- Pain management, Easing the Suffering, coming up next on Call the Doctor.

(upbeat music) - [Announcer] The region's premier medical information program, Call the Doctor.

(upbeat music) - Chronic pain is a serious health condition.

Like most long-term health issues, it often leads to complications beyond physical symptoms such as new or worsened depression, anxiety and difficulty sleeping.

Chronic pain can make it more difficult to concentrate at work, managing task at home as well as affecting a person's overall quality of life.

The treatments for chronic pain are as diverse as the causes.

The use of drug therapy, non-prescription and prescription is the most common method for managing chronic pain.

This includes non-narcotic pain relievers, non-steroidal anti-inflammatory drugs, opioids muscle relaxants, anti-depressant medications and topical pain relievers.

There are also non drug treatment options available for chronic pain.

Some of the most common are exercise and physical therapy, heat and/or cold application, ultrasound therapy, and TENS therapy, or transcutaneous electrical nerve stimulation.

Pain management, easing the suffering now on Call the Doctor.

(upbeat music) Pain Management, Easing the Suffering.

Welcome to Call the Doctor here on WVIA I'm Paola Giangiacomo.

Tonight our topic is pain management.

And joining us on the panel, Dr. Yasin Khan is a pain management specialist with Commonwealth Comprehensive Pain Centers.

Dr. Ryan Ness is a board certified and fellowship trained anesthesiologist and pain management physician at Geisinger, and Dr. Joseph Paz.

He is a certified or he is certified in pain medicine at Comprehensive Pain Management in Wilkes Barre.

Thank you all for being here.

And I would like to remind our viewers that you can participate in the conversation at wvia.org/ctd.

You can also submit your questions for future shows by emailing ctd@wvu.org or using the #wviactd.

And be sure to check our website for a listing of future programs and watch Call the Doctor episodes anytime on the WVIA app.

Now we'll begin our discussion.

So what is chronic pain Dr. Khan?

- Basically a pain which lasts a patient more than three months.

And they've been lingers on, whatever the reason behind that injury or other suffering when it goes beyond three months.

- Okay.

And Dr. Ness, what types of chronic pain?

Like what would you consider types of chronic pain?

- So chronic pain is... pain in general is an unpleasant, emotional or a sensory experience associated with actual tissue damage from, as Dr. Khan mentioned, from an injury, or from degeneration or possibly inflammatory conditions.

So types of chronic pain vary depending on the etiology or the origin and have nociceptive or somatic pain, pain from osteoarthritis or neuropathic pain, pain from injury to a nerve or from a previous surgery that caused an injury to a nerve.

And so, those are all types of chronic pain that can happen as a result.

- And Dr. Paz, do you have to have an injury for pain to become chronic or can chronic pain just develop without being injured?

- Certainly a good portion of the people who have chronic pain develops from some type of injury whether it's an injury playing football when they were young and it has degenerated, or a motor vehicle accident or workman's compensation accident.

The biggest thing we see probably though is just degenerative in nature, a lot of that is depending on your lifestyle and what kind of work you've done, but it could be wear and tear arthritis, or just bad genetics in general.

So we see it all spectrums.

- But there are some conditions that cause chronic pain like never ending pain, like fibromyalgia.

- Fibromyalgia, or patients who have, let's say multiple back surgeries.

They develop scarring in the spinal canal and their nerves are being affected and they develop a severe chronic pain, which can last forever basically.

- Like, are there tests to determine that you have chronic pain or you just go by the timeframe, Dr. Ness?

- So we do use self reporting.

Obviously we ask the patient and it's reported by the patient.

The quality, the duration, the chronicity, the type of pain, that's all self-reported from the patient.

And so a lot of the emphasis is placed on the patient's self-reporting, the descriptive types of pain they have, and their number of pain, which is very obviously subjective.

- And obviously if it affects their daily life.

So how is chronic pain treated, Dr. Paz?

- Well there's multiple treatments?

Usually starting with the most conservative treatments such as first and foremost, identifying the cause of the pain as degenerative arthritis of the knee, they have a nerve problem like a failed spinal surgery, or a herniated disc, things like that.

Once it's identified then you can more target the treatment for it.

But usually it starts with the more simplistic type approach with medicines such as Tylenol anti-inflammatories, as well as physical therapies and basic exercises, things like that.

- And then what if over the counter remedies or therapy doesn't work, what would be the next step?

- In my line of work, I believe the other gentleman's line of work also, we tend to go to a little bit more complicated things as far as steroid injections, which are done under fluoroscopic guidance to put needles into places such as knees or backs or necks.

And you combine that with a little bit more aggressive medicines such as what we call neuropathic type medicines such as a medicine as Gabapentin or Lyrica and (indistinct) is always the opioid route which we are trying to do avoid, only if necessary nowadays, but it is there in our material to consider if we need to, as well as the newer aspect of medical marijuana which is used quite commonly now for chronic pain.

- Does, is CBD oil a treatment for chronic pain?

- Yes, it has been used.

And as a matter of fact it's been quite effective, also the non medical marijuana as Dr. Paz mentioned.

That is becoming very effective way of treating these folks.

And also reducing the intake of opioids.

And by the way, we use all the spectrum of things particularly to patient evaluation.

Identifying, getting good history, doing good examination, using the injection therapy as diagnostic criteria to understand where the pain generator is and then making a plan for them, whether we're going to go to Agilent drugs, such as, as mentioned before the neuropathic pain component, anti-convulsant, anti-inflammatories, adding a small dose of narcotics if needed to be.

So the first thing first, trying to make sure what type of pain we are treating.

- Right.

And how different is it nowadays Dr. Ness in prescribing opioids compared to years ago, before it became an epidemic?

How is it different nowadays?

Are there more restrictions?

- Yeah, absolutely.

So obviously with the recent epidemic associated with opioid overdose, there's a risk mitigation associated with prescribing opioids.

You need to have a good history and obviously have a reason for prescribing the pain generator and all have it well-documented.

In addition to that, there needs to be a prescribing plan, both an escalation plan and a deescalation plan, if things are not panning out the way we expected.

So patient education, patient expectations need to be managed and also a good history, of family history and both personal history of the patient as to exposure to opioids in the past, if there is a genetic component or a high risk associated with prescribing opioids that needs to be all addressed as part of the prescribing opioids risk and benefit profile.

- And in terms of treatment, Dr. Paz, we talked about drug therapy, injections.

Are there any other types of therapy, like alternative therapies, that could help someone deal with chronic pain?

- Well, there are.

There certainly therapies such as acupuncture.

I know a lot of people have been successful with that.

Getting back to the physical therapy, massage type therapies, deep tissue, and so forth.

And there are some therapies also that we perform that are a little bit more invasive and a little bit more complicated but still can be very effective, such as spinal cord stimulators for failed spinal surgery, and (indistinct) infusion pumps which are pumps that are placed in the body that contain medicines that are given out through the spinal canal.

- And what about TENS therapy, is that an option as well?

- It's always an option.

That's correct.

TENS therapy, we use quite a bit particularly for muscle spasm.

- How does that work?

- Well, it creates sort of a ultimate pathway for, it takes the mind off the pain for a while and by stimulating the nerves with the TENS unit.

- Mmh.

And you did mention some other types of alternative therapy but would psychotherapy help people with chronic pain, Dr. Khan?

Well, as a whole pain basically has to be managed not only the physical aspect but also the depression, or the secondary anxiety issues which develops from chronic pain.

So under those circumstances, patients may get help from the counselors, biofeedback, also working with the therapist closely to help control the symptomatology of the depression and anxiety, which will in turn break the cycle to chronic pain.

- Alright.

Do patients find relief from all of these treatments that we talked about, or do most of your patients do they have to cope with this chronic pain for years, Dr. Ness?

- Yeah.

So as Dr. Khan mentioned, the bio-psycho-social model of pain is what we try to address not just the physicality, but the emotional components, and they met the depression and anxiety.

So, you know, obviously chronic pain, we get a lot of wins.

We do well with certain individuals who have presentations that are amenable to interventions in both psychotherapy, but unfortunately some folks do have chronic pain for a lifetime, but the big premise is to not lose hope.

There are all kinds of modalities out there.

And in addition to research coming down the pipeline that address some of these chronic pain conditions.

So, obviously things that you can do by yourself to empower yourself, to manage your pain.

Self-management things, weight loss, nutrition, minimizing catastrophizing, and rumination about your issues and your chronic condition is always beneficial.

Behavioral pacing and yoga and relaxation, massage, acupuncture that which was mentioned, these are all big components of a comprehensive program to address all aspects of chronic pain.

- Yeah.

Dr. Ness, you mentioned diet.

How does diet play into being a remedy for chronic pain?

- So diet in general I would say specifically weight loss is important for folks that are possibly obese, or this is Northeast Pennsylvania, we tend to overeat like our starches, and our pastas and our pizzas.

So we're all carrying around a few extra pounds and eating anti-inflammatory foods instead of pro-inflammatory foods.

So eliminate the processed foods, the high starches, all those things that can cause issues associated with inflammatory conditions, and being smart about what you're doing.

Possibly aqua therapy if you can't manage land therapy, all the things that make sense in a part of a comprehensive process.

- Dr. Paz, with some patients, do you find that exercise could actually cause chronic pain or exercise could actually relieve chronic pain?

'Cause I'm sure there are a lot of heavy weightlifters out there who are in a lot of pain.

(chuckling) - Well, I think that it's a double-edged sword with that.

We encourage activity.

So a body emotion stays in motion.

Joints likes to be moved, particularly early in the morning when you first wake up and you got that stiff back and it takes a little while for you to get standing up right or taking a hot shower, or whatever it takes to get you up right.

Water activities are always better, in my opinion.

Exercise should always be obviously tempered by how much you can do and how uncomfortable you are.

You don't wanna push it that you're so uncomfortable that you ruin your day but you do want to have some ability to push past some of the pain to get through it.

I think in the long run particularly with degenerative arthritis, exercise is certainly a big staple of treatment.

- So in the long run, Dr. Khan, is there a cure for chronic pain or for people this is just something you have to learn to live with and cope.

- Correct.

I think it's more of a patient expectation, and what their lifestyle is, and how they can cope with it.

And we are there to provide them those tools to cope with that aspect.

But there's a combination of exercise, therapy, going to physical therapy, learning how to live with that lifestyle, and trying to be active.

So I think the majority of the problems or disappointment of our patient comes when their expectations are out of charts and we are trying to get them certain place.

So my conversation with them initially is what are you looking for?

What are your expectations?

You would be happy with what type of relief?

- Does age play a role in the type of treatment that you would recommend, Dr. Ness?

- Sure.

I mean, obviously there's approaches that we use in the younger population who may have a work comp injury, or a sports related injury that may not be reasonable for folks that are in their later decades.

So, expectations as Dr. Khan alluded to are always a good conversation to have upfront, and of course for the younger population they wanna get back to being active, to enjoy things with their kids and, and possibly be weekend warriors if possible.

Again, pacing with your chronic pain condition is always important.

If you're doing too much or doing a lot on a certain day, you may have a bad day followed by a good day, and if you're having a good day, try not to overdo things.

So those are all just sort of patient education expectations that we address with our folks moving forward.

- And Dr. Paz can chronic pain be prevented or are we all at risk?

(chuckling) - So to some degree everybody's at risk.

It all depends on your upbringing.

How many times you fell off your bicycle when you were a child, to what you've done for a living.

So particularly if we're in tear arthritis which we see a lot of with bad knees and bad shoulders, and so forth, a lot of that's due to just the type of employment that people have.

So ultimately we're all gonna develop some arthritis.

It depends how badly we abused our bodies when we were younger, but it can be avoided.

I think the idea that everybody's coming out here is realistic expectations.

So nobody's going to grow old, very few people grow old without any type of discomfort or pain.

The idea is can we manage it?

Can we help manage it with simple things like steroid injections, and physical therapy and so forth and so on.

So everybody's going to like I said, to some degree have some kind of pain as they grow old, that's just the nature of growing older.

- And Dr. Ness has the pandemic changed at all the way you treat patients, or are fewer patients coming in to see you one-on-one?

Has there been any change since the onset of the pandemic?

- Yeah, sure, absolutely there's been changes and I think the challenges are numerous, with the uncertainty and the angst and hysteria associated with the pandemic has been overwhelming at times for our patients and both for our providers.

We've really leaned in with our technology as far as telemedicine, video appointments, which has been greatly beneficial, ease of use, folks that are educated about technology can use it.

The people that are really suffering are sometimes the elderly, if they don't have that caregiver or somebody who's looking out for them to help them use the technology and leverage telemedicine in order to have a doctor's appointment instead of leaving the house.

So that's really created just that personal touch that we've lost somewhat, but we've gained back with some of the winds with telemedicine and can look to continue to use that in moving forward.

- Because some patients may not want to be seen in the office, are you finding some patients who are calling in just to say, please just prescribe something.

I need something.

Are you finding that?

- I think the main thing are patients that are on let's say multiple medications and our so-called job is to keep in touch with them on a regular basis.

Telemedicine, as Dr. Ness mentioned, has provided us that.

Also there has been changes from the DEA that we are able to prescribe via telemedicine now, which we were not able to before.

Before it was in-person visit to prescribe.

So I think some of those changes in the laws as well as availability at the telemedicine has helped.

Also telemedicine has given us a tool sometime to see what type of environment patient is living in.

Because they are at their home environment, You can see what type of things are around them and yeah.

- What would-- - Basically, if there are other environment which is conducive to their getting better, or there some other issues which may cause them more harm.

- Okay.

So you would look at their home environment and then you could see something that could actually cause them more harm.

- Sure.

- Okay.

So how important is a home environment to remedy the pain?

- I think there's a lot of socioeconomic issues and things of that nature, which affect patients outcomes overall.

- In what way?

- Overall, like let's say if a patient who is in a lower social economics, they have worry of earning, where the next day's meal is going to come from, they are going to be depressed.

They're gonna be anxious about that.

Plus they have now this chronic pain, so that environment can change their view of looking at what their goals are.

- So not only do some patients have to deal with the chronic pain, but they also have to deal with the anxiety and the depression that may come along with it.

So what do you do in that instance, Dr. Ness?

- I think as part of the medication (indistinct) that was available to us, antidepressants are always a great way to address both the anxiety and depression, and chronic pain.

Some of the neurotransmitters that are part of chronic pain also cause chronic depression.

It makes sense.

So to start them out slow with anti-depressant and increase it as they can tolerate, in addition to pulling in some of our behavioral health colleagues to help out with cognitive behavioral therapy, talking through the issues, focusing on the positivity and eliminating or minimizing that negativity in their lives and sort of trying to make everyday great, make the next day better than the previous day, and really promoting that positivity because some of the folks are not in great situations as Dr. Khan said.

And we're just trying to keep them afloat and keep them happy and give them some positivity to look forward to either another intervention or another medication.

But again, lifestyle modification plays a big role.

- So if these patients are on pain meds and they're also on antidepressants, because they're feeling depressed because of the pain, are all these medications do they cause other problems like high blood pressure or any other ailments that they would have to deal with, Dr. Paz?

- So the biggest thing I see with other medicines with the medicines that we use, chronically they all have some degree of depression.

They can cause light headedness, can cause dizziness, we worry about particularly with the neuropathic medicines, like Gabapentin, Neurontin, Lyrica type medicines, people can fall and get dizzy lightheaded, as I mentioned.

So sedation is a big one because if we can't improve their lifestyle, then they can tire to do anything now because they're on the medicines versus just not wanting to do it cause they're in pain.

So there's a fine balance there that you have to kind of work with.

And the biggest misconception again is when people think they're going to come in and see us and then go home and get an injection and be done with it.

I think I find myself saying the most is that this is going to take some time, we're looking to get you better, not best, and we're over the course of this time, hopefully we'll improve your function and get you more stable at home and be able to lead a better life than you're leading not a perfect life.

- What do you say to patients who don't really want to be on medication?

Are there ways to help control the chronic pain without being on so many medications, Dr. Ness?

- Non-pharmacological approaches, as we alluded to the complimentary or alternative medication their management aspects.

So acupuncture, things of that nature.

There's a whole host of things that have low clinical evidence, but and also low risk associated with it.

They are anecdotal evidence as we discussed of folks doing great after acupuncture or massage or any of these approaches that are non-pharmacological and it can lead to great outcomes.

- Is there any advanced research on pain medication or on how to better cope with chronic pain, Dr. Khan?

- There's a lot of research and I mean, as a physician, one of the responsibility is to look at the side effect profile of these drugs and what combination of drugs we are trying to put on these folks.

A simple example, anti-inflammatory.

If somebody has gastritis beforehand, or they have some GI symptoms they will not be able to tolerate that.

So sometimes showing the medication, method of delivery of that medication to them.

Whether we need to go insert it by mouth, do the subcutaneous route.

So those types of things can help to reduce the side effect profile at the same time, optimized that relief.

- Okay.

Thank you.

Well, once again, I'd like to thank our panelists for participating in our discussion on pain management.

For more information and resources on this topic, visit wvia.org/ctd.

I'm Paola Giangiacomo for Call the Doctor.

Thank you for watching.

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