Should SCS be higher in the treatment algorithm for chronic pain?

[drusso]

Why Are Devices the Last-in-Line Treatment for Chronic Pain?

Is Roger Chou justified believing this?

"Roger Chou, MD, a CDC guidelines co-author and professor of medicine in the Internal Medicine and Geriatrics Division at Oregon Health & Science University, argues the risks outweigh the benefits. "Spinal cord stimulators and related modalities may have some role in management of chronic pain, but like other interventional procedures and surgery, their role is limited," Dr. Chou said in a written statement."

Or, does David Povenzano, MD, have a better grasp of the ground truth?

"By time someone gets to the pain doctor, on average they've suffered for five to seven years and have $50,000 in medical expenses," said Povenzano. "If we could employ SCS earlier in appropriately selected patients, we could provide more effective treatment. These devices should be moved up in the treatment algorithm, before opioids."

Dr. David Provenzano Bio | Dr. David Provenzano, MD

Roger Chou, M.D.

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[Disciple]

As it goes higher up in the hierarchy, coverage criteria needs to be tightened up.

 

[244913]

Why Are Devices the Last-in-Line Treatment for Chronic Pain?

Is Roger Chou justified believing this?

"Roger Chou, MD, a CDC guidelines co-author and professor of medicine in the Internal Medicine and Geriatrics Division at Oregon Health & Science University, argues the risks outweigh the benefits. "Spinal cord stimulators and related modalities may have some role in management of chronic pain, but like other interventional procedures and surgery, their role is limited," Dr. Chou said in a written statement."

Or, does David Povenzano, MD, have a better grasp of the ground truth?

"By time someone gets to the pain doctor, on average they've suffered for five to seven years and have $50,000 in medical expenses," said Povenzano. "If we could employ SCS earlier in appropriately selected patients, we could provide more effective treatment. These devices should be moved up in the treatment algorithm, before opioids."

Dr. David Provenzano Bio | Dr. David Provenzano, MD

Roger Chou, M.D.

most candidates won't want stim if opioids aren't on the menu

 

[Disciple]

most candidates won't want stim if opioids aren't on the menu

And therefore, maybe stim utilization goes down, fewer people get started on opioids.

 

[emd123]

Since using Abbott burst DR lately, I've been so blown away with the results, I think stim probably should be pushed higher up the list of options. More and more, I'm seeing home run results, in people I didn't think would necessarily even go to implant. People just love this system.

I don't take a penny from them. Not even food.

 

[244913]

Since using Abbott burst DR lately, I've been so blown away with the results, I think stim probably should be pushed higher up the list of options. More and more, I'm seeing home run results, in people I didn't think would necessarily even go to implant. People just love this system.

I don't take a penny from them. Not even food.

Burst is intriguing. What kind of patients are you trialling in general? Do you implant as well or just do the trials? I've mostly been doing Nevro with some tonic stim thrown in but may have to give burst a shot.

 

[drusso]

Should patients fail SCS before being offered chronic opioids OR fail chronic opioids before being offered SCS?

 

[drusso]

Since using Abbott burst DR lately, I've been so blown away with the results, I think stim probably should be pushed higher up the list of options. More and more, I'm seeing home run results, in people I didn't think would necessarily even go to implant. People just love this system.

I don't take a penny from them. Not even food.

Ditto. Abbott is on to something with the BurstDR. I think it creates a reversible "functional lobotomy" type of treatment response.

 

[Disciple]

Should patients fail SCS before being offered chronic opioids OR fail chronic opioids before being offered SCS?

Tough question.

You definitely don't want patients to be forced to try chronic opioids before having access to SCS for proper indications.

On the other hand, I wouldn't want to be forced to undergo a SCS trial. Especially cervical. Who's to say long-term tramadol, or 1-2 Norco/day for appropriate patients wouldn't be better is some cases.

 

[hyperalgesia]

Should patients fail SCS before being offered chronic opioids OR fail chronic opioids before being offered SCS?

If SCS is a serious consideration, I would definitely rather try that than continuous opioids. But I don't think I've ever had a situation that was so close. Usually one of these is not really indicated.

 

[Ducttape]

Should patients fail SCS before being offered chronic opioids OR fail chronic opioids before being offered SCS?

IMO those two should be mutually exclusive evaluations. In many (possibly all) cases, opioids should not be offered regardless of SCS status.

The supposition that one would offer opioids if one fails SCS will lead some to offer such therapy inappropriately. (“Darn, mrs. X failed stim trial, now like I promised, I’ll have to write for her Insys”)

 

[emd123]

Burst is intriguing. What kind of patients are you trialling in general? Do you implant as well or just do the trials? I've mostly been doing Nevro with some tonic stim thrown in but may have to give burst a shot.

Right now, I'm doing only trials. Sending implants to two guys I trust, an ortho spine and a neurosurgeon, simply for convenience and nothing else.

I generally stick to the usual lumbar PLS, chronic radicular pain that can't get surgery, CRPS, neuropathic pain, etc. Recently I've trialed a guy with horrible neuropathy pain from a destroyed charcot foot. Great results, and it was his last shot. Also, just trialed a lady who similarly has a destroyed, degenerated foot and ankle from fractures and OA (maybe with a touch of CRPS) who's so bad off her surgeons have said her only options were fusion which probably wouldn't take, or amputation. She didn't like those options so we did a trial. I didn't have high hopes for this one either. She got 90% relief on the trial (hasn't gotten implant, yet).

This is 100% anecdotal, but the results I'm seeing from this new system are patients "loving it" as opposed to older systems where they just "liked it." I also recently reopened and did a couple trials with Nevro and Medtronic (who I used a lot in fellowship and immediately after fellowship) to see if maybe all the systems have improved similarly, as I don't like to be loyal or locked in to one company, and I sure as hell don't speak for any of them or take money from them, other than a sub sandwich from time to time, which I'd honestly rather get on my own and eat by myself without having to talk about work stuff. Those Nevro and Medtronic trials were okay, but not great. I had super high hopes for nevro, but I just wasn't blown away, and not being able to switch over to a paresthesia generating program, even temporarily to dial coverage in, I don't like. Haven't trialed with Boston in a long time. Maybe I should.

Considering I don't do my own implants, I have absolutely zero financial incentive to steer trails that otherwise would be on the fence, to implantation. None. But I'm on a run of 100% trial to implant for a helluva a long time now, with Abbott/Burst DR. Months, maybe a year. I don't know the numbers exactly but its in the dozens. My only failed trials in recent memory were when I opened up an tried Nevro and Medtronic again. And I realize my trial to implant ratio absolutely will not stay at 100% forever, with any system, but it definitely feels like they're on to something here, that the other companies need to copy.

My advice to everyone is to try all the companies and go with what you like best, and don't be beholden to any company. If someone else reinvents a better mouse trap, I'll also switch to them immediately, with no remorse. I much prefer that freedom, over taking speaking money from a company.

 

[emd123]

Should patients fail SCS before being offered chronic opioids OR fail chronic opioids before being offered SCS?

In my humble opinion, stim should be tried first. In reality, not very many people come to me and get a stim that aren't either on, or haven't at least tried and failed opiates, since opiates are so plentiful. I do have several people with stimulators who are not on opiates, but it's not a ton.

That being said, I guaran-****-ing-tee you, that if you take 10,000 people with chronic pain (naive to opiates and stim) and give them a spinal cord stimulator, vs 10,000 with chronic pain and start them down the road of chronic daily opiates, the stim group would be a much better off, happier, more functional group, than the chronic daily opaite group.

If it was me, and this is hard to be certain, because it's not me, and I don't have chronic unrelenting pain, I would much rather someone give me a spinal cord stimulator, than a lifetime of chronic daily opiates. Again, easy to say, because I'm not the one with the pain, but based on what I see, that's a better life, IF one has the choice...If.

 

[DOctorJay]

most candidates won't want stim if opioids aren't on the menu

this is not my experience at all. I typically wean people off before a trial.

 

[Ducttape]

OTOH, my experience with Burst is so so, and I have had a great run of success with Nevro.

 

[lobelsteve]

SCS should be offered in early 20's, before the pain begins.

 

[244913]

SCS should be offered in early 20's, before the pain begins.

When you register to vote, two 64 contact leads

 

[244913]

In my humble opinion, stim should be tried first. In reality, not very many people come to me and get a stim that aren't either on, or haven't at least tried and failed opiates, since opiates are so plentiful. I do have several people with stimulators who are not on opiates, but it's not a ton.

That being said, I guaran-****-ing-tee you, that if you take 10,000 people with chronic pain (naive to opiates and stim) and give them a spinal cord stimulator, vs 10,000 with chronic pain and start them down the road of chronic daily opiates, the stim group would be a much better off, happier, more functional group, than the chronic daily opaite group.

If it was me, and this is hard to be certain, because it's not me, and I don't have chronic unrelenting pain, I would much rather someone give me a spinal cord stimulator, than a lifetime of chronic daily opiates. Again, easy to say, because I'm not the one with the pain, but based on what I see, that's a better life, IF one has the choice...If.

I agree with Duct. In my opinion patients on mod-high dose chronic opioids rarely are good stim candidates and usually resist weaning. Opioid naive patients who are interested in SCS is a relatively small group but they are out there, and they do the best.

I do my own implants. 85% of my stim patients are opioid naive. 1 is on tramadol. One upcoming implant takes 1 percocet 5 daily and I will see if we can get this off.

SCS is expensive though, implants are not risk free. I have a hard time justifying from a cost/risk perspective, choosing to go down the SCS road if someone is stable and functional on a little norco or tramadol.

Sort of sounds like the argument I heard at a medtronic conference once where the IPM guy was advocating taking anyone over 70 yo on 1-2 norco a day and putting a pump in.

- ex 61N

 

[DOctorJay]

I've trialed a couple patients with Burst who I ended up switching to Nevro because the patients were not happy with their axial back coverage. The Nevro re-trials did go on to implant. Other than that I'm very happy with Burst.

I use Abbott, Nevro, and Medtronic

 

[emd123]

SCS should be offered in early 20's, before the pain begins.

All must be simultaneously implanted with naltrexone pumps

 

[Disciple]

I agree with Duct. In my opinion patients on mod-high dose chronic opioids rarely are good stim candidates and usually resist weaning. Opioid naive patients who are interested in SCS is a relatively small group but they are out there, and they do the best.

Sounds like a win for everybody, except maybe the stim company.

Change the algorithm so it's accessible earlier in the treatment course, but tighten-up the indications.

Only a small percentage of patients will want it, so utilization goes down. Those patients are likely to be better candidates--outcomes improve.

 

[Disciple]

I've trialed a couple patients with Burst who I ended up switching to Nevro because the patients were not happy with their axial back coverage. The Nevro re-trials did go on to implant. Other than that I'm very happy with Burst.

I use Abbott, Nevro, and Medtronic

Meeting with the Abbott rep next week.

So, what's the overall take home message at this point?

Nevro--Paresthesia free and good axial back coverage, Burst Stim overall more effective for neuropathic pain?

 

[Timeoutofmind]

I've trialed a couple patients with Burst who I ended up switching to Nevro because the patients were not happy with their axial back coverage. The Nevro re-trials did go on to implant. Other than that I'm very happy with Burst.

I use Abbott, Nevro, and Medtronic

How did u go about it?
Two totally different trials, one with each company?

 

[DOctorJay]

2 separate trials different dates


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[Tapspatellas]

Right now, I'm doing only trials. Sending implants to two guys I trust, an ortho spine and a neurosurgeon, simply for convenience and nothing else.

I generally stick to the usual lumbar PLS, chronic radicular pain that can't get surgery, CRPS, neuropathic pain, etc. Recently I've trialed a guy with horrible neuropathy pain from a destroyed charcot foot. Great results, and it was his last shot. Also, just trialed a lady who similarly has a destroyed, degenerated foot and ankle from fractures and OA (maybe with a touch of CRPS) who's so bad off her surgeons have said her only options were fusion which probably wouldn't take, or amputation. She didn't like those options so we did a trial. I didn't have high hopes for this one either. She got 90% relief on the trial (hasn't gotten implant, yet).

This is 100% anecdotal, but the results I'm seeing from this new system are patients "loving it" as opposed to older systems where they just "liked it." I also recently reopened and did a couple trials with Nevro and Medtronic (who I used a lot in fellowship and immediately after fellowship) to see if maybe all the systems have improved similarly, as I don't like to be loyal or locked in to one company, and I sure as hell don't speak for any of them or take money from them, other than a sub sandwich from time to time, which I'd honestly rather get on my own and eat by myself without having to talk about work stuff. Those Nevro and Medtronic trials were okay, but not great. I had super high hopes for nevro, but I just wasn't blown away, and not being able to switch over to a paresthesia generating program, even temporarily to dial coverage in, I don't like. Haven't trialed with Boston in a long time. Maybe I should.

Considering I don't do my own implants, I have absolutely zero financial incentive to steer trails that otherwise would be on the fence, to implantation. None. But I'm on a run of 100% trial to implant for a helluva a long time now, with Abbott/Burst DR. Months, maybe a year. I don't know the numbers exactly but its in the dozens. My only failed trials in recent memory were when I opened up an tried Nevro and Medtronic again. And I realize my trial to implant ratio absolutely will not stay at 100% forever, with any system, but it definitely feels like they're on to something here, that the other companies need to copy.

My advice to everyone is to try all the companies and go with what you like best, and don't be beholden to any company. If someone else reinvents a better mouse trap, I'll also switch to them immediately, with no remorse. I much prefer that freedom, over taking speaking money from a company.

Boston wavewriter has been amazing thus far. Revisit if given the opportunity. Could OMG a trial of another brand too.

 

[Aether2000]

Increased utilization of SCS will bring on much more stringent insurance company restrictions within the next 18 months. It is all about money- SCS costs the insurers hundreds of times more both short and long term compared to medical management, esp. NSAIDs + opioids

 

[Biohazard685]

Increased utilization of SCS will bring on much more stringent insurance company restrictions within the next 18 months. It is all about money- SCS costs the insurers hundreds of times more both short and long term compared to medical management, esp. NSAIDs + opioids

Would you say the insurance companies are complicit in perpetuating the "opioid epidemic"?

 

[Aether2000]

There is absolutely no doubt they are complicit. They require high levels of evidence for most of the therapies we employ, but not for opioids, that have for a long period of time, been relatively cheap. Doctors prescribing 10-15 Norco per day for a patient were left alone by insurers, but those prescribing oxycontin 30mg TID (the same MED) required preauthorization and had quantity limits. Therefore, it is all about money, not about quality of care. Insurers really don't care if an expensive therapy works or not- they will raise the bar of proof of effectiveness for a particular therapy they find financially objectionable until the therapy can no longer meet their ever escalating standard, then they have the audacity to publish a medical policy that finds such therapy to be "investigational".

 

[Painted]

Insurers really don't care if an expensive therapy works or not- they will raise the bar of proof of effectiveness for a particular therapy they find financially objectionable until the therapy can no longer meet their ever escalating standard, then they have the audacity to publish a medical policy that finds such therapy to be "investigational"

SI RFA is “experimental” now by some insurances.

 

[Ducttape]

er, "some insurances" includes Medicare and has been deemed experimental by Medicare for over 5 years now.

 

[244913]

Increased utilization of SCS will bring on much more stringent insurance company restrictions within the next 18 months. It is all about money- SCS costs the insurers hundreds of times more both short and long term compared to medical management, esp. NSAIDs + opioids

Agree 100%. If the IPM industrial complex tries to use the opioid epidemic as a rationale for over-utilizing SCS it will be taken away. SCS may have some proven cost savings compared to repeat fusion...but not a couple of norco a day as you point out

- ex 61N

 

[Nate103]

I think SCS should be higher up in the algorithm, but with that, it would also be nice to have a trial period of longer than 1 week. Given the new paresthesia-free or minimal paresthesia therapies on the market starting with Nevro but now including Burst, and versions from Medtronic and Boston Scientific as well, it can take longer for patients to get used to the therapy, it's more subtle than "OK, my burning pain is replaced with tingling, put in the perm." If paresthesia-free can take 2-3 days for the therapy with trial to really kick in, it would be beneficial to have a longer trial. Especially if with paresthesia-free there's more chance of patients feeling discomfort from the tuohy puncture needed to place the lead, they may confound that with improvement of their pain. Obviously there's issues with infection, patients not being able to shower, lead migration with a longer trial period, etc.

 

[Aether2000]

Longer trials are frequently used in some European countries by tunneling the lead laterally and covering with tegaderm attached with benzoin to the skin. Showering is possible.

 

[Biohazard685]

I think SCS should be higher up in the algorithm, but with that, it would also be nice to have a trial period of longer than 1 week. Given the new paresthesia-free or minimal paresthesia therapies on the market starting with Nevro but now including Burst, and versions from Medtronic and Boston Scientific as well, it can take longer for patients to get used to the therapy, it's more subtle than "OK, my burning pain is replaced with tingling, put in the perm." If paresthesia-free can take 2-3 days for the therapy with trial to really kick in, it would be beneficial to have a longer trial. Especially if with paresthesia-free there's more chance of patients feeling discomfort from the tuohy puncture needed to place the lead, they may confound that with improvement of their pain. Obviously there's issues with infection, patients not being able to shower, lead migration with a longer trial period, etc.

We would extend trials during fellowship all the time.

We would also liberally switch to other companies if they offered a different waveform.