Evo Terra (Host): This is Palmdale Regional Radio. Today, we're discussing chronic pain. I'm Evo Terra, and I'm joined by Dr. Thomas Nasser, a doctor of osteopathy, and a member of the medical staff at Palmdale Regional Radio. Thank you for joining me today, Dr. Nasser.

Thomas Nasser, DO: Good morning.

Host: What is chronic pain?

Thomas Nasser, DO: Chronic pain, besides being a very hot topic in medical culture now, is strictly defined as pain that lasts longer than three months. And chronic pain-- how I like to think of it-- is the type of pain that's a little bit more unpredictable than acute pain, which is less than three months. Chronic pain is the kind of thing that can go in a variety of directions and can be a big problem for a lot of people. Oftentimes it's why they seek a pain specialist like myself.

Host: To continue on that, seeking out a pain specialist like yourself, what types and what causes of this chronic pain do you generally see in your practice?

Thomas Nasser, DO: In our practice, we see a variety of things. Anything that can hurt from head to toe that could last in terms of weeks or months beyond an initial insult. So, we work a lot with trauma surgeons and orthopedic surgeons, and we have a lot of patients that have fractures that should have healed and been without pain after two, three months, and they continue to be a problem. We also have people with multiple sclerosis that have pain, spinal conditions like pinched nerves or herniated discs that last longer than they should, people from car accidents, people who have pain from genetic disorders, a whole variety of things. And a whole variety of age groups. We have young people with injuries. I have older people with nerve diseases and Parkinson's disease or a lot of different things like that. There are a variety of physicians that treat pain. I'm a physiatrist, meaning I work dealing primarily with function, and function is our primary objective. And pain is a big barrier to function.

So if you look at a patient who's had-- we'll just say-- a leg fracture, for example, and they can't walk. And so, they have surgery to fix that fracture. And after two to three months, we anticipate that they would be better, but they're not. So, we do a lot, and this is in the chronic space. Obviously, we're working with these patients in the acute space as well, the first two to three months of injury. But in the chronic space, we're still doing therapy, prescribing medications, considering injections or other modalities that could help with the patient's pain. And the objective of the physiatrist is really function. So, we're asking them, you know, "What type of daily living activities can you not do because of this pain? How do we go after those things? What type of things that you do that would typically help you to enjoy your life that you can't do, whether it's a walk in the park with your partner, or it's playing basketball, or being able to drive yourself to and from work or the grocery store. Any of those things that we take for granted every day can be radically impacted by having chronic pain.

The other challenge with chronic pain that the physiatrist or pain specialist may often see is the social impact of chronic pain. Oftentimes if we have an injury or an insult that leads to pain, we have some resources in our bag, in our home, in our family, in our social structure that will get us through a month or two, whether it's some money saved up for time off work or some family members who can take time off to be with us or those types of resources. But often, when the issue becomes chronic or longstanding, those resources start to wear thin. And so, it just becomes more and more complicated. And there are a lot of people who are suffering from those conditions that some of them we have great success with. But unfortunately, some of them, the challenges are greater and they last a bit longer.

Host: As you speak through all the different modalities and things we can do with injections, medications, look, we live in a world where more of us are being concerned with becoming addicted to our medication. So, can you talk to us about the non-addictive medications that can be used to treat pain?

Thomas Nasser, DO: This is a very, very slippery slope in the sense that the medications that are "addictive" are also oftentimes the most effective, because the pain is very powerful. And those medications used in the short term are incredible tools for us as pain physicians to help keep things under control and keep people's lives manageable. So, it's the role of the pain medicine or pain management provider to help protect the patient from those types of dependencies or addictions. And so, it's important that we step outside of the conversation for a moment and define a few things.

One of the things that we want to define is the difference between dependence versus tolerance versus addiction. And they're often misunderstood. So, let's say, for example, that same patient who has the leg fracture goes to the doctor. And that patient happens to need a strong painkiller because they had a very bad fracture and a very large surgery. So, we give them a strong painkiller. You can fill in the blank with any of the most common names, you know, hydrocodone, oxycodone, morphine, or any of those other big scary names out there. Fentanyl is one of them, and it's a terrible, terrible drug if used in the illicit way in the streets, et cetera.

So, we give the patients some of these medications to essentially survive because the pain is debilitating and we give them in the first four to six weeks. It's the objective that, as the problem improves and the pain reduces, we reduce those medications. So, the oversight on part of the pain physician through that process is super important and super critical, and we ultimately are also using other medicines in that setting to lower the requirement of the painkiller that has the addiction potential.

However, despite our best efforts, some people become dependent. And what does dependent mean? It means, "I can't live my life. I depend on this medicine. And I have to have it every day in order to take my children to school, to clean my house, to go to work, et cetera." What does tolerance mean? It's often the next step, and works similarly to dependence. Tolerance means, "The medicine didn't work well enough. I've become tolerant to it and I need a larger dose."

Tolerance and dependence are very common, but they don't happen in everybody. And neither one of them are addiction, but both of them are often confused with addiction. So if that same patient sees me in the office, we prescribe the pain medication. And two weeks later, the pain is still bad and they go to the emergency room and they say, "Hey, doctor, I'm taking these pills from Dr. Nasser, but the pain is still bad." They're often labeled as addicted, but they're really not addicted. It's unfortunate. And in a moment, I'll explain to you why I'm laying it all out in this way. Because it's very important to understand addiction is the next level with that.

And addiction is often defined as a behavioral disorder with the objective of secondary gain. And so, addiction can occur in that same patient who is unwilling to put the energy or effort into wanting to wean down on the medicine or try their medicines or go to physical therapy, et cetera, et cetera. And that same patient who we would typically be using these medicines to help facilitate their activity, their living, or life. They'd rather sit on the couch and watch cartoons and not put the energy into really wanting to get better.

And so, there's a personal investment lack that comes oftentimes with the transition to addiction, but that's not the only time. Sometimes people are genetically predisposed and they become super dependent or super tolerant, which leads to addictive type behavior. The difference between the patient who's addicted and the patient who's dependent and tolerant, the patient who's dependent and tolerant is going to physical therapy, putting in effort, showing up at their appointments, putting everything into what the doctor-- when I say, "Hey, listen, I need the best out of you. I need you to work really hard with me as a team to get you through this problem." And those patients who are doing that, they're not the addictive patients when they show up to the emergency room or they're continuing to have problems. Those are patients who are dependent or tolerant, but just really struggling. My heart breaks for these people, because it's a true struggle. If you would for a moment, imagine the worst pain you've ever had. And imagine the doctor's giving you medication and it's still not going away, and you're doing everything the doctor says, and it's still not going away, what would you do? You'd go to the emergency department. You can't live, you can't sleep, you can't eat. It's reasonable.

There's such a gray and blurred line that's hard to define for the average practitioner and average person between that person and the other individual. This other individual is not taking the medications as prescribed. They're taking them more than prescribed. They're taking their friends' medications. They might be using illicit substances. They might be mixing cannabis or other non-prescribed medications to try to get sleep or deal with their depression or deal with their pain. And they oftentimes will even be honest with me about it. And I can tell them, "Listen, you have to do what the doctor says and to the letter, because then can run the risk of becoming addicted or having these addictive tendencies." So, that's how we understand it.

Now, you asked me a question, what are the non-addicting treatments or medications? And I lay all that out for you first so we can start to look at who we give those things to. And it depends on the patient. And so, everybody gets the non-addicting stuff. Everybody gets the physical therapy, the non-addicting medications, the counseling, the encouragement, the exercise program. We give all of our patients special nutritional recommendations with supplementation. We offer all of them behavioral modification strategies. We offer all of them counseling. We see them frequently and oversee how they're using the medications. We monitor them. We do drug testing. We collaborate with local physicians to ensure that they're only being prescribed by one practice. So, we have a lot of these safeguards in place. And there are a lot of options. I really love regenerative medicine. I love PRP, peptides, stem cells. We do a lot of that out of our practice. Not only is it good for longevity and overall health and to reduce inflammation, but it's great for patients who have pain. Why? Because oftentimes when patients have pain, it's an inflammatory, a chronic inflammatory disorder. There's a lot of inflammation of the soft tissues near the site of injury.

And so, we combine all of these things, nutrition, exercise, therapy, counseling, peptides, PRP, all of these things, and non-addicting medications. The overall objective is to really not just control the pain and inflammation, but reduce the amount of the opioid or heavy, strong painkiller-type medicines that we need. And that's the strategy. So, it's a complicated question, because it's not only is every individual an individual and we have to treat them like that, but there's a large milieu of what we would actually do and how we would actually treat these patients and gauging the amount of-- we call them addictive type medicines-- gauging the amount that we give really is based on the individual, the type of injury, the chronicity or age of the injury, their response to other types of treatments, et cetera. And I haven't even entered the spectrum of interventions like injections or surgeries or things like that, which are great options, but sometimes those cause more pain.

So, it's a big world. But for me, personally and professionally, it's incredibly exciting, because I think despite what we're reading in a lot of culture and literature, we have a lot of success. We have a lot of success. People are not stuck in that horrible state forever. And the ones that are, if you find the right practitioner that's not willing to quit and continue to wrestle with it, you can have some good outcomes. I hope that wasn't too cluttered for you. It's a big explanation.

Host: Yeah. No, it's a great answer and I think what it really clears to me is, since I am not a sufferer of chronic pain, when I think pain, I think medication to fix the pain. But clearly, that's fine if I've got a headache. But for something else, it sounds to me you've got a big tool belt, lots of things that you can use to evaluate what's going to be effective for any given patient. By the way, how often do you have to adjust that initial treatment plan?

Thomas Nasser, DO: It really depends. And speaking to a big tool belt, you have to have one. You absolutely have to have a big tool belt because, sometimes we're making decisions based on how well something worked. And if something didn't work, we better be ready to pitch. We better be ready to look for something else. You better have something else in your corner or that poor individual is in trouble. And a lot of times, as pain management providers, we're the end of the line. The surgery's already been done, the cancer's already been removed, and they're still having this horrible pain that won't go away.

 I often joke, like things end at my desk. There's no desk past mine for me to hand it to. And so, I have to have options for my patients. One of those powerful things I can do is look my patients in the eye and say, "I will not quit. I will look for something. I'll find something. And if I can't, I'll make a call for you. I'll get a colleague involved, but I'm going to do everything that I can and more to make sure we're overturning every stone find something for you."

So, what I often do is, each year, I add something new to my practice. I do a lot of training, a lot of courses. I learn new surgeries, I learn new objectives. I learn new skills in order to increase that tool belt. as you speak. And I think that it's just heartbreaking to be honest with you, the suffering that a lot of patients are going through. And it comes back to not only the physical pain that they're experiencing, but the psychological and emotional pain that they're suffering, especially in the patients who are very high functioning prior to whatever caused their problem.

So, it depends on the patient. So for example, I saw a patient recently who had nerve pain from shingles and the patient was asking about nerve blocks and injections and how we can help with that. But the particular area where the shingles were, the nerve to that was very-- the nerve block is dangerous. It's a risky procedure. So, I wanted to try some medications first. But I noted that during the visit the patient was tearful, really having a lot of pain. They were struggling a lot. And so, I gave them some medication and typically on an average patient, I might see them in a month. I asked this patient to come back in a week, because I wanted to see the effectiveness of the medication. And if the medication was effective, then we wouldn't schedule her for that procedure, which is a bit risky. But if it was not effective, then we would lean more into it.

Contrast that with a person who just had a knee replacement. They're doing decent, but they still need some pain medication. And pain medication's helping, and they're taking it once, maybe twice a day at the most, and they're participating in physical therapy. I would say, "Hey, you can see me in six weeks, and we'll take a look then." And I might even give them some instructions. And I'd say, "If you continue to do really well, let's back off on that medicine in a week or two. And you can call my office and let me know how you're doing." And then, I would also give them instructions to just primarily use the medication for therapy and for mobility and not just every day to use it. So, you have a couple different scenarios there.

Most often in a chronic pain patient, we're seeing them about every 30 days, but there are flareups where we have to see them a little more often. So, there's this world of literature and science and what the DEA and the medical groups tell us, and we try to stick to the guidelines as best we can. But I think the best physicians are human, and they really are sensitive to humanity. And they can look at their patient and say, "I need to see this guy or this gal in a week," "I need to see this guy or this gal in two days." Or this person, they're stable, they're strong, they got it under their thumb, I could see them in two or three months and gauging that as a human and trying to really absorb the level of experience that that other human being is having. What is your pain experience and how do I positively impact that experience as your medical provider? And if that's the mentality that we're having, we find that it's a variety of times that we're making adjustments, we're seeing the patient's back. And it's not by some hard, strict rule book, you know, we have to be human beings here.

Host: Yeah. That's so important, because we have to treat people like people, and be people as you're treating them.

Thomas Nasser, DO: Absolutely.

Host: It really sounds to me like for the people out there who are suffering from chronic pain, there's hope.

Thomas Nasser, DO: Yes.

Host: Yeah. They should come and see someone like yourself, yes?

Thomas Nasser, DO: Yeah. Listen, if we don't have hope, we don't have anything. You know, what's the point? If I don't have hope that my car is going to get me safely to work today, why would I get in it? And so, we want to give people a reason to keep living. The motivated mind will be able to push through anything really.

And so, when patients come to see a pain provider, that provider should be able to not only just metaphorically, but physically hold that patient's hand and look them in the eye and give them some hope. One of the things, my biggest pet peeve as a doctor that just drives me nuts is when a patient comes to me and says, "I saw Dr. So-and-so. And they said they had nothing left for me. There was nothing else they can do." And I guess, I just don't understand that, because they referred the patient to me, and that's something that they can do. And when you tell a person, there's nothing I can do, it's like you're giving them a death sentence. You're telling the person you're stuck with this horrible condition. "Sorry. What do you want me to do about it? I don't care." Like, it's so awful to say that to a human being. I think, I mean, the least we could do is care.

There are patients where I don't do a lot of doctoring. But because I just try to help them feel like we care at our practice, and we're with them and we're shouldering this situation with them. They feel better. And there's a psychiatric and emotional part of this that we have to apply to. We really have to. Because I'll be honest with you, many times that's more powerful than any medicine I can prescribe or any surgery I could do, is to help these people believe in themselves, to have hope, and to leave my office with some degree of encouragement. And there's people who will look at me and say, "Oh, that's hocus pocus. I don't believe your fancy words." But I'll say, "Nope, I believe in you. You're going to get through this. We're going to figure something out." And I try to just really stay on that route. And I think that's something that we really-- listen, if we're not doing that, we're not doing anything. If we're not giving people hope, why? Why go have the surgery? Why get the injection? Why take the pills? Like if you can't give a person hope as a medical provider, even in the context of, God forbid, a fatal cancer or bad disease, to encourage a patient that their final days will be comfortable, to encourage a patient about their lives, and that people around-- I mean, just to find something, there's got to be something to help people. Otherwise, what are we doing? What's the point?

Host: Right. Well, Dr. Nasser, this has been a fascinating, enlightened, and honest conversation, a hopeful conversation, that I hope everyone, has listened to and watched and said, "Yeah, I can do something." Once again, Dr. Nasser, thank you for being with me today.

Thomas Nasser, DO: Thank you. It's a pleasure.

Evo Terra (Host): And that concludes another episode of 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 remember to subscribe, rate, and review this podcast and all of the other Palmdale Regional Medical Center podcasts. For more health tips and updates, follow us on your social channels and please share this on your social media and be sure to check out the other interesting podcasts in our library.

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