ms. Kram was charged with building the CPM program, there were no models to follow, and telemedicine for pain management hadn’t been done. “There weren’t any pain management programs like this in the country,” she said. “It was one of those ‘you build it, they will come.’ Sometimes people can be kind of skeptical about seeing a doctor on a TV screen, but they usually end up saying, ‘That was pretty cool.’”

Two weeks ago, the American Medical Association (AMA) also endorsed telemedicine. At its annual meeting in Chicago on June 15, the AMA voted to update its ethics code to endorse “the diagnosis of patients through telemedicine,” as long as strict limits are observed. The new language recognizes that technological advances “offer new ways to deliver care.”

Telemedicine between MVH and Martha’s Vineyard is done via Vidyo, a highly secure videoconferencing program. It’s the same program the emergency room doctors at MVH have used to consult with doctors at MGH for years.

Treatment at the MVH Center for Pain Management focuses on attacking the source of the pain, not dulling the body’s ability to feel pain. “It may involve medication, like a muscle relaxant for spasmodic condition, or it may require a steroid injection or radiofrequency lesioning,” Ms. Kram said. “We never recommend narcotics. In addition to the risk of addiction, studies that show that narcotics actually make the pain worse. We look to treat the specific pain they’re having, and we almost always recommend physical therapy. It’s the best way for someone to see long-lasting benefit.”

Ms. Kram said the most frequently treated issue at the CPM is low back pain. “Low back pain is huge here,” she said. “This is a community where a lot of people work hard.”

A recently released study of the Martha’s Vineyard Hospital CPM in the Journal of Pain Medicine, “A Telemedicine Service for Pain Management,” showed a high degree of patient satisfaction with the program, and an embrace of telemedicine by Vineyarders.

According to the study, over the course of 13 months, 238 virtual telepain evaluations were performed (185 initial consultations and 53 follow-up visits). One hundred twenty-one onsite evaluations and procedures were conducted during the same period. Overall, surveyed patients gave the experience a 4.3 on a scale of 1 to 5.

“Telemedicine has made a lot of headway,” Dr. Hanna said. “Fifteen, 20 years ago it was used in neurology for stroke care. Pain is one of the newer areas to use telemedicine. This is the first study of its kind to measure patient satisfaction in pain management, and the results are very encouraging. It’s now one of the largest telemedicine pain management programs in the United States.”

Worth the wait

Last Tuesday, The Times spoke to several Islanders who have been treated at the Center for Pain Management. They were unanimous in their praise.

“I love it. They’re really so caring. It’s like ‘Cheers’; everybody knows your name,” Edgartown resident Audrey Harding said. Ms. Harding was a nurse for 50 years, and goes to the center for back pain, which is being treated with sacroIliac injections. “Before I went to the [MVH CPM] I was going off-Island for my injections, and it was getting to be a real drag. We’re so lucky to have this here.”

“I had a wonderful experience with Dr. Hanna; he was very attentive and very skilled,” Helen Anderson of Tisbury said. Ms. Anderson, also a former nurse, said her treatments for sciatica on her left side have been “very successful.”

“I couldn’t have had a more compassionate doctor,” Tisbury resident Jean Renear said, referring to Dr. Shiqian Shen. “Even my daughter said she’d never seen such a compassionate doctor. The nurses are also so knowledgeable. They keep calling me back, checking in on how I’m doing. It’s been a completely pleasant experience.”

Ms. Renear, 90, said the only downside is the long wait for the initial appointment. “It took a long time, but it was worth the wait. Once you get started, they really stay with you.”

“Right now we’re booking August and September,” Ms. Kram said. “If patients don’t want to wait, we can set up an appointment at the pain clinic at Mass. General. They can see a doctor in Boston and continue treatment down here.”

Starts with a referral

“The whole process starts when we get a referral from the primary-care physician,” Ms. Kram said. “We do not order prescriptions, we do not order tests. We make recommendations to the primary-care physician.”

After receiving the referral, Ms. Kram or nurse Pamela Thomas schedules a “televisit” with an MGH pain specialist. Prior to the televisit, the nurse takes the patient’s vital signs and updates his or her medication list. The information is shared electronically with the doctor. Once the doctor is online, the nurse performs an exam, which can involve checking reflexes and range of motion. Before the televisit is over, the doctor will make recommendations, which will go to the primary-care physician. “Often he will recommend medication and physical therapy,” Ms. Kram said. “Only about half of the patients are scheduled for a procedure.”

After the televisit, Ms. Kram or Ms. Thomas will also follow up with the patient and his or her primary-care physician, and make sure all doctors are constantly updated.

Ms. Kram said patients who are on long-term prescription painkillers are sometimes reluctant to go to the CPM for fear of having their drugs taken away. “We don’t take anyone’s medication away,” she said. “Obviously our goal is to get the patient off of opioids, and we hope by addressing the pain, they’ll want to stop taking them. People don’t realize the damage opiates can do over the long run.”

Ms. Kram said that it’s important for patients to have realistic goals when they enter treatment. “The goal is pain management, not pain elimination,” she said. “We do our best to set realistic expectations. We don’t cure pain, we manage pain. We look at quality of life — helping the patient get back to a level of functioning that’s within reach. I was just talking to someone who had a procedure last month. He wasn’t pain-free. He said his pain was only better by 20 percent, but still that allowed him to play tennis again, which he hadn’t been able to do in a long time. That’s a big win. We can’t fix your arthritis, but we can get you functioning again.”

Dr. Hanna expects the on-Island treatment days for MGH doctors will grow to four or five days a month. In August, he will leave the program to begin a new practice in New Jersey, but he’s confident Islanders will receive top-notch care. “We have physicians at Mass. General who are chomping at the bit to take part in this program,” he said. “These are some of the foremost pain doctors in the world. People here will be in good hands.”