Transcription:
Alternative to OPIOIDS

Melanie Cole, MS (Host):   Use of opioids has skyrocketed in recent years. As a result, addiction to them has increased as well. More and more often people are looking for alternatives to the use of opioids for acute and chronic pain management. Welcome to Palmdale Regional Radio. I'm Melanie Cole and today we’re discussing interventional pain management, an alternative to opioids. Joining me is Dr. Jaspreet Singh. He’s a double board certified physicians in pain management and physical medicine and rehabilitation, and he’s a member of the medical staff at Palmdale Regional Medical Center. Dr. Singh, it’s a pleasure to have you join us today. Before we get into pain management—this burgeoning field that you're in—tell us a little bit about pain itself. Since it’s so subjective, how do you measure it?

Jaspreet Singh, MD (Guest):   When it comes to pain, the first step is to decide what type of pain it is. We can generally put them in two broad categories—nociceptive pain or neuropathic pain. Nociceptive pain is like mechanical pain. This is if you get burns, it’s the pain coming from joints. This is the achy pain from your muscles. Neuropath pain, as the word might suggest, is more of the nerve pain. That’s burning, tingling, maybe some weakness. So typically we decide what type of pain it is because the way that we’re going address these two pains is very different. The biggest thing about pain management is coming up with the diagnosis. Often when I see patients they usually come with low back pain. Low back pain, unfortunately, is not a diagnosis. I typically rely on a good history, a physical exam, and imaging to figure out what the pain generator is and then come up with an individualized plan for that specific patient to treat that pain generator.

Host:   So then what are some of those things that might be pain generators that you're dealing with? What have been the parameters or guidelines for prescription of opioids in the past and what’s different now? Tell us a little bit about stewardship and things that you might look to to help someone with their pain besides opioids.

Dr. Singh:   So once we figure out what the pain generator is—For example, let’s talk about facet generated low back pain. Facet joints are the small joints that run from your neck all the way down to the low back, and that’s one of the most common pains. Now that’s coming from a joint. So that’s mechanical pain, nociceptive pain. This causes inflammation. So the first choice of drug should be an anti-inflammatory, just like ibuprofen. Now we have a lot more anti-inflammatories that are prescription strength. Then these patients are the ones that are going to go to physical therapy. Not just focusing on patient’s pain. We want to focus on their function. For example, some of my patients they have grandkids. So all they want to do is be able to lift their grandkids. So we figure out okay. So what is keeping you from doing that and how do we go about helping you with that? So if anti-inflammatories, physical therapies, or muscle relaxer medications don’t help then we’d go with the interventional management right.

What interventional pain management is, we do injections. There are a number of injections that we do, but they're all done with a purpose. Just speaking of the facet pain, what we do is we do a facet injection or a medial branch block. If that helps the patient, obviously it helped them but that confirmed the diagnosis that that’s where the pain was coming from. Now in the future we can do radiofrequency ablation which burns those nerves, and that lasts six months to a year. So I have some patients that come to me every six months to a year and get that done, and we never start opioids on those patients.

The reasons opioids became some huge was when it was mandated to become a fifth vital sign. So every time you went to go see your doctor or were in a hospital for whatever reason, they would always ask you about your pain. Because, like you said pain is so subjective, people were getting all sorts of numbers. Just like if your blood pressure was high, you would get a medication to bring that down. If the patient’s pain was say six, seven, eight even though they were able to have a conversation because they said it was six they need a medication to bring that down to a two or a three or even lower. So every time you went in, you got more opioids. That became the first line drug to reduce pain no matter where your pain was coming from, no matter what the reason for your pain was. Then it was a big pendulum. When the opioids became a problem, then the pendulum shifted the other way. Now it was, “Hey, we can't give opioids at all.” That was a problem too because some patients actually do need opioids, especially for acute pain, post-surgical pain. There is a need for opioids, but a lot of the surgeons now that were giving six/seven day supply of their medications didn’t feel comfortable doing that anymore. So now the pendulum is this way.

There was a study in University of Michigan that what they followed was they followed dentists and ophthalmologists. So one was a small eye procedure and the other one was a root canal. They found that 50% of the patient that had root canals, six month from their root canal they were still on opioids. They found 55% of patients that had that eye procedure, six months down the line they were still on opioids. So that’s what gave rise to the opioid epidemic. Unfortunately because of the COVID-19 pandemic, the opioid epidemic is actually getting worse but it’s very under the radar.

Host:   That's so interesting. Thank you for telling us about injection therapy and other types of procedures available. So as you said, the pendulum is swinging back and forth. Tell us about some of the things that patients can do on their own. You’ve mentioned NSAIDs and injections. What can they do as far as exercise, lifestyle, meditation, relaxation, biofeedback? There are so many ways today. Speak about some of those.

Dr. Singh:   Yeah, you're right. There are a lot of things that patients can do. So I usually compare sometimes pain management to cardiology. If you have heart problems, you get medication, but you have to make lifestyle changes as well. You do all of the preventative things that you're supposed to. Same thing goes for pain management. Of course you need medications, interventions, but when you go to physical therapy you go with the goal to learn a home exercise program. So I don’t like to send my patients blindly to physical therapy because we get limited number of sessions per year. I only send my patients for like five/six sessions and keep the remaining in our back pocket in case the patient needs “a tune-up” later on down the line. You go there, you learn a home exercise program, and you make that part of your life, daily part of your life. Do 20 to 30 minutes of those exercises.

Another part of pain management that often gets ignored it behavioral health. A lot of patients that have depression, bipolar disease, other psychiatric problems, if they're not addressed their pain will not get better. I tell my patients I've never met anyone who is depressed, and their pain be controlled and vice versa. So if you're in pain, obviously your mood is not going to be controlled. So I typically team up with—depending on patient’s insurance—local behavioral health expert and form a partnership with them so that between us I can help with pain and they can help with mood. They do a lot of biofeedback as well. So this way patient gets an insight in their own diagnosis and they can be well rounded, and we can provide a better multimodal approach.

Host:   Well that’s what’s so important is that multimodal approach. You’ve given us really something to think about Dr. Singh. As we wrap up, please give listeners your best advice that are suffering from chronic pain whether it is in their back or their legs or their knees, wherever they suffer pain, and why you think it’s important for them to see an interventional pain management specialist. Tell us a little bit about what's exciting in your field and give the listeners your best advice about pain.

Dr. Singh:   I tell my patient don’t be okay with just living with pain. Often chronic pain, it’s called chronic for a reason. So if you come to me and you're thinking, “Hey, my pain will be zero,” that might not be true. If you're living at a six/seven, my goal is to bring you down to like a two to a four. This way we go back to the functional aspect of things. So your pain is lower where you can do things that you enjoy doing. Also, you don’t have to come to me. Anyone you go to, make sure you do your research because not all pain doctors are alike. So make sure that your physician that you're going to is fellowship trained in pain management. That’s very important. Because if you're not fellowship trained then you're not trained on a lot of the interventions that are out. We talked about the injections, radiofrequency ablations, but now technology in the past five to ten years have changed significantly. So if you're a patient who’s had a back surgery but still have back pain, leg pain, there are other modalities. So what we do is spinal cord stimulation. So spinal cord stimulation is kind of like pacemaker for the heart, going back to the cardiology. What we do is we put these two leads in your spine, and we do a trial. Meaning it’s a test drive before you actually get the implant. You go home for seven days and you compare what your quality of life was prior to the procedure and after. Seven days later you come back, we pull the leads out from your back, and we haven’t changed your body. It was no surgery, but you decide if that was worth it. Then you get the implant. So that’s been huge in reducing opioids use, and there’s level one data. This therapy has actually been around since the 1970s.

Some of the other things that we’re doing is doing a lot of minimally invasive lumbar decompressions. So patients that have a lot of chronic comorbidities like diabetes, COPD—they can't be put under for surgery—there are other options for you. Next time when you're at the grocery store, just see a lot of the older people that are there, they're always leaning on the grocery carts because when they bend forward their pain gets better. That’s called spinal stenosis with neurogenic claudication. So there is hope for these patients. They just need to see their right physician. I think opioids is not something you need to rely on.

Host:   Great information. So important for us to hear. Thank you for telling us what's going on in this burgeoning field of pain management. Thank you, again, for joining us. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. Please visit our website at palmdaleregional.com for more information and to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Palmdale Regional Medical Center podcasts. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. I'm Melanie Cole.