Every year, about 1,500 new patients with head, face or neck pain go to the Tufts Craniofacial Pain Center at the School of Dental Medicine, according to Shuchi Dhadwal, the center’s interim director. One of the largest centers of its kind in the country, the Craniofacial Pain Center is dedicated to a holistic approach to pain management, according to their website. The most common problems patients come in with are temporomandibular disorder (TMD), which is pain in the jaw joint and surrounding areas, and related cervical spinal dysfunction or neck pain, according to Dr. George Maloney, clinical professor at the Dental Health School.
“Being a part of a multidisciplinary team can be very helpful when treating such patients with complex medical issues and chronic pain,” Dhadwal wrote to the Daily in an email. “Our team consists of [an] orofacial pain specialist, neurologist, psychologist and sleep medicine specialist.”
According to Maloney, this interdisciplinary approach is the driving force behind the center and allows doctors to comprehensively treat a patient.
“A holistic approach simply means treating the patient as a whole person,” Maloney told the Daily in an email. “In the case of pain management, this refers to devising a treatment plan that is targeted to the mechanisms of pain that are active in an individual patient.”
The patients who go to the Tufts center are looking for alternative methods of achieving pain relief without having to use opioid medication, which are commonly used to relieve pain but may not always be the best option, Maloney explained.
Pain management is a topic that is also being explored at the Tufts School of Medicine in the Pain Research, Education and Policy (PREP) Program. This is the only program in the nation that offers an intra-professional program solely focused on pain and its treatment, according to the website.
Carol Curtiss, an adjunct clinical instructor in the PREP program, stressed the significance of a holistic approach to treating pain.
“When tests do not show an abnormality, it doesn’t mean that there isn’t something wrong,” she wrote in an email to the Daily. “Pain is subjective — we can’t measure it with anything other than the person’s own report of the existence of pain and its intensity. We can further our understanding by completing a comprehensive assessment including physical exam, but it is often the patient’s own narrative that tells us the most.”
According to Curtiss, pain is a personal and subjective feeling, and therefore varies by each person, influenced by our upbringing and environment.
“Self-report from the person with the pain is the best way to understand it,” she said. “There isn’t an easy test, like taking a temperature for fever, to ‘see how much pain a person has.’ Anytime a symptom is subjective without objective data, our personal experiences, values, beliefs and biases intrude and doubt increases.”
Curtiss explained that the way people react to pain is different between individuals and families as well.
“Socially we are each raised to react to and respond to pain uniquely, and those social biases influence our perception of another person’s pain,” she said. “Many people in the United States value those stoicism, and tire quickly of hearing someone report persistent pain. Families ‘wear out’ and want to move on, while the person with pain wears out from the consequences of enduring relieved pain.”
One alternative method Maloney is exploring at the Craniofacial Center is acupuncture, a natural way to treat head and neck muscle pain. This includes electro-acupuncture, which attempts to stimulate pain inhibitory mechanisms that are naturally present in the human body. When inhibitory neuropeptides are released, they can reduce the patient’s experience of pain, Maloney explained.
“I believe acupuncture will become mainstream in the area of pain management,” he said. “I do not believe we should be attempting to use acupuncture for every human ailment. However, for pain management in general, and muscle pain in particular, there is evidence of treatment effectiveness. For muscles disorders like TMD, tension-type headache and chronic neck pain, acupuncture can be a safe and effective treatment that will be preferred by many patients.”
Maloney added that while many patients come to the center for acupuncture, some opt for it once they are there.
On March 14, Governor Charlie Baker signed into law a measure that places tighter state control on opioids to combat opioid addiction and substance abuse. The bill limits initial opioid prescriptions to a seven-day supply and requires practitioners to check a prescription monitoring program before prescribing the drugs. In addition, there are several exemptions to the bill, including that initial opioid prescriptions for chronic pain, cancer pain and palliative care can be for more than a seven-day supply.
While the bill is a good step in the direction towards addressing the opioid crisis, Curtiss pointed out that it can have negative impacts as well. Most insurers will only cover one prescription of a medication per month, so if the patient needs an additional prescription beyond seven days, it may be an out-of-pocket expense, she said.
“People with persistent pain are already stigmatized,” Curtiss said. “This bill has the potential to increase that stigma. I frequently hear patients report that their health care provider will no longer prescribe opioids for any reason to any patient.”
Curtiss explained the term “persistent pain” is being used to replace “chronic pain” to help decrease the stigma of persistent pain.
“Think of what the word ‘chronic’ conjures up- negative thoughts of complaining, being difficult…the change to persistent allows us to use a more value-neutral word to talk about pain that does not go away as expected,” she said.
About 100 million American adults are affected by chronic pain and cost the country about $600 billion each year, according to the U.S. Institute of Medicine, in a winter 2016 article by the Magazine of the Tufts University Dental Alumni Association.
“Medications alone are almost never the answer to treating pain of any kind,” Curtiss said. “Multi-modal plans of care work best.”