Carl Maronich (Host): Meaningful Medicine is a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Carl Maronich. With me today is Dr. Kent Cochran, an anesthesiologist and pain medicine specialist from Novant Health. Today, we're going to be talking about pain. Welcome to the podcast.

Dr. Kent Cochran: Thank you, Carl. Appreciate it.

Host: Maybe we could start by having you talk about what are some of the biggest misconceptions you hear from patients when it comes to pain?

Dr. Kent Cochran: Absolutely. So, the first thing that I see often is when people come and see me, they want me to tell them about their pain. Pain is subjective, it is nothing that I can tell them. It is something that comes from them to me. I think the misconception starts with how we even talk about [00:01:00] pain in this country.

So, the way that we describe pain within the medical field is a number from zero to 10, and that doesn't suffice. There are many things that go into understanding pain, but it has to come from the patient. That's a departure from virtually any other field of medicine. I spend a lot of my time trying to get that out of patients where they tell me where their pain's located, what makes their pain worse, where the location of their pain is, how it radiates, certain positions or activities or times of day where they feel it the most.

Those things help me more than any imaging study. They tell me more than most physical exam findings as well. So, the key really is talking to the patient. I think in a lot of fields of medicine, it's obviously very important, but definitely within our field. That's the crux of all of this, is how are you feeling, and then trying to figure [00:02:00] out why are you feeling that way and where's that coming from?

Host: A lot of elements to it, obviously. Is pain always a sign that something's damaged or can you have pain without actually having had an injury?

Dr. Kent Cochran: Yes, Again, pain is a subjective finding. It is something that you feel and no one can tell you otherwise. Pain is a sign of nerve injury. The other signs of nerve injury would be weakness, numbness, tingling, and also pain. Those are the things that we're looking for to where there's some type of injury happening in a nerve that's going from a peripheral nerve or to the spinal cord, and then acting on the brain to where you feel that.

The question is, where is that happening? How is that happening? We want to stop that before it becomes more of an issue and more of a [00:03:00] problem for the patient in their everyday life.

Host: A lot of people think of pain, as something just happens when you get older. Is that a reality or is there something else to that?

Dr. Kent Cochran: I would say that we see pain more as we age, but pain is abnormal. Pain is a pathology of the central nervous system and the peripheral nervous system. It's abnormal and it warrants a response from the person where it's happening to. I think a lot of people just expect that to happen. I hear a lot of people say, "Well, I'm getting older, so these things just happen." That's how things were felt to be the case and how it should be for a long, long time. But pain is abnormal. If you have numbness in your leg or you have pain in your back, those things should be addressed. There's a certain period of time, and we'll get into this somewhat, but there's a certain period of time where we can let things go [00:04:00] and see how things go, because the body has an amazing ability to heal itself.

If there's been anywhere from 12 weeks or three months where that pain has been plaguing you every day and that pain hasn't gotten better, then it's time to look at that. But, pain and age aren't the same thing, and pain with age should certainly be addressed.

Host: Doctor, maybe we could go into what you were talking a little bit about and that's if you delay seeking help for some pain you may have. Like many things, waiting doesn't usually help it. So, maybe you could speak a little bit to that. If someone first has pain, when do they really need to start getting help?

Dr. Kent Cochran: Carl, this can be confusing because again, the body has an amazing ability to heal itself. For greater than 90% of all episodes of pain, it's going to heal itself. Whether you come see me, whether you take over-the-counter medicines, whether you see other types of [00:05:00] providers like a chiropractor or a physical therapist or a massage therapist, those pains are going to heal themselves. I would never tell anyone to not pursue medical care to try to get better, because that's definitely a key and that's going to help you to respond to some type of injury or some type of pain sooner, yet it can be confusing with that statement.

The crux of this is we want to address pain as it presents. So, if it's been two, three weeks of something nagging you, bothering you, then I would definitely try something over-the-counter, a medicine that you're able to take, exercise, stretching, movement, walking, because that's key to get those muscles active, get those nerves that are inflamed and causing pain recentered.

If it has been a [00:06:00] longer period of time, then I would seek care because we want to avoid an episode of acute pain from transitioning into chronic pain, because acute pain can allow for healing. It can allow for you to return to your baseline to avoid this episode, this feeling from becoming something that's chronic, something that you'll live with and something that we'll have to manage.

Host: Maybe you could speak a little bit more to the difference of those acute pain versus chronic pain, how they may present and what the long-term implication could be of those.

Dr. Kent Cochran: Absolutely. Acute pain is defined as a single episode of pain that has occurred for less than three months. The nervous system hasn't produced memory.[00:07:00] Within our nervous system, there's the development of nerve fibers that are associated with chronic pain. That's a burgeoning area of research. There's a lot of things that we don't understand about that, and everyone's a little different. With the timing of that, there's some time between six months and 18 months where those nerve fibers will develop. Then, your nerves will have memory of that pain. Then, that pain can be something that you deal with.

There are basically three phases of pain that I'm trying to figure out whenever I talk to my patients as they're describing this. Is this acute pain? That would be pain, that particular episode, that event being newer than three months. I have lots of patients where they've had a certain bout of back pain come up for the last 10 years, maybe about every six [00:08:00] months, where it comes up every three, four weeks. That's okay. That's something that we definitely need to watch and make sure it’s not becoming recurrent to where it's going to become chronic pain that would still be classified as acute pain. But, as a certain bout of pain that you felt every day is getting into three, four, five, six months, then we transition from acute pain to something called subacute pain, and that's a very important distinction, because during that phase is really important to seek care. Because we want to treat those symptoms of nerve injury and treat that nerve injury to where that doesn't develop into chronic pain, to where that nerve is going to be constantly firing inflammatory signals to where your body feels that.

Getting back to your question about injury and damage, there's a lot of conversations about this. [00:09:00] Just to give you kind of a caveat as we're starting here, I am talking about non-surgical chronic pain. So, surgeons would classify this differently. I think other fields might classify this differently. I'm talking about lesions, I'm talking about injuries, I'm talking about symptoms that haven't warranted surgical correction and trying to manage those things, either through conservative remedies or medication remedies or interventional pain procedures. That subacute phase is really key, because we don't want that true transition to chronic pain because the expectation when we reach chronic pain is that we can't cure this. We can't fix this, but we can manage it. My field is chronic pain management. I tell my patients, all three of those words are very important whenever chronic pain has reached that phase.

Host: Doctor, [00:10:00] if there's trauma that causes pain, they need to go to the ER. That path is pretty clear. If someone has some other type of pain, they may go to their primary care provider first. Maybe you could speak a little bit to the journey somebody who has some pain might go on as they try to navigate their pain issue.

Dr. Kent Cochran: Absolutely. I would say oftentimes when they see their primary care doctor, they're going to get some baseline imaging, which is important. There are a lot of things we rule out with imaging rather than rule in. Oftentimes, it's showing us what we expect. There isn't a lot out of the ordinary with simple X-ray. Then, probably some medicine, some adjuvant medicine that might help relax muscles or treat inflammatory conditions. Maybe a steroid that could quiet some of that inflammatory reaction. Then, possibly some conservative therapy like seeing a chiropractor, doing physical therapy, [00:11:00] seeking massage therapy. Using a TENS unit, using a back brace. All those things would be helpful in that acute phase.

Now, at some point, we would hope that the body would be healing this injury to where you would see either this pain resolve or lessen and lessen over time to where you notice it much less. Hopefully, by that time, you don't need to see me. Whereas if we are not seeing benefit from those things, then it's probably time to see me. Something else that I see a lot along the journey with pain is people try these therapies and maybe they try one and it doesn't work, so they're not going to use that anymore. They're going to try another one, and that doesn't work, so we're not going to use that again. Then, we're going to try another one, and that's not working. We've taken three good therapies. They haven't worked, and they have not restored baseline [00:12:00] function. They haven't taken away pain. Pain is typically a threshold that we need to clear.

Oftentimes, when I'm seeing patients, it's a collaboration of therapies, maybe medicines from different classes, because pain isn't just one thing. When I hear the word pain medicine, we're talking about the class that's opiates. Opiate medicines. But, pain medicines come in many different forms, because pain is affecting a lot of different areas of our body. Again, pain being this threshold that we need to clear, maybe physical therapy helps this much. Well, we didn't see that benefit yet. Maybe NSAIDs help you this much and we're still not clearing that. Then, maybe you can come see me. I'd give you an injection that actually treats that area that hasn't been kind of invasively treated, where we're actually going [00:13:00] after the nerve that's inflamed. We clear that threshold. My injection itself probably didn't make it. But, alongside those other therapies it is allowing you to feel better and also will allow you to return to function.

I think that that's where people can get frustrated with chronic pain management treatment plans, is that we are hoping for the one thing that's going to treat everything. The spine is an amazing part of our body. It can take on loads of stress. Oftentimes whenever we look at imaging, we're seeing our spine degenerate at age 30, 35, 40. People hear that and they think, "Oh my gosh. This is going to be terrible and I'm not going to be able to make it and I'm going to have this terrible life." Well, our spine is able to take on loads of stress to be a mammal that's [00:14:00] upright, it is our spine that is a huge part of our ability to take on these actions. So, we can see degeneration and degenerative disc disease is a very common diagnosis given after imaging, but that doesn't mean that the prognosis that you have for your life is going to be terrible.

It's treating those individual nerves, making sure that we're clearing that threshold to where that pain is treated, to where the body can recover, to where that inflammatory response that caused that initial nerve injury is finally quieted down.

Host: Doctor, you mentioned imaging and is it possible or you sometimes hear stories of folks that will have an X-ray, an MRI that appears normal, yet they're still in pain. How can that happen and how would you address that?

Dr. Kent Cochran: Well, a lot of my professors from medical school would [00:15:00] take issue with the word normal. Whenever we were taught to read imaging or to have a physical exam. People don't come to us to hear the word normal, because that's not a part of what we're looking at. I think maybe unremarkable might be the better word.

Again, pain is subjective. Pain is not something that is seen. Pain is not something that I can tell from a CAT scan or an MRI or an X-ray. That is something that you feel. I even want to equate what imaging is. Imaging is a picture of your anatomy. That is what imaging is. Saying that an X-ray is normal really isn't complete, maybe it's unremarkable. You don't see anything that's necessarily standing out or [00:16:00] abnormal, yet the patient is feeling something abnormal. There are ways to test nerves, but we still don't know a test that really tells how someone feels.

The way that I mention this to my patients is I treat patients, I don't treat pictures. While imaging is a part of the story, it isn't the story. There is a puzzle that we're trying to figure out, and imaging is the piece. I think people have kind of made it this key that unlocks everything.

But again, the vast majority of what I hear from my patients with non-surgical, chronic pain management is going to come from them and trying to find these trigger points, trying to find these joint spaces, trying to find these nerves, trying to find these muscles that are constantly given this feedback of pain. Finding ways to [00:17:00] treat them and ways to optimize that treatment.

Host: Well, you kind of started by saying pain is a very subjective thing. Not everyone handles the amount of pain in the same way. That makes it an additional challenge, I'm sure, for physicians to treat when everybody's a bit different.

Dr. Kent Cochran: It certainly is. I think a big challenge of what we have within my field is insurance coverage and making sure that we're doing the right thing for the right patient because everyone needs to have guardrails and ways to make sure that we're doing things correctly within our fields. I think the challenge with that is trying to quantify things. Pain has always been a number. We focus on that number. Then, we focus on the relief of that number.

What I would love to see in my career and in my time in pain is talking about the significance of pain within someone's life. On the other hand, the significance of the treatment of that pain and what that means for them. Oftentimes I have patients focus on time. I can talk about this a little bit with my procedures, but whenever I'm doing procedures, there are two components to my procedures. Those components are a diagnostic one and a treatment side. On that diagnostic portion, what I want to know is how much this is affecting their pain, okay? This has nothing to do with the number. This has nothing to do with a percentage. Rather, what difference are you noticing? If I ask someone, “How much did this help your pain?” and they say, "Well, it helped 90%." I think you'd feel good about that, Carl, wouldn't you?

Host: Yeah, I think so. Maybe.

Dr. Kent Cochran: I've had certain patients say, "Well, I still have [00:19:00] 10% left. That 10% is killing me." Then, I have patients who will say, "Well, I'm about 30% better." When I was early in my practice, I was somewhat deflated hearing that. I was like, "Argh, only 30%." He was like, "No, no, no. Dr. Cochran, I can do 30% more than I was doing. I can go to the mailbox and I can go pick up my grandchildren and I can walk for a mile today. I feel so much better. I still have pain, but I'm so much better.” That's where I think that our focus needs to be significant. “What does this mean for you?" Putting words to pain rather than putting numbers to pain. Because I can understand what insurance companies need and I want to give them those things to make sure that we're doing things correctly.

But, one of the challenges with back pain is oftentimes it isn't just one area of the back that's causing issues. So earlier, I had talked about one part of the treatment [00:20:00] plan. People trying physical therapy and that not helping and they kind of get rid of that or trying NSAIDs and that didn't really help. But, they're not doing both those things at the same time. Oftentimes, back pain is coming from multiple places and people are looking for that one procedure that's going to take away everything. In many cases, I'm having to layer injections alongside multiple medicines from multiple classes—trying to keep people as active as we can by getting them to go to physical therapy and continuing a home exercise regimen. Because going through physical therapy, that's not anything that you can ever graduate. I have patients come to me and say, "I graduated physical therapy." Well, in order to maintain that function, to avoid this becoming a recurrent problem, it's really key to keep those gains that you got at therapy because the natural reaction for [00:21:00] injury to nerve is for a nerve to affect a muscle, and whenever a muscle is affected, its natural reaction is to clamp up. It's called hypertrophy, where everything guards itself. It's our body's way of guarding you from further injury. The problem is that that muscle over time can be calcified and rigid. It needs to be long and strong and flexible to where you can maintain that range of motion. While everyone's different, everyone's response to injury's going to be different.

Host: Doctor, you started talking a little bit about different interventional treatments. Maybe you could expand on that a little bit and talk about the variety of those that you do and how they benefit different patients.

Dr. Kent Cochran: Absolutely. There are numerous. That's grown a lot since I've been in my practice. The point of these procedures is to get [00:22:00] people feeling the best they can for the longest that they can and get them moving better. Because oftentimes, what I'm doing with these procedures are very pinpoint. I'm going to go down to one spot, one spot only. I often tell patients, "Well, this injection, part of it is for you and part of it is for me. The part of it for you is to obviously feel better. I wouldn't be putting a needle in you if I didn't think that you'd be better, but the part for me is to understand what that means for you."

There are many joints, many nerves, many muscles, many spaces within our body where we can see significant changes that can correlate with pain, whether that's epidural steroid injections or nerve blocks. Radiofrequency ablations that are all done in the office, all done on an outpatient basis. They take about five, 10 minutes to do. They give us a lot of data about [00:23:00] what we think the problem is for a patient.

There's also a burgeoning growing area of our field where there's a lot of non-invasive procedures that do the exact same thing that treats specific areas, specific nerves, and that's something that really drew me to the field, because it used to be do an epidural, kind of see what happens. Whereas now, we're getting to pinpoint a lot more areas and understand a lot more, and that can even set people up well for surgery to where oftentimes, surgeons will send me patients in preparation for surgery for them to better understand where a patient's pain might be coming from, because I want to give patients the right tools. My injections or what patients need to manage their pain or to cure their [00:24:00] pain or to improve their pain or to resolve the issue. If that's not the case, then I'm going to do everything I can to get them in the right hands. Surgeons will send me patients where they're trying to pin point, "Okay, what level of the vertebra, what nerve root is most affected?" We can pinpoint that and see the response that someone has. While it might be short-lived, if it takes away the vast majority or all of their symptoms, then a surgeon's able to say, "All right, I'm going to go after this area and we're going to do this procedure."

Host: How much would you say of pain is physical versus neurological or even emotional, which is a big aspect when someone's in pain? It really plays on the emotions.

Dr. Kent Cochran: Absolutely. We are physical beings. We're definitely affected by the pathology of our body that causes these symptoms. Yet, I think taking them [00:25:00] in the US because we have so much information, we can figure things out so much that we downplay the fact that while we're physical beings, we're also mental, emotional and spiritual beings. We take on a lot of these things within our body and a lot of these things are happening in our lives. When that comes out, it can come out as pain or it can worsen our pain. Living with chronic pain is a big challenge. I always equate it to other medical conditions. When we're treating certain conditions, we're focused on the result, and we're focused on how things will go.

Well, there's a lot that you're living with chronic pain that you don't with other conditions. Te condition that I always use is high blood pressure. It's pervasive and it's very common. [00:26:00] It's also called the silent killer. Well, chronic pain is not silent. Chronic pain is making you respond to everything in your day. Every movement that you have, every position that you have, every task that you need to complete can be affected by chronic pain. It is the non-silent, non-killer. It is affecting you and it is affecting your ability to do things, and not only from a physical standpoint, but living with it.

I think that that's the biggest challenge that we have. Fifteen to twenty percent of the adult population has chronic pain. We focus so much on the diagnostic criteria and on the treatment of these things and understanding and recognizing the size of these things to where oftentimes we miss these things you're talking about. That's a big focus that I have. I think that we can definitely fall short. But, I definitely want to spend time with our patients, [00:27:00] have these relationships with our patients where we can talk to them about it. Because there's been a ton of research that shows the outlook that you have as a patient dictates a lot of how you will do, and a big part of that is having a clinician address these things. It is our job to treat the patient, to treat the pathology, to treat the problem, to treat the nerve injury, but also to see the patient as a whole, especially when it comes to chronic pain.

Host: Doctor, to wind down, let me ask, what would you tell someone who's trying to decide whether or not to see a pain specialist?

Dr. Kent Cochran: I would say the important thing is to really take inventory of what's going on with you and have a good understanding as to what's going on with your body and finding someone who's going to hear you, [00:28:00] someone who's going to listen to you, but also has a plan, someone that has a treatment plan to address all of these symptoms. I think someone that's going to be honest with you. Something that got me into this field was whenever I was in anesthesia, I really enjoyed the procedural aspect of medicine, but missed that connection to the patient. Chronic pain allowed me to see that. But, there was this article written whenever I was going through my training that showed that most chronic pain patients saw nine physicians from different specialties before they made it to a chronic pain physician.

Now, that's gotten much better. That has improved vastly. Yet what I saw as I was going through my training is that chronic pain medicine was not something that everyone was well-versed at. It was a language that many people didn't speak. I feel like that pushed patients to the margins. [00:29:00] Whenever I saw that and I rounded on chronic pain medicine, I saw these patients were very happy in their care because they found someone that took care of them, someone that spoke their language, someone who understood what the problem was and could address it. I think also someone that was honest with them. I think if you're seeking a chronic pain physician, you want to have someone who's going to tell you what they think and is going to come up with a plan to where you can improve and also what to expect.

Because whenever I see a patient, there's two things that I hold in my hand, and I don't ever want to lessen one or lessen the other. I think they're both important and I think they can counterbalance one another. I think in the fullness of what they can be, we want to get the most out of them. One is hope. I don't ever want to lose hope with anything because I've mentioned living with chronic pain, oftentimes you aren't curing things, you aren't fixing things, you're managing things. Well, [00:30:00] I always hope I'm wrong.

There was an attending that I had during training who was an expert in ALS and he would tell patients, "I think you have ALS, but I hope that I'm wrong." And hearing someone who was a nationally renowned physician say that stuck with me because that meant a lot to the patients. That's how I feel, is that I hope that I'm wrong. I don't think I can take this away, but sometimes we hit a home run.

The other thing that I hold my hand is expectations. These tools that I have, these interventions, these procedures that we've talked about, they are tools and they serve a certain function. We can't have them be more than they are. I want you to have expectations that are real to where you can build your life around them and that you can have goals to where you can have a life that brings you joy. That you can meet the daily goals that you want for your life [00:31:00] that meet your family and your hobbies and your job. I want to be the one to take you there. I think anyone seeking a pain management physician should want someone and hopefully find someone like that.

Host: Well, Dr. Kent Cochran, you speak very passionately about pain and pain management. We appreciate all the insights and information you provided today.

Dr. Kent Cochran: Thank you, Carl.

Host: To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. If you found this podcast valuable, please share it on your social channels and explore our complete library of podcasts. This is Meaningful Medicine from Novant Health. Thanks for listening.