Melanie Cole:    Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine, I'm Melanie Cole, and I invite you to listen as we discuss the management of chronic pain after spine surgery.

Joining me is Dr. Daniel Pak. He's an assistant professor of clinical anesthesiology at Weill Cornell medicine. Dr. Pak, it's a pleasure to have you join us for this really great topic. Boy, we're hearing so much in the media about opioids and this epidemic and pain management. We know this is such an important aspect of quality patient care. So why is it so important for you to pay special attention to the amount of opioid medications that you're prescribing patients? Tell us what you're seeing.

Dr. Daniel Pak: There's been a lot of press and attention on opioid use, as you're probably aware, and patients were previously prescribed very large doses of opioids. So in addition to the dependency issue that are pretty much well known now at this point, we found that these patients weren't doing so well afterwards, if the outcomes weren't that great.

So for example, patients weren't doing better and they were on higher doses, and getting less pain relief because, ultimately, they build a tolerance to these medications. Chronic opioid use also has other effects that can affect immune function, cause constipation. It can also affect hormone levels. They've been great from that aspect. And at high doses, patients can actually become sensitized to their pain. And so for that reason, we really tried to reserve opioids more for acute and postoperative pain or to bridge to surgery for severe pain issues.

We do try to use what we call the lowest effective dose and use other non-opioid adjuncts or other medications such as nonsteroidal anti-inflammatories, other nerve pain medications, for example. And we also try to follow these guidelines that are set by the CDC now in terms of how much opioids prescribed people.

Melanie Cole: Well, thank you for that. And again, it's such a great topic. So tell us how you work with patients after surgery with a multimodal approach to chronic pain. You just sort of briefly touched on it a little bit. First, tell the listeners what does multimodal even mean? And what does this look like, this type of after surgery pain treatment? What does that look like?

Dr. Daniel Pak: There is a recovery phase after surgery and patients should always be aware of that. And how long this is, is really dependent on, for example, the patient's functionality before surgery and also the type of surgery that they're getting, right? So there's a full spectrum of surgery. There's small spine surgery, and there's also a larger spine surgery.

And so the recovery process will differ depending on those things. Now, we always try to utilize a multimodal approach. And so what that means is utilizing a variety of different types of treatment modalities. This includes things like physical therapy, so that helps to improve function, a variety of medications, which we already talked about, but that includes opioids in the kind of the immediate post-operative period and also non-opioid medications.

We always try to utilize interventions if patients are candidates. So for patients who are amenable to this and sometimes injection therapies can provide more targeted therapy that can reduce medication use. And there's also other alternative medicine techniques such as cannabinoids and acupuncture and stuff like that. So those are other tools that are really at a patient's disposal.

Melanie Cole: And so you sort of layer these on to each other, right? I mean, because that's the thing that I think a lot of patients have questions is how do these things all come together? And since pain is somewhat subjective, how do you even go about measuring it?

Dr. Daniel Pak: So pain is subjective, but there are other ways that we can measure it. So traditionally, we've used a number of scales. So when you go to a pain physician’s office, they'll oftentimes ask you to give them a pain score between one to 10, 10 being the worst pain. Also, they may give some questionnaires that ask about the nature of the patient's pain. Other things that we look at include things like pain medication consumption. So you would expect as the patient's pain improves, you would expect to see the patient using less medication.

But now we're also using functional measures, too, right? So specifically for patients who have spine surgery, we'll often ask them how far can you walk after surgery? What kind of range of motion do they have? Can you stand for longer periods of time? And so these functional measures are oftentimes more objective and also more reliable to not only monitor pain, but also monitor how well the patient is doing. And so this is a great way to actually show the patient that they are in fact doing better after the procedure and after the surgery.

Melanie Cole: And also you briefly touched on the role that opioids do play. Tell listeners what you want them to know about the need that sometimes these are what you need to use maybe just right at the beginning, explain a little bit about the parameters for opioid use so that listeners understand that sometimes this is what needs to be used, but then we can look to these other options and move along from there.

Dr. Daniel Pak: So opioids definitely have a place for patients with acute pain to your point after surgery for example. Pain is expected after a procedure and so we do prescribe these for patients. Just even a decade ago, we weren't really aware of all the negative effects of chronic opioid use the way know now and those were some things that I had talked about and touched on previously. But there is a place for it after surgery.

Now, chronic use is a little bit more controversial and, for patients who are on existing chronic opioids, we do try to reduce the dose in a responsible manner in the longterm for all the reasons that we had talked about before, because it doesn't really benefit the patient in the longterm to be on these on the longterm.

So there are some guidelines that we try to also follow, and we will try to use the lowest effective dose in the shortest course that's feasible. And also, there are other recommendations that we follow from, for example, the CDC. So for patients with non-cancer related pain syndromes, we try to stay under 90 milligrams of morphine equivalent a day.

Melanie Cole: Doctor, thank you for telling us about multimodal approach, but we do know there is a role for opioids, especially right after surgery. Can you tell us for listeners that have questions, what role opioids do play and what you'd like us to know about them?

Dr. Daniel Pak: So usually I want them to utilize them in conjunction with one another, so really attack the pain from a multitude of different angles. So including the use of physical therapy, some of the other things such as yoga, acupuncture, other things such as injection therapies whenever they're appropriate and also non-opioid-based pain medications, for patients who have continued pain, despite some of these more traditional treatments, then we also consider other therapies.

And one of the things that we offer is something called neuromodulation. And so an example of this is a therapy called spinal cord stimulation, and it's a cutting edge therapy that delivers essentially small pulses of energy to the spine to scramble the pain signals so that the patients get relief. This is oftentimes for patients who have pain related to spine surgery, and these patients will often complain of back and/or leg pain. And what it does is it provides relief without affecting normal nerve function. So that's a question that we get fairly often, is that is that going to affect my ability to sense other things or is it going to affect my motor function? And it doesn't do that.

And so this is something that has really been kind of at the forefront of our field. And what's also nice about this therapy is that you go through a trial period before actually committing to the therapy. So it is an implantable treatment. But before they actually commit to this, they do a trial period where we place these leads and we just tape the battery to the back, and then the patient goes home for about seven days and essentially test drive the therapy before having to commit to it. And so it gives them the opportunity to see what kind of benefits that they would get. And this has worked out very well for a lot of our patients who had persistent pain following spine surgery.

Melanie Cole: That was pretty cool. So I'd like to-- because we're going to talk just a little bit more about those approaches, but how has COVID affected patients with chronic back pain? What have you seen happening as far as the opioid epidemic and chronic pain management? Since it's not necessarily something that can be done very well via telehealth, but I don't know. Tell us what you've been doing during this pandemic.

Dr. Daniel Pak: So I think much like other patients, our patients were certainly affected. At the peak, when it was occurring in New York, our clinic was closed and we had minimal in-person visits. So obviously, patient visits were limited and we couldn't offer a lot of our therapies to patients who really needed them.

Other facilities where patients could get treatments were also closed. So rehab centers were also limiting the number of patients they were taking, if they were taking them at all. And then also elective surgeries weren't being performed. So I think these, all in combination, really affected our patients tremendously.

Now, this has really drastically changed as we have learned to adjust to the circumstances. And so, we're doing a lot of telemedicine visits and so this has really increased access for patients, even before the pandemic had occurred. So, we can do video visits so patients don't have to come in the office necessarily to see us. We've also resumed in-person visits as well. So for patients who do need to come into the clinic, we're happy to see them and the necessary safeguards have been put in place to make sure that the providers and the patients are all safe for those encounters. And we've also resumed doing interventions for patients as well. And so, now a lot of the issues that we had before have been corrected and more or less we're operating at normal capacity at least at our hospital.

Melanie Cole: And what about as we wrap up, Dr. Pak, what about new techniques that have been developed? Is there anything exciting in your field? I mean, the field of pain management and anesthesiology is such a burgeoning field and pain management being relatively new, tell us what's exciting in your field and are things like medicinal marijuana or massage or any of these kinds of techniques coming in to your field as well?

Dr. Daniel Pak: So we're really trying to utilize a lot of these other alternative methods, such as medicinal marijuana, acupuncture, massage therapy, different types of other therapies, such as yoga. And also in addition to that, other newer interventional techniques like neuromodulation, and I think patients have really benefited tremendously from this.

We, for example, have an office in a division specifically that offers some of these more new age techniques, such as medicinal marijuana and acupuncture, and it's actually led by a physician. So I think a lot of our patients have gotten a good amount of benefit from that. So certainly those are techniques that we're utilizing.

Melanie Cole: And doctor, do you have any final thoughts you'd like to share with listeners? There are so many questions surrounding opioids and pain management. Please give us your best advice. Let listeners know what you'd like them to know about how you can help them with their pain with this multimodal approach that's so unique at Weill Cornell medicine.

Dr. Daniel Pak: I think with what we know now about the opioid epidemic, the way we treat our patients post=spine surgery is drastically different. And again, it's with the utilization of multimodal techniques, some of the newer atrial techniques. And again, there's a lot of other newer interventions that we have now that weren't available even five to 10 years ago.

So what would I tell patients is to really discuss this with your spine surgeon and also your pain management physician. There are certainly options out there that weren't available several years ago. And certainly these are things that we're offering at a multidisciplinary spine center, such as Weill Cornell Medicine and New York Presbyterian.

Melanie Cole: Thank you so much, Dr. Pak, what an important episode. Thank you for sharing your incredible expertise with us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to thank our listeners and invite our audience to download, subscribe, rate, and review Back to Health on Apple podcasts, Spotify and Google Play Music. For more health tips, go to WillCornell.org and search podcasts. Parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole.

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