Darrell Rebouche (Host): Pain, it's something everyone knows. Chronic pain, it is pain at a different level, the kind of pain that impacts lives on a long-term basis. Hello, everyone. I'm Darrell Rebouche. And this is Health On Point, presented by Willis Knighton Health. Our guest today is Dr. John Noles, who is a pain medicine specialist. Dr. Noles, thank you for joining us.

John G. Noles, MD: Thank you for having me, Darrell. I appreciate you calling me to set up this interview.

Host: Sure. Tell me what a pain medicine specialist does.

John G. Noles, MD: Well, primarily, we treat patients with neck pain and back pain. We are the conservative spine pain specialists. We don't do surgery, but we can take care of neck and back pain problems all the way up until the point where you need surgery.

Other common conditions that we treat are arthritis, joint pain, sciatica, nerve pain, pain after surgery, chronic conditions such as chronic regional pain syndrome, and also cancer-related pain. You know, our main goal with treating chronic pain is not just to cover it up with medications. Our goal is to find the source of the pain, treat the pain and improve a patients quality of life. That's the most important part of what we do.

Host: Chronic pain has always been a part of life. We've all known people growing up who suffered. There's a real need for what you do. Tell us a little bit how you got here, because you're an anesthesiologist by training, but then you did a very impressive fellowship in pain medicine.

John G. Noles, MD: Yes. Actually, pain medicine fellowships have evolved and improved dramatically over the last 20 years. Pain medicine is a specialty of anesthesiology, physical medicine and rehab, or neurology. All of those different specialties play a very important role in what we do as a pain specialist. And I chose the anesthesia route to get to where I am.

Host: Dr. Noles did his pain medicine fellowship at Duke University Medical Center in Durham, North Carolina. He didn't want to brag, so I'll brag on him. So, it's very impressive, Dr. Noles.

John G. Noles, MD: Oh, thank you.

Host: So, what kind of treatments do you perform? What do people see of all the chronic pain you described? You said it's not surgery necessarily. What is it?

John G. Noles, MD: Well, we use a multimodal approach to treating the pain, meaning we have multiple tools that we use to try to help our patients. First of all, we try to precisely diagnose the problem using physical exam, history, imaging and even some diagnostic injections to get to the source of the pain. And then, interventional procedures are a major part of what we do to help treat patient's pain. We also, of course, highly recommend physical therapy, lifestyle changes such as exercise, diet changes, all those things are a very important part of treating chronic pain.

Medications also play a role, especially the non-narcotic medications. We use anti-inflammatories, neuroleptic medications, muscle relaxers. And opioids are appropriate in certain situations, but we're careful with those. One of the biggest misconceptions about chronic pain management is that what we do is not just about prescribing pain medications. We do focus on functional restoration and trying to minimize long-term medication use.

Host: How does someone decide it's time to seek the care of a pain medicine specialist?

John G. Noles, MD: Most patients with neck and back pain, they typically start having episodic flares that come in waves. They get better on their own. And then, over time, patients oftentimes will seek care once that pain becomes either severe in intensity or the duration is lasting longer, or it's happening more frequently.

Typically, most patients have had pain for three months or longer when they come to see us. It doesn't have to have lasted that long. Most of the patients that come to see us have already seen their primary care doctor or maybe gone to an urgent care center or an orthopedic surgeon or a spine surgeon. But, you know, the earlier they get to us, typically, the better the outcomes

Host: You bring up something. You say that most people have seen the primary care physician or have been to an urgent care center like a Willis Knighton QuickCare. Can someone call you directly and make an appointment or are you referral-based?

John G. Noles, MD: We're referral-based at this point.

Host: Okay. So, you ask your primary care physician, "I want to go see Dr. Noles and one of his partners." Okay, good. It's a very important thing to clear up. You mentioned that, over the last, I don't know, decade or two, things have really changed. So, how is pain management and what you do different than it was 10, 15, 20 years ago?

John G. Noles, MD: In the past 15 or 20 years ago, we were heavily medication-focused, especially opioids. We were less precise about locating the actual pain generator for the patients. We had limited procedure options at that time. So, the mindset was basically based off of the Joint Commission recommendation in 2001, that pain is the fifth vital sign.

And so, we got wrapped up in this cycle of treating a pain score, treating the high numbers of pain scores. And opioids were the most common treatment that we had at that point. So, unfortunately, with the overtreatment of the pain scores, there was an overuse of opioids. And so, modern pain medicine is focused on finding the exact source of the pain using diagnostic imaging in combination with our clinical correlation, of course, and augmenting our exam and findings with diagnostic injections, which were not really widely used before modern fellowship training. So, we have a number of advanced procedures now that can really help patients. And, you know, opioids have moved to the bottom of the algorithm for us when we're deciding how to treat our patients.

Host: It seems to be a point of emphasis to really get away from using opioids. Can you explain to us why that's important?

John G. Noles, MD: Well, as with every facet of medicine, the more time we have to study the effects of different medications and different treatments, we've realized that there are higher risks and fewer benefits and limitations with opioids that we didn't fully realize 10 to 15 years ago. And so, the practice has evolved as the medical evidence has evolved.

Host: This is Health on Point presented by Willis Knighton Health. It is the point where life meets medicine. And our guest is Dr. John Noles, a pain medicine specialist in Shreveport, in Bossier City, Louisiana. I've heard you talk about a number of methodologies you use. Radiofrequency ablation, what is that? And what conditions does it treat?

John G. Noles, MD: Radiofrequency ablation is one of the most common procedures that we use in addition to epidural steroid injections and selective nerve root blocks. But the radiofrequency ablation is a procedure that is used primarily to treat neck pain and back pain that doesn't radiate into the extremities. It treats arthritis and the joints of the neck. And the cervical spine and the joints and the back and the lumbar spine.

We can also use it to treat sacroiliac joint pain. And more recently, in the last couple of years, we developed a technique where we can use it to treat arthritis of the knee as well. And it's primarily used in that application for patients who are not surgical candidates or patients that have knee pain, continued knee pain after surgery. So, the procedure itself is minimally invasive. We do it in the office primarily. It uses heat generated by radio waves to target very small nerves that are carrying the pain signals. We interrupt the nerve's ability to send this pain signal to the spinal cord and then to the brain. The procedure takes about 10 or 15 minutes. We use a very thin insulated needle at multiple sites to block the nerves. We apply the electrical current for about 60 seconds in most cases. So now, the nerves do regenerate slowly over the course of six to twelve months. So, we oftentimes have to repeat this procedure roughly once a year.

Host: Breaking news, I'm probably going to call you, I think, to come see me. All right. You know, we hear about spinal stenosis. It sounds like a big word for somebody who doesn't really know why that is. Maybe you can explain what spinal stenosis is and you have some minimally invasive procedures that can help with that.

John G. Noles, MD: Yeah. Spinal stenosis is one of the conditions that we see very commonly in the elderly population. You know, as our medical care has advanced, people are living longer and longer. And so, we're seeing more and more patients who have back pain related to lumbar spinal stenosis. Stenosis is essentially narrowing of the spinal canal causing compression of the nerves. Most patients that have spinal stenosis have the symptom of back pain and leg pain with walking. Most of these patients will often have some degree of numbness or heaviness in their legs. They tend to get relief when they stop walking, or when they sit down or when they lie down, those are the common characteristics of lumbar spinal stenosis.

Host: Any minimally invasive procedures to address that?

John G. Noles, MD: Yes, we have a number of procedures that we use to treat it. Typically, we will start with epidural blocks or nerve root blocks. Because for some patients, these can last weeks to months. Epidurals don't really fix the structural problem of the narrowing or the pinching of the nerves. But they do provide decreased swelling and decreased irritation of the nerves, which can give pain relief. And some patients do very well with these. Some patients we have to do it once every six months, once every year, some patients are more frequent. If you get to the point where we have to do the epidural procedures every two or three months, or if they stop working because the stenosis is too severe, then we look to more advanced procedures that we have available. Oftentimes arthritis is a big component of the stenosis, because just like the joints of our fingers expand as we age, the joints in the lumbar spine and the cervical spine also expand and they encroach on the nerves. And so, arthritis is often a component of lumbar spinal stenosis. So, the radiofrequency ablation that we just talked about can often be an option. But again, that doesn't necessarily fix the structural narrowing that we are trying to treat.

One of the newest procedures that we have developed is called the MILD procedure. It's a minimally invasive lumbar decompression, and this is a great procedure for patients who are not candidates for a major surgery, maybe due to their advanced age or medical comorbidities. It is a procedure where we go in through a very tiny incision on an outpatient basis, we remove part of the bone. And the thickened ligament or the folded ligament that's pressing onto the spinal canal, causing the stenosis. This takes about 20 or 30 minutes. It can be done with a sedation anesthesia-wise. And so, you don't have to undergo general anesthesia for this procedure. And we've had some really good success with this procedure as well.

Host: That's not spinal cord stimulation, though. That's a different thing. What is that?

John G. Noles, MD: Yeah, that's a different modality that we use. Spinal cord stimulation is used primarily for patients who have failed back surgery, meaning that they've had one, two, three, four, or maybe even more lumbar spine surgeries. And for whatever reason, they are still having severe pain. In recent years, we have studied spinal cord stimulation for the use in spinal stenosis, and it absolutely does help many of the patients with this problem. I'll tell you a little bit more about it if you would like.

Host: I'd like that very much. Yeah, please. I think that's very important for everybody to know.

John G. Noles, MD: Right. So, spinal cord stimulation, again, it's one of those procedures that's best used for patients who are not surgical candidates, because we are not fixing the structural problem of the spinal stenosis with this device. It's based on a pacemaker technology. We put two electrical leads next to the spinal cord. And we use a very gentle application of electricity to the spinal cord to block how the pain signals are sent to the spinal cord and then to the brain.

The way the device works is we have to do a trial phase first. So, the good news about it is we test it to make sure the patient is going to get relief with a stimulator before we go ahead and do the implant. The stimulator trial is done in our office under our x-ray machine. And we leave the leads in for about a week. That gives us plenty of time for the patient to test it and for us to go through multiple different programs to make sure that it is going to be a device that works. And after a week, the patient comes back to our office, and we remove the leads. And then, we can schedule a date to put in the pacemaker battery and the leads under the skin to leave it in more on a more permanent basis.

Host: I can imagine that some of these things are a little bit intimidating to the average patient, especially someone who is seeing you for the first or maybe the second time, and you're offering these kinds of recommendations. But generally speaking, can you speak to how your patients respond? I can assume they very much trust you and very much want their pain to be relieved and say, you know, "Dr. Noles, do whatever you got to do." Can you kind of characterize an average interaction with someone who's seeing you early on in their treatment plan with you?

John G. Noles, MD: Sure. I mean, you're touching on a very good point there, Darrell. The advanced procedures that we do, typically, we don't offer them right off the bat to most patients. We want to take a step-wise approach to managing their pain. Oftentimes I'll tell patients that, "Hey, look. There's no magic fix to your pain that I can give you today. Pain is a complex problem and we're going to take a step by step approach and go through the safest, least invasive options first." And then, we will advance towards the newer, modern technologies that are a little bit more invasive. So, it does take some time for us to identify the source of the pain and go through some treatment options until we find the right one for every patient.

Host: And the more I think about it, and not only are you a physician, but you also are a relationship builder, you and your partners. I mean, when you talk about this, it is, it's a progression from, "Hello, I need you" to "Hello, I can help you, I hope" to "Wow, you've got a kind of a longstanding relationship." Is that how the arc typically goes?

John G. Noles, MD: It does. You know, I have some patients who I have been seeing for over 10 years now. And like I kind of mentioned at the beginning, a lot of our patients, their pain is episodic and it comes in waves. So, they may come in and I may do an epidural injection or a nerve root block injection for them, and I may not see them again for two or three years. And then, they come back. It's amazing. It's kind of neat to see the same people that I've known for over 10 years. Hopefully, I don't have to see him very often, but It's nice to have a continuity of care and build up a level of trust. And you kind of see a response and you get a feel for how each individual patient is going to respond to the therapies over time.

Host: You mentioned that your referral base. Now, I'm kind of curious about who most often refers to you? Is it orthopedics? Is it rheumatology? Is it primary care physicians? Is it all of those? I mean, how does it break down?

John G. Noles, MD: it's really all of the above. We have a very broad referral base, I would say. The primary care doctors send patients to us who are not interested in surgery. The orthopedic surgeons send patients to us who the patient may think they have a hip problem or a knee problem, but really they have a back problem. And then, you have the spine surgeons who often see the patients and they want to try to go through all the conservative therapies first before considering surgery.

Host: What should patients generally speaking know before they see a pain specialist?

John G. Noles, MD: I think probably one of the most common misconceptions is that, a lot of people think they're going to be forced to take pain medication when they come see us. And that's never the case. We never force anybody to do anything, whether it's the medications or procedures or imaging, you know, it's always a collaborative effort. So, that's one of the most important things.

I think it's important for patients to do the best they can to bring all of their medical records with them when they come see us, because pain is often a complex problem and often patients have seen multiple doctors. And the more information I have to look at the first-time I see the patient, the more quickly we'll be able to start the patient's care plan.

Host: Okay. I have an operational question about that. You have people bringing like a folder with their medical records. You have access within the Willis Knighton system, I assume, to a lot of medical records as well. So, what's the best way for patients to bring their medical records to you?

John G. Noles, MD: That's a great question. So, most of the time our referral coordinators will request the records from other physicians' offices if they're outside of the Willis Knighton system. The beauty of our health information system that we have now, the Expanse system, is that all of the records gathered within the Willis Knighton system are there for me to see. So, I can see all the primary care notes, I can see the orthopedic notes, I can see the ER visits, which is a huge advantage. It's a huge advantage to the patients for us to have a system like this. So if you've been seen within Willis Knighton, it's very easy for me to see what's been done. It's really the patients that have been seen outside the system or if they've been getting care for their neck or back for 10 years and they've seen multiple doctors over the years, that's when it gets a little more complicated. But we have referral coordinators who are happy to assist and they work tirelessly to gather all the records that we need, and we do our best to try to have as much of that information for the patient's first visit.

Host: That's great. So to sum it up for people who might be intimidated by the prospect of having to gather all these records, you have people with a lot of experience who can help with that. So, thank you very much for that. So, we've talked about what got you here and what you do, but what do we look ahead to? What is the most exciting to you about the future of pain management and pain medicine?

John G. Noles, MD: Our specialty is very technology-driven, especially with our spinal cord stimulator devices that has the same level of technology as a pacemaker, defibrillator. And we are incorporating iPhone compatibility, and we can monitor patients and their functional status better now than we ever have been able to. That's really what we're focusing on, is functional status. You know, pain relief is obviously very important, but the most important thing is for us to get patients back to living a normal life. So, we're having better and better ways of doing that.

There's also major advances in the realms of regenerative medicine, therapies. A lot of our therapies that we have now are, focused on treating the pain symptoms and treating the problems, but not necessarily healing the body. And there's a number of regenerative therapies that are in the early phases that I think are going to be very important for us to help treat patients with neck pain, back pain, joint pain, I'm looking forward to that too.

In fact, we have one recent advance of procedural called VIA Disc, which is injecting the nucleus pulposus of a disc back in a patient, and we're seeing some really good results with that. And that's an option for a lot of patients with degenerative disc disease and back pain.

Host: Well, thank you, Dr. John Noles, for your time. Thank you for your expertise. And thank you for doing what you do all day, every day, and that is giving people relief and making people feel better.

John G. Noles, MD: Thank you, Darrell. I appreciate you having me on the show today.

Host: All right. Well, this is Health on Point, presented by Willis Knighton Health. I'm Darrell Rebouche and, again, for Dr. John Noles, thank you.