James Boesiger, DMSc, PA-C, has been at the forefront of pain medicine’s evolution for over three decades. However, he still can’t forget the profound effect of his childhood experience when he came home to his mother wearing sunglasses in bed and vomiting from chronic pain brought on by severe migraines. And so, it is no coincidence that along with his specialty in chronic pain medicine, Boesiger has a sub-specialty in headache medicine. In his interview with Top Doctor Magazine, Boesiger describes some of the recent advances in chronic pain treatment, the unique challenges of practicing pain management during the pandemic, and where he sees the field moving towards the future.
From Emergency Medicine to Pain Medicine
Boesiger started his career practicing emergency medicine in 1986, but in the fall of 2005, a life-changing continuing-education conference sponsored by the American Society of Pain Educators (ASPE) inspired him to change fields, follow his passion for pain management, and become one of Nevada’s first Certified Pain Educators (CPE) by the American Society of Pain Educators. The field of pain management has grown considerably since the first 50 people at that Las Vegas conference. Now, Boesiger has seen that small group grow into PAINWeek, a massive annual pain management conference taking up three floors at the Cosmopolitan conference center in Las Vegas with thousands of attendees. Boesiger was also a Credentialed Pain Practitioner from the Academy of Integrative Pain Management. In 2019 he earned his Doctorate of Medical Science (DMSc), from the University of Lynchburg, the first of its kind and an innovative program designed specifically for PAs.
Advances in Headache Medicine
This path into chronic pain management would lead Boesiger to one of his passions, headache medicine. The field has experienced evolution since the 1960s when Boesiger’s mother suffered from migraines -“we are light-years ahead of where we were.” He first learned of the sub-specialty through the Diamond Headache Foundation, promoting headache education in the medical field. Boesiger has a Certificate of Added Qualification (CAQ) through the American Headache Society. He tells Top Doctor Magazine that one of the first breakthroughs during his career was moving from opioid treatment of migraines to using a class of drugs called “triptans” , the first one, sumatriptan approved for use in 1991 as a subcutaneous injection. More recently, Calcitonin Gene-Related Peptides (CGRP) has been lauded as a profound paradigm shift in the treatment of migraines, “Right now, we are in the middle of another revolution in migraine medicine. It’s definitely an exciting time for a headache medicine.”
Multimodal Pain Management
Today, Boesiger practices at the Nevada Comprehensive Pain Center in Las Vegas. The company has six clinics spread across the Las Vegas valley and incorporates a multi-disciplinary approach to chronic pain. “There are a variety of pain conditions we treat, but the majority of patients at the pain center are treated for cervical, thoracic or lumbar spine pain.” Osteoarthritis of the knees and other joints, post-surgical pains, diabetic peripheral neuropathy are seen frequently as other neuropathic conditions including fibromyalgia. The clinic uses various interventional procedures such as epidural injections and nerve blocks for pain relief. On the more technical end neuromodulation is implanted for spinal stimulation for severe neuropathies and radiculopathies. Nevada Comprehensive Pain Center also firmly pushes for conservative therapy, weight loss, stop smoking, physical therapy, yoga, and chiropractic care. “With pain patients, there’s no such thing as one size fits all,” Boesiger says.
A Challenging Regulatory Environment
Strict government regulations of medications are necessary but complicated for pain management, especially for the prescription of opioids. For Boesiger, Nevada’s AB 474 statute brought on several confusing mandates for medical professionals, “It really changed the face of pain management in this state, and I’m sure other states that adopted similar restrictive mandates.” Boesiger recalls that these laws’ language was so confusing that several primary care physicians, dentists, and pain management specialists just stopped prescribing pain medication altogether. Likewise, patients had to jump through several expensive hoops just to receive the same pain medication they have been reliant on for years.
COVID-19 and Pain Management
In April 2020, Boesiger’s practice went full telemedicine, which is not an easy choice for a field that traditionally relied on face-to-face interaction. Fortunately, for Boesiger, his clinic had already transitioned to some essential systems to be fully electronic, such as the electronic prescription software system for medications, “I can only imagine the complications we would have endured just to deliver paper prescriptions. It would have been quite complex.” At one point in late 2020, so much of the staff was either quarantined from being sick or for being in direct contact with a family member that was sick, that it was just Boesiger and his medical assistant seeing the patients for a few days. We were “Last Man (and Woman) Standing!” Although so much of the practice during the pandemic was improvisationally problem solving on a daily basis, the Nevada Comprehensive Pain Center’s six clinic locations allowed for some staffing flexibility during the peak of staff infection or quarantine. Boesiger gives credit to the management team who was able to shuffle staff around from different clinics just to continue patient care.
What’s in the Future for Pain Management?
Boesiger believes in telemedicine expansion, but it remains a complicated issue for pain management due to several drawbacks. If you have a good audio and visual interface, you can assess breathing and respiratory rates. Moreover, you can also assess specific muscles and teach patients particular body movements and therapeutic maneuvers online. Protocol for documentation of the visit has serious potential and could be an invaluable data set down the road for a patient’s treatment. “Some ailments, like headaches and migraines, are all in the patient’s history, so much of that can easily be done with a telemedicine visit.”
Traditional Ways Beyond the Limits of Telemedicine
With over three decades of experience, Boesiger is wary of his field drifting too far into the telemedicine world. One of the first concerns is a practical one, insurance reimbursement. Some payers will pay 40% less for a telemedicine visit versus an in-person one, which is untenable for most businesses showing thinning margins due to recent complicated regulatory laws and already diminished payouts from insurance companies. Deeper concerns for Boesiger are losing the traditional hands-on approach and relationship-defining moments with patients, “The hand holding, the touch, the compassion, the empathy, the ‘pat-on-the-back’ if you will.” COVID-19 reminds us that we take simple treatments like listening to the lungs and palpitating the abdomen as a given during a hospital visit. Still, these crucial interactions are lost during a telemedicine assessment. Patients are overall reporting to Boesiger that most prefer in-person visits, aside from a few specific cases.
Stigmatization of People in Chronic Pain
Boesiger’s doctoral thesis focused on the stigma that pain patients experience sometimes on a daily basis. He looked at the impact of glances from strangers, the rolling of eyes from a pharmacist or a co-worker, the challenge of even picking up medication. It can sometimes be attributed to severe depression or adverse developments in mental health observed during the pandemic. For Boesiger, the key to pain management is the earned trust and relationship during the healing process, “The subtle moments of looking into a patient’s eyes as they tell their story, means so much to them, perhaps more so than getting a prescription or a shot.”