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Chronic Pain Management
Dr. George Munoz discusses chronic pain management and a recent study that examined these management options.
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Learn more about George Munoz, MD
George Munoz, MD
George Muñoz, MD, is a board-certified rheumatologist and internist, fellowship trained in rheumatology/immunology at Harvard Medical School affiliates the Brigham and Women’s Hospital and the Beth Israel Hospital in Boston. He completed a second fellowship in integrative medicine at the University of Arizona Center for Integrative Medicine founded by Andrew Weil, MD, and was the first recipient of the Jones/Lovell Rheumatology Scholar Award for 2006-2008. He is a national speaker, lecturer, published author, and co-editor. He serves as chief of integrative medicine and integrative rheumatology for the American Arthritis and Rheumatology Associates (AARA), the largest rheumatology super-group in the US. He is a futurist and innovator, “specializing in the patient journey and experience” as a cornerstone and guiding principal for healthcare stakeholders to emulate and innovate.Learn more about George Munoz, MD
Transcription:
Bill Klaproth: Welcome to Oasis Rheumatainment, a podcast with Dr. George Munoz, Chief Medical Officer and founder of both the Arthritis and Osteoporosis Research Institute, Arthritis and Rheumatology Association Care center, and the Oasis Institute, a fully integrative multidisciplinary clinic in Aventura, Florida. I'm Bill Klaproth.
And on this episode, we talk with Dr. Munoz about chronic pain management. Dr. Munoz, thank you for your time and your insight as always. So let's jump into this, when it comes to chronic pain management, why is this an important topic to discuss?
Dr. George Munoz: Hello, Bill, and such a good question and topic, chronic pain management. This is really important because chronic pain is, number one, very common in the general population. And, number two, it's common in everyday medical care, both in the general medical clinic setting as well as in specialty clinics, such as rheumatology, neurology, orthopedics, physical medicine, rehab, and, obviously, the clinics of chronic pain management. So this is really a very widespread medical condition and there are many types of approaches, so we want to talk a little bit about what some of these approaches are today.
Bill Klaproth: Well, managing chronic pain is something that is needed because a lot of people do suffer from this. So tell us about this new study focused on chronic pain management options and surprisingly good results out of Stanford Rheumatology and Medical Anesthesia group.
Dr. George Munoz: Yeah. So this was a very interesting study that was recently published. We see that the article came out in JAMA just within the past week. And since the opioid crisis is still a thing as people would say, a multidisciplinary value care approach that applies to chronic pain management seems very important and that's what the study looks at. It looks at what are the differences between interventional and educational models of a single session versus eight sessions of what typically has been done in patients with chronic pain in having them enroll in what's called CBT or cognitive behavioral therapy programs, for example, for chronic low back pain.
So this was a randomized clinical trial by the Stanford Group that really had a multi-disciplinary approach, as you said, of both rheumatology, anesthesiology and general medicine. Essentially, this study looked at the single session versus eight sessions of CBT or cognitive behavioral therapy, which is the more standard approach and which obviously eight sessions takes longer than one single session even if it's longer. And also the eight sessions are going to cost more and actually may reduce patient access, desire, or the ability to complete the whole session group for a number of reasons.
Bill Klaproth: Okay. So let's talk more about the eight sessions. You just mentioned a few reasons that limit the eight sessions' completion rate. What are some of the others?
Dr. George Munoz: As I mentioned, cost is going to be one of them, so therefore, monetary reasons for patients to be able to actually afford these. They may not always be completely covered their health insurance or they may have copays that if you have eight sessions, you're going to have eight copays versus one copay and obviously that's going to affect the total price.
And the second thing is time. People having to take off time to do other things from work, from family, from childcare, their responsibilities. So the single shot versus a more drawn out process is what we're looking at here.
Bill Klaproth: So, can you explain to us what value-based care is and how does that play into the study results?
Dr. George Munoz: That's another good question topic, Bill. We are moving in medicine in general now to a time era of looking at the results of what we do in medicine from the value perspective. In other words, does it work and is it worth the cost of what we do in accomplishing the goals in helping patients, depending on what the medical condition is?
So in terms of pain, value-based care is going to look at not only does it work in reducing pain, but how does that benefit affect the individual in having a better, more productive life, whether it's family, work and quality of life. So this is what the trend in value-based care looks like, which is not simply bottom line, but how well does the treatment work?
Bill Klaproth: Right. So you said, does it work and is it worth the costs? So can you also explain to us what a catastrophizing pain scale is and what does that mean?
Dr. George Munoz: This scale is studied and actually one of the metrics used in the study that we were talking about, the educational interventional single versus eight sessions of cognitive behavioral therapy. This scale, which has quite an interesting name, catastrophizing pain scale, means that there are certain neurocognitive and neurologic pathways, that chronic pain causes changes in the brain architecture, function in neural pathways, as well as changes in anxiety, depression, and what people feel in terms of their anticipatory pain that can affect their daily function. So this scale helps us determine how we can change those neural pathways, how we can restructure thinking cognitively and how we can help improve function by minimizing some of this major catastrophizing pain activity that sometimes is not at the very foremost of one's recognition. So we're giving people tools to implement to be able to become more self-aware and be able to self-intervene in their daily life.
Bill Klaproth: Okay. So when you talk about self-intervening in their daily life, is there a special training that someone would need to do this or who can do this type of training?
Dr. George Munoz: So this type of training would be done by a parahealth specialist, a licensed clinical social worker, a physical therapist, cognitive behavioral therapists trained as well as an individual who is possibly an MD or DO, physiatrists, neurologists, rheumatologists, paraprofessional that deals with patients and individuals with chronic pain, but also is trained on using mindfulness techniques, breathing techniques, meditation, being able to teach it and model it as well as self-awareness and mindfulness to be able to redirect when anxiety is occurring due to anticipation of pain in the setting of daily activities.
Bill Klaproth: That's really interesting. And it seems very comprehensive. And one more question, Dr. Munoz, when it comes to chronic pain management and this new study out of Stanford Rheumatology and Medical Anesthesia Group, what's the bottom line on all of this as it relates to chronic pain management?
Dr. George Munoz: Well, the great thing is is that this can be done in line virtually or in groups, both in a clinical setting in a more relaxed atmosphere outside of the standard medical location. But the essentials are timely, they're transferable and transforming. So I like to call them the three T's. They are also the three C's, which are cheap, clinical, conditioning with evidence-based approaches. We have really more efficiency in terms of treatment option that is particularly useful in being able to reduce pain scales and works in favorably altering brain function, and we're able to change structure.
So the ability to contribute to improving someone's disability from chronic pain through CBT and avoiding multiple barriers to access such as time, costs and therapist availability are part of why this worked in the single model.
Bill Klaproth: So, I guess what it comes down to me as a listener listening to you, this gives someone a more efficient way or more efficiency and treatment options, allowing them to better manage their pain. Would that be a simple way to put it? I mean, this is good news.
Dr. George Munoz: That is exactly how I would say it, and this is now probably going to become more and more the trend in both acute and in outpatient settings to begin to address chronic pain in a more efficient and more cost-effective manner.
Bill Klaproth: I love that. That is so good. Well, thank you for bringing this to our attention and explaining this to us. We always want the latest updates and we know we can count on you, Dr. Munoz, to give us those updates, especially when it comes to things like chronic pain, which many of us suffer with on a day-to-day basis. So as always, thank you for your time and your knowledge and information. We really appreciate it. Thank you again, Dr. Munoz.
Dr. George Munoz: Bill, thank you. It's always a pleasure and always a pleasure to reinforce and revisit some of these more difficult topics and get some guidance for listeners.
Bill Klaproth: One-hundred percent. And thank you again, Dr. Munoz. And this is the Oasis Rheumatology Podcast featuring Dr. George Munoz. And for more information, just call (305) 682-8471 or you can visit the oasisinstitute.com. Thanks for listening.
Bill Klaproth: Welcome to Oasis Rheumatainment, a podcast with Dr. George Munoz, Chief Medical Officer and founder of both the Arthritis and Osteoporosis Research Institute, Arthritis and Rheumatology Association Care center, and the Oasis Institute, a fully integrative multidisciplinary clinic in Aventura, Florida. I'm Bill Klaproth.
And on this episode, we talk with Dr. Munoz about chronic pain management. Dr. Munoz, thank you for your time and your insight as always. So let's jump into this, when it comes to chronic pain management, why is this an important topic to discuss?
Dr. George Munoz: Hello, Bill, and such a good question and topic, chronic pain management. This is really important because chronic pain is, number one, very common in the general population. And, number two, it's common in everyday medical care, both in the general medical clinic setting as well as in specialty clinics, such as rheumatology, neurology, orthopedics, physical medicine, rehab, and, obviously, the clinics of chronic pain management. So this is really a very widespread medical condition and there are many types of approaches, so we want to talk a little bit about what some of these approaches are today.
Bill Klaproth: Well, managing chronic pain is something that is needed because a lot of people do suffer from this. So tell us about this new study focused on chronic pain management options and surprisingly good results out of Stanford Rheumatology and Medical Anesthesia group.
Dr. George Munoz: Yeah. So this was a very interesting study that was recently published. We see that the article came out in JAMA just within the past week. And since the opioid crisis is still a thing as people would say, a multidisciplinary value care approach that applies to chronic pain management seems very important and that's what the study looks at. It looks at what are the differences between interventional and educational models of a single session versus eight sessions of what typically has been done in patients with chronic pain in having them enroll in what's called CBT or cognitive behavioral therapy programs, for example, for chronic low back pain.
So this was a randomized clinical trial by the Stanford Group that really had a multi-disciplinary approach, as you said, of both rheumatology, anesthesiology and general medicine. Essentially, this study looked at the single session versus eight sessions of CBT or cognitive behavioral therapy, which is the more standard approach and which obviously eight sessions takes longer than one single session even if it's longer. And also the eight sessions are going to cost more and actually may reduce patient access, desire, or the ability to complete the whole session group for a number of reasons.
Bill Klaproth: Okay. So let's talk more about the eight sessions. You just mentioned a few reasons that limit the eight sessions' completion rate. What are some of the others?
Dr. George Munoz: As I mentioned, cost is going to be one of them, so therefore, monetary reasons for patients to be able to actually afford these. They may not always be completely covered their health insurance or they may have copays that if you have eight sessions, you're going to have eight copays versus one copay and obviously that's going to affect the total price.
And the second thing is time. People having to take off time to do other things from work, from family, from childcare, their responsibilities. So the single shot versus a more drawn out process is what we're looking at here.
Bill Klaproth: So, can you explain to us what value-based care is and how does that play into the study results?
Dr. George Munoz: That's another good question topic, Bill. We are moving in medicine in general now to a time era of looking at the results of what we do in medicine from the value perspective. In other words, does it work and is it worth the cost of what we do in accomplishing the goals in helping patients, depending on what the medical condition is?
So in terms of pain, value-based care is going to look at not only does it work in reducing pain, but how does that benefit affect the individual in having a better, more productive life, whether it's family, work and quality of life. So this is what the trend in value-based care looks like, which is not simply bottom line, but how well does the treatment work?
Bill Klaproth: Right. So you said, does it work and is it worth the costs? So can you also explain to us what a catastrophizing pain scale is and what does that mean?
Dr. George Munoz: This scale is studied and actually one of the metrics used in the study that we were talking about, the educational interventional single versus eight sessions of cognitive behavioral therapy. This scale, which has quite an interesting name, catastrophizing pain scale, means that there are certain neurocognitive and neurologic pathways, that chronic pain causes changes in the brain architecture, function in neural pathways, as well as changes in anxiety, depression, and what people feel in terms of their anticipatory pain that can affect their daily function. So this scale helps us determine how we can change those neural pathways, how we can restructure thinking cognitively and how we can help improve function by minimizing some of this major catastrophizing pain activity that sometimes is not at the very foremost of one's recognition. So we're giving people tools to implement to be able to become more self-aware and be able to self-intervene in their daily life.
Bill Klaproth: Okay. So when you talk about self-intervening in their daily life, is there a special training that someone would need to do this or who can do this type of training?
Dr. George Munoz: So this type of training would be done by a parahealth specialist, a licensed clinical social worker, a physical therapist, cognitive behavioral therapists trained as well as an individual who is possibly an MD or DO, physiatrists, neurologists, rheumatologists, paraprofessional that deals with patients and individuals with chronic pain, but also is trained on using mindfulness techniques, breathing techniques, meditation, being able to teach it and model it as well as self-awareness and mindfulness to be able to redirect when anxiety is occurring due to anticipation of pain in the setting of daily activities.
Bill Klaproth: That's really interesting. And it seems very comprehensive. And one more question, Dr. Munoz, when it comes to chronic pain management and this new study out of Stanford Rheumatology and Medical Anesthesia Group, what's the bottom line on all of this as it relates to chronic pain management?
Dr. George Munoz: Well, the great thing is is that this can be done in line virtually or in groups, both in a clinical setting in a more relaxed atmosphere outside of the standard medical location. But the essentials are timely, they're transferable and transforming. So I like to call them the three T's. They are also the three C's, which are cheap, clinical, conditioning with evidence-based approaches. We have really more efficiency in terms of treatment option that is particularly useful in being able to reduce pain scales and works in favorably altering brain function, and we're able to change structure.
So the ability to contribute to improving someone's disability from chronic pain through CBT and avoiding multiple barriers to access such as time, costs and therapist availability are part of why this worked in the single model.
Bill Klaproth: So, I guess what it comes down to me as a listener listening to you, this gives someone a more efficient way or more efficiency and treatment options, allowing them to better manage their pain. Would that be a simple way to put it? I mean, this is good news.
Dr. George Munoz: That is exactly how I would say it, and this is now probably going to become more and more the trend in both acute and in outpatient settings to begin to address chronic pain in a more efficient and more cost-effective manner.
Bill Klaproth: I love that. That is so good. Well, thank you for bringing this to our attention and explaining this to us. We always want the latest updates and we know we can count on you, Dr. Munoz, to give us those updates, especially when it comes to things like chronic pain, which many of us suffer with on a day-to-day basis. So as always, thank you for your time and your knowledge and information. We really appreciate it. Thank you again, Dr. Munoz.
Dr. George Munoz: Bill, thank you. It's always a pleasure and always a pleasure to reinforce and revisit some of these more difficult topics and get some guidance for listeners.
Bill Klaproth: One-hundred percent. And thank you again, Dr. Munoz. And this is the Oasis Rheumatology Podcast featuring Dr. George Munoz. And for more information, just call (305) 682-8471 or you can visit the oasisinstitute.com. Thanks for listening.