Transcription:
Interventional Pain Management: Many Ways to Manage Your Pain

Melanie Cole (Host):  Constant pain should not be a part of conquering cancer and constant pain should not be a part of anyone’s lives or something that people have to live with every single day.  If you’re someone who’s experienced constant pain, you know how debilitating that can be.  My guest today is Dr. Andrew Leitner.  He’s an Assistant Clinical Professor of Anesthesia and Interventional Pain in the Department of Anesthesiology at City of Hope.  Welcome to the show, Dr. Leitner. Constant chronic pain:  people have it, it keeps them from work and sometimes the family members and even their doctors don’t understand what they’re talking about.  Tell us about this field about interventional pain management.  What’s going on today? 

Dr. Andrew Leitner (Guest):   Thank you so much for having me on.  We generally separate pain into two realms.  The first is pain from tissue injury or the threat of tissue injury.  In our cancer patients, that’s an ongoing issue if the tumor is active or with cancer treatment.  The second area is dysfunction in the nervous system itself.  Whether its irritation of nerve endings or even changes on a cellular level in the spinal cord or even in the brain where it produces the perception of pain and that becomes a chronic condition for the patient even if there isn’t ongoing injury of their tissue.  A lot of this field is about trying to separate out those two causes of pain and determine what the best approach to it once we have made that determination.

Melanie:  Why do you think people say, “Oh, the pain is in your head,” or sometimes even their doctors don’t quite understand when someone describes their pain.  Why do you think that is?

Dr. Leitner:  The first response I would say to that--and I tell this to a lot of my patients—is I think it’s extremely unlikely that someone would choose to live in pain, choose to have the suffering associated with it.  We have to understand pain as being a highly personal, highly individual experience even though a good component of it is subjective.  We can’t do a blood test that shows the extent of somebody’s pain, although we are getting closer to those types of measurements.  I would say that because the only way we perceive pain is via a series of nerves that ultimately connects the higher centers in our brain and then are also attached to some of the more emotional aspects of the experience, this is probably where the expression “it’s in your head” comes from.  We know that things like stress, psychological or otherwise, can worsen the sensation of pain.  We also know that people who are genetically predisposed to certain stressful responses or anxiety or other conditions may also have worse pain experiences.  It does not mean that the pain is made up but it means that the experience the patient has with the pain may be a bit different.

Melanie:  So, let’s start with a first line of defense.  When someone comes to you and says, “I am in so much pain,” talk about medications a little bit, Dr. Leitner, and what medications you prescribe.  Some people have been prescribed anti-depressants for their pain so explain a little bit about the different medications and why they’re prescribed for various pains.

Dr. Leitner:  Going back to the two broad categories of pain, we can either look at the site of tissue injury and if there’s nothing correctable there then often times the pain medications are designed to decrease inflammation or to directly block pain receptors.  These are the opioids or alkaloids known as narcotics.  However, if pain is transmitted because of nerve dysfunction there are a whole other category of medications that can stabilize nerve endings, slow down transmission.  These medications may even include anti-seizure medications or other types of medications that used to be prescribed for different purposes but have also been shown to be effective for nerve pain.  Then there are other categories of medications such as anti-depressants where we have found that they do work on similar receptors that transmit and often perpetuate pain.  In the acute setting, it will not help but for patients for whom a pain has become a chronic issue and then becomes associated with certain mood disorders or certain pain behaviors, these medications can be quite effective.  It’s also important to note that taking medications by mouth is only one route of administration.  Many patients do benefit from either topically applied creams, gels, patches or potentially injectable medications as well.

 Melanie:  Let’s move on to injectable medications.  In interventional radiology and pain management, this is a burgeoning form of controlling that pain.  Tell us about some of those injectables and what’s going on.

Dr. Leitner:  A lot of the basis for targeted injections comes from the fact that oftentimes pain is a localized phenomenon and yet we are giving medications by mouth that affect the entire body and have impact on organs and organ systems that have nothing to do with the painful area.  This is one of the reasons why the field of interventional pain management developed and grew because we know that we can effectively target specific areas of the body and that can help us spare some of the side effect profiles and other implications of medications by mouth.  It’s not always an option but certainly if pain happens around a known nerve distribution or is at a targeted part of the body that would be responsive to an injection, then that’s certainly an option.  This can range from injection of local anesthetic and steroids for patients who are suffering from joint inflammation or degeneration with arthritis anywhere to nerve damage or nerve irritation in a limb or other parts of the body.  Doing an injection by itself does not change the structure or fix the process that causes ongoing tissue injury which may require another treatment.  But if pain becomes chronic and transmitted along that nerve, a series of injections may help decrease it over time. 

Melanie:  When we’re looking at cortisone injections, people get those quite often. Then there are things where you have to use guided imagery to make the injection, right?  Facet joints.  What is the difference?  What are blocks all about and are these things something that last a good long time or have to be repeated every six months or so?

Dr. Leitner:  Image guidance has really advanced the field.  Before the benefit of image guidance, there were certain types of blocks that could just as adequately be performed with a good knowledge of anatomic landmarks and good experience from the practitioner.  However, there are parts of the body that really just are not amenable to these what we would call these “blind techniques” and you alluded to that with the facet blocks.  There are certain parts of the spine that simply cannot be injected blindly, both for reasons of accuracy and also safety.  In terms of having to repeat the blocks, it does vary.  There are patients for whom they are in a cycle of pain, inflammation, nerve injury and one injection really breaks that cycle.  Unlikely to bring pain down to zero but then patients find that they are able to some of the treatments that are really crucial for long-term recovery such as physical therapy and rehabilitation. But for other people who have a problem that is likely to rear its head again, let’s say you have a herniated disc and we have calmed the flare episode but we do know that those discs are prone to re-injury or re-leakage of this material, so I advise my patients ahead of time that we may very well need to repeat the injection but the time frame of that really depends on their response and their recovery.   

Melanie:  Just tell us a little bit about something like TENS, transcutaneous electrical nerve stimulators.  People hear about these electrical nerve stimulation techniques. Are these effective for people and how long do they last?

Dr. Leitner:  That’s a great question.  TENS units stands for “transcutaneous electrical nerve stimulation” and these have been around for a long time and for some patients can be highly effective.  It goes back to one of the founding theories of pain advanced perhaps 60 years ago which is the “gate control” theory of pain.  Ultimately, our bodies are not particularly good at transmitting two signals at the same time.  So, as a child if you scrape your knee and then you rub it right afterwards that actually does help relieve the pain somewhat or, at the very least, distract you from it.  So, a TENS unit operates on a similar principle that if at a painful site, we start producing a tingling electronic sensation, that can be an effective full or partial substitute to some of the pain signals that are coming through.  It does not work for everyone but for the select group of patients, and this is often done under the guidance of a physical therapist, it can be a highly effective mode of treatment.  The limitation of this and other forms of using the gate control theory of pain, is that only when you have these units on are they actively blocking or reducing pain signals.  However, some research has shown that the benefits do continue for a period of time afterwards and even in the long term but generally speaking this is not a one-time treatment.  Patients get used to a habit of using a TENS unit at times of pain flare or anticipation of pain flares and generally pretty regularly.

Melanie:  So, in just the last minute, Dr. Leitner,  you’ve been giving us such great information for those millions of people out there suffering with chronic pain, give us your best advice for what they should do when they are suffering from chronic pain who they should seek out.

Dr. Leitner: This is a great question.  The first piece of advice I give to all of my patients is you do not want to stop moving.  Our bodies are not designed to be sedentary, were not designed to stay in one place and we have now found that a lot of inflammation and degeneration of our joints and ligaments can be accelerated by not moving.  So, whatever the treatment plan that you are pursuing currently, make sure it’s in the context of staying moving.  Now this is easier said than done for many patients.  I don’t mean run a marathon.  There are some people who are very ill and have other limitations in addition to the pain that will keep them from being particularly active but even the smallest bit helps whether it’s walking every day, getting in a pool and floating. All types of activity can be more useful but staying still and not moving is not good both physiologically and psychologically.  The reason I mention this is because that will affect the choice of treatment we will make.  For some people, taking high dose medications by mouth causes a side effect profile that prohibits them from moving.  They are too affected by some of the cognitive effects or it makes them dizzy or makes them sleepy all day, so that’s clearly an issue that prevents them from moving around.  For other people, they may have medical reasons why they can’t do other treatments.  In general, the approach I take for treatment is how much does it afford my patients the ability to move, to continue to work, to continue to do the things they enjoy.  Our psychological well-being depends on that and, of course, that’s a crucial component of how we recover from chronic pain syndrome.

Melanie:  Absolutely great information.  Thank you so much, Dr. Leitner.  You’re listening to City of Hope Radio.   For more information you can go to cityofhope.org.  That’s cityofhope.org.  This is Melanie Cole.  Thanks so much for listening.