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FINDING THE SOURCE OF THE PAIN Unique to Western Reserve Hospital and to Dr. Narouze is the use of ultrasound to pinpoint the source of pain and treat it. "Ultrasound is an inexpensive mode of imaging; it can be done at the bedside, and it's dynamic," Dr. Narouze says. "The patient can move the joint while you examine the joint and the tendons and muscles around the joint with ultrasound. With X-ray and MRI, you cannot put the joint or muscle into range of motion and examine it. So ultrasound is an unbelievable advantage." He also performs interventions, such as nerve blocks, with ultrasound to determine the cause of pain. Traditionally, nerve blocks are performed with X-ray, which emits radiation. With ultrasound there's no radiation, so it's safer and can be used with pregnant women. Another benefit of ultra- sound is its high-resolution images, which are better than X-ray and even better than MRI. And ultrasound is less expensive than X-ray and much less expensive than MRI. "We use diagnostic nerve blocks to deter- mine the cause of back pain. Is there nerve impingement? If so, what's the source? The spine? The disk? Or is the impinge- ment distal? If you numb the nerve and the patient gets pain relief, then the disk that's sitting on that nerve is causing the pain," Dr. Narouze explains. He points out that MRI sometimes shows two or three bad disks, but only one of those disks may be causing the pain. "So if you numb only one nerve root at one level, you pinpoint the pain at this level, and you do the surgery at this level," Dr. Narouze says. "It's outpatient surgery, and the patient goes home the same day." In addition to back pain, ultrasound- guided nerve blocks can be used to pinpoint the cause of head and neck pain. Dr. Narouze literally wrote the book on this topic two years ago. (It's entitled Interventional Management of Head and Face Pain: Nerve Blocks and Beyond.) He also holds two patents for ultrasound-guided delivery of therapy devices. "So again, you try intervention for head- ache pain before considering putting the patient on a strong opioid," he says. "Like the CDC guidelines recommend, you try A, B, and C before trying Z." While he applauds the guidelines, he feels that they don't go far enough. They failed to address a few issues, namely, physician education, patient education and research. They also failed to address the question of when to refer a patient to a pain medicine specialist. "The answer, quite simply, is when the primary care physician is not comfort- able treating a patient ... when the patient has persistent pain despite trying non- pharmacological therapy or short courses of opioid," Dr. Narouze says. "If the pain persists after that, it's time to stop the opioid, rethink the diagnosis, reevaluate the patient and refer the patient to a pain physician before the patient starts on a cycle of addiction." He adds this analogy. "It's like the endocrinologists. They want to see diabetic patients before they have gangrene and have to have a leg amputated. It's the same with pain medicine physicians. They want to see the patient before they're dependent on opioids. By then it could be too late." The Center for Pain Medicine at Western Reserve Hospital has clinics located at the main campus in Cuyahoga Falls, and in Hudson, Streetsboro and Akron. Visit westernreservehospital .org for more information. To refer a patient, call 330-971-7246. ■ Glenn Rech, RPh, monitors potential drug interactions for patients on site at Western Reserve Hospital's pharmacy. PHOTOS BY KEN LOVE COURTESY OF WESTERN RESERVE HOSPITAL 0 8C O V E R S T O R Y