Pain, your body’s way of telling you that something is wrong or damage is imminent, is an essential part of life. But what happens if the pain never goes away? Chronic pain burdens the lives of people from all walks of life and of all ages, ruining their sunniest days and disturbing their deepest sleep. Living with chronic pain can easily become a life of chronic pain, but it doesn’t have to be that way.  

SRQ: How common is the problem of chronic pain and how do you separate it from acute pain?  Dr. Eugene Pereira, Sarasota Memorial Hospital: Chronic pain is becoming a well-recognized problem. It has been classified as a catastrophe waiting to happen by the Institute of Medicine and estimated costs are more than the cost of heart disease, cancer and diabetes combined. A conservative figure is in the $55 billion range and that was two years ago. Acute pain and chronic pain can be differentiated by time. Usually a three-month period from the onset of pain will then cross over into a chronic pain situation. Studies have shown that at the molecular, cellular level there are changes in the nervous system around that time that turn acute pain into chronic. Dr. Fabian Ramos, Pain Relief Center of Sarasota: Anything beyond what you expect to be acute could also potentially be considered chronic pain. In our community, due to the nature of the age bracket in our community, chronic pain can be very prevalent and is devastating for the families.

Do we know what causes chronic pain and why nerves don’t desensitize over time?  Dr. Raymon Priewe, Pain Medicine Institute: Yes—a lot of studies have shown the neuroendocrine changes and changes that occur in brain tissue and nervous tissue over time that are chronically stimulated in those states become a chronic pain situation. There are multiple chemical mediators that will continue this endless loop of pain. We look at those neuromodulators or chemicals and try to regulate and control those. When people think of pain, they almost immediately jump to opioids, which is sometimes more of a problem than a solution. There are many other medications that can be used that will reduce that chronic pain state. Some of them are anti-epileptic drugs, drugs that are normally used to treat seizures, or antidepressants. There’s a whole host of neuromodulators that can be utilized.

What goes into the initial pain evaluation when a patient comes to see you? Pereira: The ideal consult is a patient who has had an evaluation by their primary or referring provider. A patient would have had a workup for organic, anatomic, pathologic causes of their condition. The results are there and everything that could be done to fix it has been done. When the patient comes in we do a detailed interview so we can understand the whole situation rather than treat it piecemeal. Ramos: There are complex situations in a patient who has suffered pain for a long time. Our brains have what is called plasticity. We facilitate the pathway of pain by previous pain, so after a certain amount of time, that pain is reaching faster, easier through the same pathway, and a pain that might not have been as intense for a person at the beginning may grow more intense. So we have the diagnoses, the time, the complexity of that pain and how the person is now and an array of psychological and personal problems that come with it.


What are some things that the average person can do at home to deal with chronic pain, whether it’s preventative or palliative?  Pereira: Prevention is better than cure. The life we choose to live in our younger days will dictate the outcome of comfort or discomfort as the body ages. Keeping your weight under control, maintaining an active lifestyle of moderate exercise (no CrossFit or extremes) and healthy sleep patterns. All these will go a long way in preventing chronic-pain states later on in life. Ramos: The importance of prevention is also to identify genetic and family patterns, and knowing that if you have family history of degeneration, such as in the spine, for example, then you must avoid obesity. The epidemic that we see now with obesity is causing tremendous amount of problems at a younger age in the degeneration of our frame. Priewe: In palliative care, we want to identify what the pain generators are. There are various modalities that can be utilized to diminish or entirely make that pain go away. Some are procedural in nature—various nerve blocks, radio frequency lesioning of nerves and neurolysis, which is destruction of nerves either through a radio frequency method or chemicals.

 How often do you see a patient with chronic pain? How often do you feel they should be seen?  Ramos: As needed. Each case is an individual. We see patients who suffer chronic pain that relapses very infrequently and they are able to go along with their lives with adjustments. There are other patients who need much closer monitoring. It really is an individual-based decision.

For a patient with chronic pain, what treatment options are available and how do you as doctors decide which path to take?  Priewe: There are multiple factors that will enhance a person’s pain. It’s not just the local area of pain, but the outside inputs - social stressors, financial stressors, psychological stressors - and this is why pain medicine is multi-disciplinary. There is no one case that is treated in exactly the same way, and these types of modalities are needed to help treat the patient, whether it be a psychiatrist or a neurologist, a rheumatologist, we draw that all into the matrix. Pereira: Just like a diabetic needs to be seen by a kidney doctor, to make sure the kidneys are functioning, or an ophthalmologist, to make sure the eyes are not getting cataracts or glaucoma, the pain patient has to go through a similar spectrum. In most cases, they have to be encouraged to maintain their weight or lose it, so they need a dietary consult. They need to see a physical therapist for supervised exercise and a psychologist or psychiatrist to deal with depression that’s common with people who are suddenly rendered immobile. We need a multidisciplinary team. Ramos: And it can be so wide in the early spectrum, from a more aggressive surgery to a very preventative treatment, for example putting railings on a person’s home, depending on the situation.

How often do you find yourself needing to prescribe narcotic drugs to treat chronic pain?  Priewe: Narcotics are largely overprescribed, and partly that’s cultural. The United States represents approximately 4 percent of the total world’s population, yet we consume 98 percent of the world’s narcotics. Narcotics have an immediate effect, and in our society we’re used to immediacy. Many times patients want something to be done immediately. Some of these problems, especially if they are chronic situations, will require long-term complex therapy. Pereira: The narcotic prescription programs in this country mirror the culture and conditions of the country. Unfortunately, the trend of consumption has increased again, opioids have been misused and the people that mentioned it was safe have retracted their statements. At the molecular level in the brain, opioids stop pain by blocking pathways and attaching to receptors to prevent the transmission of the awareness of pain. But they are also found to release a chemical that worsens the very neuropathic pain state that most people with chronic pain have. A rough analogy would be trying to douse the fire with gasoline. Priewe: Hyperalgesia. Which very simply means that more opioids cause more pain. I’ve had patients who were clearly opioid-hyperalgesic. The drugs were actually causing their pain. Once we took away 90-95 percent of their opioids, their pain state improved.

What are the consequences of long-term use of these narcotics and opioids? Is it true that people will need increasing doses over time?  Priewe: It can be. Although opioid use does not escalate if the pain is well controlled. With conjunctive agents or therapies, opioid use remains the same or may actually go down. Long-term, we do see some problems with habituation, which is not addiction. It has just become a routine for them. Addiction is a bio,-psycho- and social phenomenon where a patient will actually go through severe problems such as withdrawal if they do not receive that substance.

How often is surgery necessary to alleviate the pain?  Ramos: It’s very prevalent. We try to avoid it, the patient tries to avoid it, but if it’s needed, it’s needed. There has to be a clear gain. Surgery doesn’t come with a guarantee and no surgeon, especially treating degenerative medical problems, will guarantee an outcome. The patient has to face that. Priewe: If someone has a degenerated hip or knee, it’s probably better to replace that hip or knee or have a surgical procedure than to treat the pain continuously with medications. On the other hand, someone who’s had five back surgeries is probably not going to benefit from a sixth back surgery at that point. There is a point when you have to realize that there are failed surgery syndromes.

Do you integrate alternative or complementary therapies into your pain treatment regimens, like acupuncture, meditation, massage or biofeedback?  Pereira: Pain psychologists exist within the system that practice biofeedback, muscle relaxation, light therapy and other complementary pain therapies of that regard. Acupuncture is slowly coming to the mainstream, though limited data exists about the long-term benefits of acupuncture. Yoga is espoused as a means of keeping the body limber and flexible, which is 180-degree turn from lying up in bed. Ramos: Physical therapy is a very important part of a chronic pain program. Psychological programs as well, not because the patient necessarily has a psychologically driven pain, but because chronic pain has an impact on the behavior of the patient and their family members. They need help with how to cope with it. Caroline Michael, Sarasota Memorial Hospital: Though the challenge for patients is cost, they don’t always have these complementary therapies paid for. They may not have mental health benefits. Their insurance company may not recognize massage therapy. There are many that do, as they become more mainstream, but if they don’t have the money to pay for them, that’s their challenge. Priewe: This is a huge problem. Some patient’s financial resources preclude any other therapy and medications. It’s unfortunate in those cases that you’re limited to almost strictly pharmacologic treatment. But there again lies the problem. Some of the medications that are more useful than opioids cost a lot of money. Every day I have a stack of denials from the insurance companies that will not pay for medication. They’ll pay for the opioids, but they won’t pay for this other one. You have to go through step therapy. You have to fail five or six agents and to get to that level it’s very costly, not only in money, but in time.

How do you define successful pain management?  Pereira: I ask my patients to name a list of things that they want to do but cannot because of the pain. If they cannot go to their mailbox and pick up the mail, or they cannot play with their grandkids or walk their dog,  those are all benchmarks that I would ascertain in the early stages of their treatment, and then afterwards try to get them to a better state, so that they can actively participate. There are patients who say the pain is a 7 out of 10. If you give them opioids and it goes down to 6 out of 10, we’ve really not achieved a meaningful therapeutic pain reduction. If the opioids are helping but now they have to take three other medications to mitigate the side effects of it, then you have to look at switching the opioid around. You have to make sure you’re not robbing Peter to pay Paul. Priewe: The one factor that we focus on: is the quality of their life improved? Are they able to do things they couldn’t do before? Are they able to have interactions on a more normal basis? Are they able now to have employment or other activities that may be helpful? That’s a successful outcome there.

Have there been any recent breakthroughs of note in the field of pain management that give you hope for the future, or get you excited for the possibilities in your field? Ramos: Stem cell regeneration could be used in the near future. The development of better implantable techniques and devices to manipulate the pain signal and the perception of pain in the brain are continuing to evolve. Hopefully, we’ll continue to improve the opioid itself. The inventory is very old, and it’s very imperfect because it works in the pain receptors but it works also in an array of other receptors we don’t want. Priewe: One of the most exciting areas in pain medicine right now is the use of neuromodulatory techniques to eliminate pain. One is transcranial magnetic therapy, where we can actually alter the activity of nerve cells and neurons in the brain and modulate the perception of pain. These are exciting new areas and hold a lot of promise. Pereira: They are doing genetic testing now to tailor medication therapies to individual patients. It’s in the very early stages, but there have been strong attempts.


How do you all feel about the use of medicinal marijuana for pain management? Ramos: As a pain doctor and as a physician, I want my patients to get better, and I’m absolutely open to medical-based research to help patients. For example, there’s a pediatrics seizure disease that’s being helped by the use of one strain of marijuana. Nobody’s talking about how it has a very minimal amount of the intoxicating THC. Priewe: There are 27 active ingredients or more in the typical marijuana plant, and we have to look at what those chemicals are and that’s the basis for prescribing. A lot of this is almost a fallacious issue - the medication has been out for 20 years. It’s in pill form and it’s called Marinol or Dronabinol, which we’re indicated to write for cancer patients. It doesn’t have the bad side effects of regular marijuana such as psychosis or euphoria. If you look at the populations in all the other states, it’s less than 5 percent of people with conditions like HIV or failed surgery syndromes where you prescribe so-called medical marijuana. Now we open up a whole box of things. Do we want a larger supply of these kinds of things out on the streets, in the schools? Pereira: As a society we have already shot our memory and we are basically repeating the past, with regards to legislation making alcohol legal or illegal, and the consequences of that. Alcohol is a much bigger problem in this country than most would care to accept—the amount of fatalities, disease and death, the amount of family and social structure breakdown all due to alcohol consumption. Now that alcohol is legal, all you see is The Captain and pink and green liquids sold in different flavors to make it more palatable to people who don’t really want to have it. Marijuana is going the same way. We are trying to glorify it as a medical situation, but more likely than not you can expect to see a lot of turmoil if some form of legalization happens. It is a very dicey razor’s edge that we’re walking on. 



Raymon D. Priewe, M.D. DABA, DABPM, DAAPM; Fellowship Trained in Pain Medicine, Medical Director, Pain Medicine Institute. As medical director of the Pain Medicine Institute, Dr. Raymon D. Priewe, D.O. has a long career at the forefront of pain management. After completing his residency in anesthesiology at the University of Miami, he completed his fellowship at the University of South Florida.941-758-7300.


Eugene Pereira, M.D., Pain Medicine Program of Sarasota Memorial Hospital, St. John’s Medical College, Bangalore, India. Internship at Maimonides Medical Center, Brooklyn, NY. Residency West Virginia University Hospital, Morgantown, WV. Licensed Anesthesiology/Pain Medicine. 941-917-9000.

Fabian Ramos, M.D.,  Director, Pain Relief Center of Sarasota, Dr. Ramos is trained to plan for and provide anesthesia locally, regionally or generally, and reduce the amount of pain felt during operations and similar procedures; Dr. Ramos is also trained to manage chronic pain. 941-708-9555.

Caroline Michael, R.N.,Director, Pain Medicine Program of Sarasota Memorial Hospital, 941-917-9000.