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Archive December 2019 XX, No. 12

Chronic Pain in the Era of the Opioid Crisis

Image-guided interventions like epidural steroid injections, radiofrequency ablation and spinal cord stimulators are in high demand.

Jared Bilski


Johns Hopkins Medicine
SAFE AND STEADY With virtually all pain interventions being performed using some type of image guidance — whether it's X-ray, ultrasound or even CT guidance — the procedures are safe and easy to perform in an outpatient setting.

In the absence of antibiotic alternatives, physicians in the early 1900s had no choice but to treat every infection with penicillin. Chronic pain went through a similar "penicillin phase." No matter the type of back pain — radicular, axial or arthritic — patients got an epidural steroid injection (and perhaps a recurring script for opioid painkillers). But with the advent of treatments like radiofrequency ablation and spinal cord stimulators, pain management is shedding its penicillin phase.

"Pain management is just starting to come out of that one-size-fits-all approach to treating patients," says neurologist Vladimir N. Kramskiy, MD, the director of the Ambulatory Recuperative Pain Medicine Program at the Hospital for Special Surgery in New York City.

With facilities pressed to find opioid-free ways to manage chronic pain, the timing of these promising interventions couldn't be better.

1. Epidural steroid injections. Steroid injections in the epidural space around the spinal cord to reduce the inflammation of a problematic nerve root remains chronic pain medicine's bread-and-butter procedure. It's quick and effective (for the right patients). Roughly half of the 5,000 injections administered each year at the Montefiore Multidisciplinary Pain Program are epidurals, says Naum Shaparin, MD, the program's director at the Montefiore Medical Center in the Bronx, N.Y.

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