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The Pain Managers

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Jaideep Sajdeh, owner of Mumbai-based textile recycling firm Texool, and an active club-level cricketer, sustained a nasty knee injury while playing two and a half years ago. As a result, he had torn a ligament and cartilage, and the ensuing pain was unbearable. Doctors advised surgery, but the 42-year-old was not ready for it and thought of trying alternative medicine. That too did not work. After 4-5 months, a physiotherapist suggested a visit to Pain Clinic of India, run by Dr Kailash Kothari, an anaesthesiologist and pain management specialist.

“The doctor gave me three injections at an interval of 1-2 weeks. With the first injection itself, the nagging pain was gone,” says Sajdeh. The entire treatment spread over 3-4 months cost Rs 15,000, while surgery would have cost Rs 1.5 lakh. “If I go for the same treatment in the US, it would have cost around $800,” says Sajdeh, who is now getting a nagging pain in the heel treated, and also plans to take a few booster injections to strengthen his knees.

Gone are the days of living with excruciating and recurring pain. A new breed of super-specialist pain healers is the go-to solution. The speciality is being added to leading public and corporate hospitals. Moreover, standalone pain clinics and even chains are coming up.

“Pain medicine is the youngest of all specialties. It used to be a sub-branch of anaesthesia,” says Dr Assad Hussain, who specialises in anaesthesiology at the sports medicine centre of Fortis Healthcare-controlled Quality Healthcare Medical Services (QHMS) in Hong Kong. Says Dr Anupam Sibal, group medical director of Apollo Group of Hospitals: “With the loss of manpower, stress, psychological trauma and various other socio-economic issues a patient has to undergo, pain should be considered a disease.”

Modern healthcare providers recognise that chronic pain patients need multi-disciplinary care. The pain management department is no longer an extension of the departments of physiotherapy or palliative care (comprehensive treatments to improve the quality of life of patients and their families who are facing problems associated with life-threatening illness).

Specialist Solution
Experts say that in India, chronic pain affects 30 per cent of the adult population, particularly women and the elderly. About 20-25 per cent of them suffer from musculoskeletal disorders or MSD (which affect muscles, joints, tendons, ligaments and nerves) and joint disorders. Back pain accounts for another 25-30 per cent. Headache and migraine is the reason behind 5 per cent of cases of persistent pain, while another 2 per cent suffer from pain related to cancer.
“Of the 100-120 patients who visit each of my centres every month, the majority comes for treatment of backache and slipped discs, followed by neuropathic (nerve-related diseases or damage) issues and accident victims,” says Kothari, whose chain has six clinics in Mumbai, and one each in Goa and Mauritius.

Says Dr K.J. Choudhary, chairman of Samvedana Hospital and Pain Management Institute in New Delhi and senior anaesthesia consultant with the Apollo Group: “Of the 10-15 chronic patients I see every day, only 2-3 require surgery to control the pain.”

Apart from pain specialisation at leading hospitals, an estimated 30-40 standalone pain clinics have come up in India in recent years, including Pain Clinic of India, Delhi Pain Management Centre (promoted by G.P. Dureja, who set up a pain management clinic at the All India Institute of Medical Sciences, AIIMS, way back in 1986), Samvedana Hospital in Noida, Dardia Pain Clinic in Kolkata, among others. Mumbai alone is estimated to have 15 such clinics. And then there are the centres in tier-2 cities such as Dr Hitesh Patel’s Livewell, Giriraj Pain Management Centre and Pain Care Clinic in Ahmedabad. Experts say that most cities have at least 2-3 pain clinics.
 
ADVANTAGE: Fortis Healthcare is implementing an interventional pain management programme in many of its hospitals (Biwash Banerjee)
TENDER CARE
Pain clinics specialise in more than a dozen methods of treatment
• Epidural (spinal) injections: given under real-time X-rays using a fluoroscope
• Radio frequency ablation: a high-frequency alternating current is used to treat a medical disorder
• Microscopic discectomy: a surgery to cure pain due to slipped discs
• Ozone therapy: more oxygen is introduced in the body by injecting ozone; used in back pain management
• Sympathetic blocks: involves injecting numbing medicine around the nerves in the lower back or neck to get rid of pain temporarily
• Blocks for cervical pain: an injection to relieve neck, shoulder or arm pain
• Cancer pain management
• Diabetic neuropathic pain management: treating pain or loss of feeling in the toes, feet, legs, hands, and arms due to diabetes
• Advanced neuromodulation therapy: advanced medical device technologies to enhance or suppress activity of the nervous system for the treatment of a disease
• Ultrasound-guided nerve blocks
• Spinal cord stimulator: a device used to exert pulsed electrical signals to the spinal cord to control chronic pain

A reason for the profusion could be the relatively low cost of setting up a pain clinic. “The investment in a pain clinic is about Rs 50 lakh (for a rented building in a tier-2 city) and breakeven can happen within a year,” says Kothari. Compared to this, a modern eye care clinic may require 2-3 times the investment, and a longer gestation period; a corporate hospital with 250 beds breaks even in 5-7 years.

The infrastructure required is also not much for a pain clinic — one or two consultation rooms and small operation theatres, physiotherapy equipment, etc. Pain clinics do not need an in-patient ward as most of the treatments do not need hospitalisation. “We have tie-ups with hospitals for surgeries that require hospitalisation,” says Kothari. 

“Pain management is an upcoming speciality and it is yet to develop as an organised specialty,” says Amit Mookim, partner, global strategy group and industry head of healthcare at KPMG. He notes that the most profitable segment is the specialised injections used in such clinics. Although no industry figures are available, the size of the pain management market is at least Rs 200 crore for just the standalone centres, and this does not include the cost of related pain medication.
 
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Existing set-ups are also planning to expand. Pain Clinic of India, for instance, plans to extend its network to 50-100 clinics within the next five years, and is in discussions with venture capitalists for funding. It is looking to set up more centres in Mumbai, Delhi and Goa.

Hospitals, too, are expanding their pain management departments. “The pain departments in most modern hospitals do not require huge additional infrastructural investment. Pre-existing CT scan, MRI and ultrasound machines, radiological support plus the availability of specialists and operation theatres are more than sufficient,” says Dr Murali Chakravarthy, chief consultant cardiac anaesthesiologist at Fortis Hospitals, Bangalore.

According to Dr Bishnu Panigrahi, group head of medical operations at Fortis Healthcare, the healthcare chain has rolled out pain clinics in many of its hospitals and is implementing a comprehensive interventional pain management programme. “Interventions range from medicines to treat chronic pain conditions to minimally invasive (tiny incisions instead of one large opening in the body), non-surgical and target-specific procedures.”

The Apollo Group has also implemented a comprehensive pain management programme for in-patients based on ‘pain scores’ (0 meaning no pain, while 7-10 means severe pain). “Hospitals in the Apollo network conduct some 600 surgeries every day and pain management related to post-surgical care is an important aspect of our disease management programmes,” says Sibal, adding that eight hospitals in the network are Joint Commission International-accredited, for whom pain management is one of the six vital areas of excellence.
 
“OF THE 10-15 CHRONIC PATIENTS I SEE EVERY DAY, ONLY 2-3 REQUIRE SURGERY TO CONTROL THE PAIN.” DR K.J. CHOUDHARY Chairman, Samvedana Hospital And Pain Management Inst., New Delhi
Painfully Costly
Managing pain, though usually less expensive than surgery, can still be a costly affair. Take the case of a patient suffering from a slipped disc (also known as a prolapsed or herniated disc; a spine disc ruptures and the gel inside leaks out). First, the pain specialist will usually prescribe 4-6 weeks of medication. If there isn’t any relief, the patient is usually asked to undergo an X-ray or a CT scan or even an MRI to pinpoint the exact source of the pain. If the patient has pain in the leg or arm due to a slipped disc, the common treatment employed is to inject a few doses of cortisone selectively over the inflamed nerve root. Such injections and treatment typically cost Rs 8,000-25,000 for a cycle.

If the patient suffers from a facet joint block (back pain due to a block in a nerve joint) and undergoes a few sittings for radio frequency ablation, the cost is in the Rs 55,000-70,000-range. In a similar price range are other procedures that pain specialists use, such as DeKompressor, automated percutaneous lumbar discectomy, ozone discectomy and vertebroplasty.

The treatment of radiating leg pain due to sacroiliac joint (a joint bone in the pelvic area) inflammation may require a mixture of local anaesthesia and cortisone, and may cost Rs 10,000-12,000. A single injection for osteo-arthritis-related knee pain (effect lasts for 1-2 years) costs about Rs 5,000.

Then there are the more expensive treatments such as spinal cord stimulation (SCS), which can cost Rs 5-7 lakh. This involves implanting small electrodes on a wire near the spinal cord to provide low-level electrical impulses to interrupt transmission of pain signals at the level of the spinal cord before the impulses reach the brain. “SCS is actually implanting a pacemaker for the spinal cord. I have done about 15 SCS implants in the past 4-5 years,” says Kothari.

While most of the medicines used in these treatments are covered by medical insurance, some health insurance providers demand a waiting period of 1-2 years before covering expenses related to treatment of diseases such as arthritis (inflammation of one or more joints), osteoarthritis (arthritis due to aging and wear and tear of joints) and osteoporosis, rheumatism (a medical condition which affects connective tissues and joints), spinal disorders and joint replacement therapy.
 
RELIEF ROSTER
• Acute post-operative pain
• Acute pain due to trauma, traffic accidents and fractures
• Labour pain during childbirth
• Breakthrough cancer pain (severe intermittent cancer pain that does not respond to the usual pain medicines)
• Myofascial pain (muscle pain)
• Trigger-point pain (muscle knots pain)
• Neck and back aches with no surgical indication
• Complex regional pain
• Neuralgia (pain in nerves caused by a change in neurological structure or function of the nerves)
• Fibromyalgia (long-term, body-wide pain and tenderness in the joints, muscles, tendons, and other soft tissues)
• Phantom limb pain (pain that is felt in the area where a limb has been amputated)
• Failed back surgery syndrome (chronic back and/or leg pain that occurs after spinal surgery)

Experts Needed
While there is a growing demand for pain management centres, there aren’t enough specialists. The Indian Society for Study of Pain (ISSP), which is affiliated to the International Association for Study of Pain, has 2,000 member doctors. Among these, 70-80 per cent are practising anaesthesiologists, while the others are neuro surgeons, orthopaedic specialists, palliative care specialists, etc. But only 200-300 are active pain management specialists.

“Anaesthesiologists on their own learn a bit (about pain management) during their studies and that is why most pain specialists are anaesthesiologists,” explains Kothari, who is now training other doctors on the subject.

“There are only about 30 pain physicians in India who are certified by the World Institute of Pain. They are mainly anaesthesiologists and a few orthopaedic surgeons and neurologists,” says Panigrahi. At present, there are no government-certified pain management courses in India.

“In 2005, it was recognised as a speciality in its own right in Australia. In Hong Kong, this year will be the first year that the field will be recognised by the HK Academy of Medicine as a speciality,” says Hussain.

In the US, a pain specialist needs to do two years of intensive post-doctoral study, and also be certified by the American Board for Pain Management before being allowed to practice. In India, only two institutes offer post-doctoral certificate courses in pain management, of one-year duration — Institute of Medical Sciences of the Banaras Hindu University, and the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow.

Of course, such small efforts are inadequate, especially since the potential of the field is huge. Till that happens, many of us will have to live with our aches and pains.

p(dot)jayakumar(at)abp(dot)in

(This story was published in Businessworld Issue Dated 31-12-2012)