NEW YORK—

New treatment advances can offer significant relief to the millions of Americans who suffer from chronic pain, but interventions can only be effective if physicians begin making more accurate diagnoses, specialists in pain management said here at an American Medical Association conference on pain last month. Conotoxins, for instance, are one new category of pain relievers that may help many patients, experts said. Proteins derived from the venom of sea snails, conotoxins are currently available only via pumps that are implanted in the epidural space. Conotoxins seem to alleviate most types of pain by stopping pain messages from reaching the brain, according to Nelson H. Hendler, M.D., clinical director of the Mensana Clinic in Baltimore, Md. But conotoxins or other treatment advances will work best only if pain is more accurately diagnosed, said Dr. Hendler, also an assistant professor of neurosurgery and psychiatry at Johns Hopkins University in Baltimore.

In a study conducted by Dr. Hendler and colleagues, the overall rate of inaccurate diagnoses ranged from 40% to 66.7% among 180 patients at Mensana who reported chronic pain. Other developments in the pipeline include a new laparoscopic surgical technique that could help effectively treat certain disc problems that cause chronic back pain. During the procedure, the surgeon enters the patient from the front and fuses a titanium plug in the disc space. The plug is then packed with bone and grows in place, Dr. Hendler explained. Not yet in widespread use, this procedure is less expensive than traditional surgery and has a two-day recovery time, compared with about three months for conventional fusion surgery, Dr. Hendler said.

For patients with severe, untreatable diseases, epidural stimulators—or wires implanted over the covering of the spinal cord accompanied by electrical stimulation delivered across the skin—are radical, but effective, Dr. Hendler said. Still, "it is so important to have a [proper] diagnosis, because without a diagnosis, you can’t analyze the problem" and treat the pain effectively, he said. Chronic pain is often misdiagnosed because physicians frequently rely on inaccurate tests, Dr. Hendler said. "A lot of doctors are using MRIs or CT scans to make a diagnosis instead of using clinical judgment," he noted. When it comes to diagnosing the cause of chronic pain, MRIs yield high rates of false-positives and false-negatives, and CT scans often miss problems among patients with chronic back pain, the Baltimore neurosurgeon said. In addition, physicians often favor anatomical tests over physiological tests even though physiological tests are more likely to identify chronic pain, he added.

And when physicians are unable to identify the cause of pain, they may suggest that the pain does not exist, he said. Fifty percent to 55% of patients at Dr. Hendler’s clinic are scheduled for future surgery because appropriate testing has pinpointed a correctable problem, he added. Barriers to effective pain treatment will be removed as new drugs and techniques with fewer side effects become available, said Phillip O. Bridenbaugh, M.D., professor and chairman of the department of anesthesia at the University of Cincinnati Medical Center in Ohio. Many patients are reluctant to report pain because they do not want to take painkillers for fear of addiction or other side effects, said Dr. Bridenbaugh, also the president of the American Society of Anesthesiologists.

"For many patients, the dream medication is one that relieves pain while leaving them alert with no side effects," he said. "But in reality, the best treatment is usually a combination of medications used in lower doses that reduce side effects."

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