Episode 033: Pain Points

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Brian: Hello, and welcome to today's podcast. My name is Brian Fortenberry, and we are going to be talking about targeted pain treatment options. We have an expert here to help us out with that and navigate all of these questions and issues. It's Dr. Stephanie Vanterpool. Welcome!

Dr. Vanterpool: Thank you.

Brian: Tell us a little bit about yourself and about your background before we start jumping into talking about this targeted pain treatment.

Dr. Vanterpool: Certainly. Well, I'm the Director of Comprehensive Pain Services, here at the University of Tennessee Medical Center in Knoxville. I'm also the Medical Director of the University Center for Pain Management, where it is our institution's comprehensive pain management center. My focus is the accurate diagnosis and targeted treatment of pain, and really as a clinician what that means is I focus on helping my patients reclaim belief in functional quality of life by figuring out what's causing their pain, and then targeting treatments to that cause. But also as an educator, my responsibility is to train and educate my peers and my colleagues on finding out the importance of finding out the source of pain and then targeting treatment. And then finally, as a researcher and as a clinical investigator, I feel that my role is to help expand the body of knowledge when it comes to identifying the cause of pain. So that's kinda what I do.

Brian: That sounds fantastic, and I'm really going to be looking into that educator part of you today.

Dr. Vanterpool: Certainly.

Brian: So Doctor, what really led you into the interest of this specialty of treating people's pain?

Dr. Vanterpool: Well, that's an excellent question. It started out actually the third year of medical school, when I was following one of my mentors in the pain clinic at Duke University. I was able to see the effect that she was able to have on patients who were coming in with severe pain, and by treating the source of their pain. And then, when I continued my training as an anesthesia resident at University of North Carolina at Chapel Hill and then pain fellowship at Wake Forest, it helped me to hone my skill set and understanding how important it was to diagnose and treat pain, and then see the effects on these patients that came in bent over, not able to walk, and leaving out standing up straight after we had done a series of injections that targeted the source.

Brian: That's got to be incredibly satisfying, not only from a physician standpoint, but just from a human nature, to be able to help someone-

Dr. Vanterpool: Absolutely.

Brian: ...in a way that it's really life altering for them.

Dr. Vanterpool: It is.

Brian: So, we hear all about, in the news and in just society today, about the opioid crisis. It's a big deal. And in particular, right here in our own home state of Tennessee, it's a pretty big deal as well. It's really affecting a lot of the things that we have going on here, and in our nation as well. I've heard you mention this thing called the Tennessee Chronic Pain Dilemma. What is that? And how does it relate to the current situation that we have here?

Dr. Vanterpool: The Tennessee Chronic Pain Dilemma is a term that I kinda came up with to explain the triad, if you will, of trying to reduce chronic opioid use in the state of Tennessee while also effectively treating pain, but most importantly, improving the function of patients who have pain. So it's almost like a triad, almost like a seesaw, if you will, but it doesn't have to be. What we're trying to do, is we're trying to really reduce the prescribing of opioids, but we don't want to reduce the prescribing of opioids at the expense of our patient's pain and our patient's inability to function because they're hurting. But the beauty of it is that there are very good ways that we can figure out what's causing pain and treat it without using opioids or minimizing the use of opioids. That's where my role as a clinician and an educator really comes into play.

Brian: I've heard you refer to pain as a symptom of an underlying condition. Can you tell us a little bit more about what that means?

Dr. Vanterpool: So, when I refer to pain as a symptom of an underlying condition, if you think about a vital sign, for example, you may have heard the term pain is the fifth vital sign, and a vital sign is a marker of something that's going on with the body. But you don't treat the vital sign. You don't treat the blood pressure, you don't treat the high heart rate. You treat what's causing the elevated or low blood pressure, you treat what's causing the elevated or low heart rate. It's the same with pain management.

Zero out of 10 pain, and a 10 out of 10 pain, there's a reason for why the patient is experiencing that. It's not treating the number or the pain score, it's treating what's causing the pain. My role as a clinician is to figure out the cause of the pain.

Brian: I can relate to some extent because I know before whenever I've had issues and been to the doctor, I really felt that some of the medicine that they gave me was alleviating the pain, but it wasn't really alleviating, as you said, what's causing the pain there. And it sounds that you feel that the physician must get to the real cause-

Dr. Vanterpool: Absolutely.

Brian: ...of that pain. How do you get there? And why is it so important, in your eyes, that we make sure we're getting to that point that we're treating that? And is that a change of philosophy for some physicians?

Stephanie: Well, I don't know if it's as much of a change of philosophy as it is an expanding of the scope. So, there's a term that we use here that I coined called targeted pain treatment, which is getting to the root cause of the pain or accurately diagnosing the cause of the pain, and then targeting the treatment to the cause. And so, when we're trying to understand what's going on with the patient, it's important to understand a few things.

What type of pain are they experiencing? There's a concept called pain states, where there are four particular pain states, and we can get into the specifics at a later date, but really it's about understanding that inflammatory pain, say from an arthritic knee, is going to be different from nerve pain, from a herniated disc that's pressing on a nerve, which is going to be different from centralized pain such as a fibromyalgia type pain.

So depending on what's causing the pain and what type of pain state you want to be able to target the treatment to the cause. In the same way pain is transmitted in different ways, there are different mechanisms that apply. So, there can be just direct, susceptive transduction, where a simple pressure or insult to the body produces a very consistent response versus there are times where people have sensitization, which is where a similar or small impulse will produce a very overreactive response.

So, there's all kinds of combinations and ways that pain can be transmitted, so as a clinician, it's important to understand what type of pain and how it's being transmitted, because then we're able to target the treatment to the cause and the way it's being transmitted.

Brian: What are some of the approaches that you use to treat the pain once you have identified what that root cause is?

Dr. Vanterpool: Well once we have identified the root cause, there's a combination of treatments, and an algorithm we use called MIPS: Medications, Interventions, Physical Therapy, and Psychosocial Therapy. We already use a P for physical therapy, so we have to use an S for psychosocial.

Brian: I gotcha.

Dr. Vanterpool: But in doing that, it makes us be certain that we're targeting the different components of the pain. So from the M or the medication standpoint, that targets the physiologic source of the pain. Is there an inflamed nerve that needs to be calmed down? Is there actual inflammation within the joint that we can use an anti-inflammatory medication for? Is there a muscle spasm for which we can use a muscle relaxer. That's what the M targets.

Then the I for interventions, that targets the anatomic source of the pain. Where is the pain coming from? Is it coming from a joint? Is it coming from a bursa outside of the joint? Is it coming from a nerve or a disc or some combination, or is it coming from multiple anatomic structures in the same physical location that overlap and can cause pain in the low back? A key example of that is somebody with low back pain that may have both a bulging disc, pressure on the nerve, and arthritis in the facet joints at the back of the spine. When you have all three of those things going on, if you only treat one and don't treat the other two, they'll still have back pain.

Brian: Gotcha.

Dr. Vanterpool: So we've got to make sure that we address or identify all the causes and then treat them. Then from a physical therapy standpoint, that's important because that targets the functional limitation that the patient's experiencing. Is there an altered posture that is causing them to consistently have back pain because of how they're walking? Or are they sitting ergonomically in a bad position, so they now have neck pain and shoulder pain every time they work? Those are things that we kind of function.

Finally, when it comes to psychosocial, there's a major component of psychosocial interaction with patients with severe anxiety and chronic depression. And if you treat the pain without treating those conditions, you're not going to get the amount of function improvement you're striving for.

Brian: So it's really important to use this combination of all these treatments it sounds like.

Dr. Vanterpool: Absolutely. When indicated, and we look for reasons for them to be indicated, meaning we want to make sure we're not overlooking any one of those MIPS components. We don't want to overlook if there's a targeted medication. We don't want to overlook if there's an intervention we can use. We certainly don't want to overlook any functional limitation that can be addressed with physical therapy. And if we have any psychological or psychosocial things, they certainly need to be addressed.

Brian: So a physician sees a patient that is having those issues, and you know you have all of these options on the table, how do you know where to start, which one of those? Do you go right in order? I would think in some patients maybe medication right off the bat is not necessarily needed. You might need to go to some of those other components. How as a physician do you know where to go and how to start with that, and how expansive you should make it?

Dr. Vanterpool: It really goes back to the first part of targeted pain treatment, which is accurately diagnosing the cause of the pain. So, when it comes to diagnosing the cause of pain, what I have found to be the absolute most useful component is to get a very good history and I use an abbreviation to help me with that, and it's called a SCRIPT history, which stands for the story, current symptoms, relevant medications, interventions, physical therapy, and tests. What that means, though, is that I build a picture starting from the very beginning of what happened around the time of the onset of the pain, and as I go down the line of that SCRIPT history, I'm able to kind of plug in pieces like a puzzle and figure out what is the most likely cause.

I'll give you an example. If somebody's coming to me with neck pain after a car accident, but it's only on one side of their neck, for example on the right side of their neck, I'll ask them a story, "Tell me about the car accident," and they'll say, "Oh, I was rear-ended." Okay, well tell me a little bit more. I want to get the details to the point where I can envision almost what happened, almost like crash test dummies, you know?

Brian: I gotcha. Yes.

Dr. Vanterpool: So I've had patients come in and they tell me, "Well, I was rear-ended, but I was in the passenger side, and I was rear-ended from the back right of the car and we spun out, and my head hit the passenger window." So now I said ...I said left, but I meant right. You know what I'm saying?

Brian: Yes.

Dr. Vanterpool: "So now my pain is only on the right side of my neck." I'm like, "Makes perfect sense. Your head whiplashed to the right when you hit the window." So that makes sense that I need to target that. So just getting a really good story.

Then the current symptoms, and that's where it comes into what type of pain state they're dealing with. Is it a burning pain that's going to be more consistent with the nerve pain? Or is it more of an aching, throbbing pain, more consistent with inflammation? So once you've built all of the different components of the history together, you've already plugged in what the cause is by the time you've gotten to the physical exam for the large majority of cases, and you use the physical exam to confirm what you're considering.

Based on that information, you can target the treatment because if you know that this patient has primarily an inflammatory pain that also has a component of muscle spasm, you might tell them, "Take some ibuprofen and we'll add this muscle relaxer for you to take at night and send you to physical therapy." No injection needed, they don't have any psychosocial or psychological issue combined, so we don't have to address it, but we make sure we don't miss it.

Brian: Sure.

Dr. Vanterpool: Then there are other cases where there are just more specific sources of pain, such as a pinpoint bursitis or a pinpoint trigger point or herniated disc and based on what you've gotten from a history and physical exam, then you target the treatment.

When it comes to interventions, however, I do have another way of kind of planning for how I target that, and that's specific, strategic, and safe.

Brian: Okay.

Dr. Vanterpool: What that means is we want to be specific. We want to target the source of the pain as specifically as possible. An example would be shoulder pain. You might have a patient that comes in with shoulder pain, but it only affects them when they reach forward. I had a patient who was kayaking, he was an avid kayaker, and he could not paddle his kayak. But he could raise his arm to the side and he could reach his arm behind him no problem. He'd had shoulder injections by his orthopedic surgeon, but they didn't really provide much relief. The issue was that he did not have intra-articular intra-joint shoulder pain, he had bursitis under the subacromial bursa on the front of the shoulder. So when injected the subacromial bursa because it was a specific injection, he got full relief and he actually came off his hydrocodone that he'd been on for a year for the shoulder pain that was due to the bursitis.

The other two components of the triple S for procedures or how to choose interventions are strategic and safe. We already covered specific. When it comes to strategic, it's important to understand that there are multiple causes in the same physical or anatomic location of pain, and there are two strategies that we can apply. The first is to get the worst pain first. For example, if somebody has a bulging disc, radiating leg pain, but has sacroiliac joint pain that they cannot sit, they cannot stand, they cannot roll over, if I help their radiating leg pain and I have not touched their SI joint pain that is setting them on fire, they're going to think it didn't work.

That's part of the issue when patients say that the procedures didn't work, it's that we weren't necessarily addressing either the worst pain that they had, or the other component is working from the inside out, we weren't addressing the underlying cause of pain, we just addressed the superficial muscle spasm pain with say a trigger point, but we didn't get to the herniated disc underneath it.

Brian: And therefore they believe the injection or the-

Dr. Vanterpool: Did not work.

Brian: ...did not work. I gotcha.

Dr. Vanterpool: But it was because the strategy was not employed that would help it be effective. The last and most important, very important component is that the injections need to be safe. So specific, strategic, and safe. That involves everything from making sure that you're doing the procedures safely with image guidance, whether it be fluoroscopy or x-ray guidance or ultrasound guidance as indicated, making sure the patient is appropriately off any anticoagulants as indicated, if not on any blood thinners so there's no increased risk of bleeding, not doing these procedures so frequently that you have an over buildup of steroid in the system that can cause it's own set of problems and sequela down the road.

By using the specific, strategic, and safe, we can target injections to be the most effective for the patient and really help improve their function.

Brian: It sounds like there is no one size fits all when it comes to this, because I think the key component of what we're talking about, targeted pain treatment, you're really going to have to do the work as a physician it sounds like to find out exactly where you need to be, and that's going to drive everything else, right?

Dr. Vanterpool: It is, it is. I use the example sometimes of using opioids for chronic pain or for pain in general as kind of like trying to cover a bleeding stab wound with a bandaid. Okay?

Brian: Yeah.

Dr. Vanterpool: If you don't stop the bleeding, you're going to need a bigger bandaid, and that's what happens with opioid dose escalation. You're not treating the source of the pain, you're just covering it up with the opioid. And as the patient's body gets used to it, because there is a physiologic change that occurs, where you have dependence and tolerance to the medication, you need a larger and larger dose in order to get the same "pain relief". However, if you stop the bleeding, treat the source of the pain, get to the root cause of the problem, then you don't need as much medication because you've gotten the problem at its source.

Brian: I think what you were saying is so valuable with your analogy of you putting a bandaid over this stab wound, and then the bleeding keeps continuing, and the patient comes back the physician and goes, "You didn't fix my problem. I am still hurting, and it's getting worse. Do something." And then I'm blaming you for my lack of comfort.

Dr. Vanterpool: Right. And I think the challenge really stems from, again, as physicians and as medical professionals, we have so many things that we have to focus on, and pain is absolutely an important component, but there's not as much focus on how to really accurately assess it. That's why I think the importance of stressing taking a good history, taking a SCRIPT history, understanding the importance of a MIPS treatment plan, to where you're targeting all the different components of the source of the pain are important. And really the takeaway is that as a provider, you shouldn't be afraid of chronic pain. Chronic pain does not equal narcotics. I want people to understand that. Chronic pain equals let's figure out the cause, and let's treat the cause with targeted pain treatment.

Brian: And I think there's a lot of patients that think pain equals narcotics.

Dr. Vanterpool: And it doesn't.

Brian: I've heard people before go, "Well I'm having this pain, and the only way they treat pain is giving narcotics, and I don't want to become addicted and don't want to have all those issues, so I'm not even… I'm just going to live with it and try to fight through it."

Dr. Vanterpool: And they suffer unnecessarily. And I've had patients come to me. So here at the University Center for Pain Management, I've had patients say, "Well, my doctor referred me, but I didn't want to come to a pain clinic. But now that I'm here, I realize that you all are different. You don't just write medicines." I'm like, "No sir, no ma’am. We actually try to figure out what's causing your pain and then treat the cause. Our goal is to help you reclaim relief and function. It's important for you to be able to participate in life again."

Brian: Why do you think that doctors are really afraid of pain? Do you think it's because it’s the hot topic in the news today and they don't want to be part of what they perceive as the problem? Or are they just scared of it because they just don't know that much about it and I'm scared to jump into something I don't understand? Why do you think it is this way?

Dr. Vanterpool: I actually think it's a combination of both of the things that you mentioned. I think there's a challenge with it being such a hot topic and you not wanting to mess up, you not wanting to make somebody worse by not doing the right thing for them, but also not really being 100% confident in how to assess it and how to get to the root cause. And honestly, there's a component of not wanting to fail. You want to get almost a quick fix for the patient. So they come in, they're hurting, you want to give them something that you know will take their pain away.

Targeted pain treatment works well, and in the hands of an interventional pain specialist such as myself, I can absolutely do an injection that you can come in, crawl on the table, and walk off the table and dance out of the room. Not every time, but it can happen, right?

Brian: Right.

Dr. Vanterpool: But in other specialties where you don't have the ability to place a needle with an x-ray machine down by the spine, you can't necessarily get those results as quickly, so it's more frustrating as a provider to try and treat the patient when you can't make them better right away. And opioids seem to make them better right away, but they don't. They just cover up the bleeding stab wound, right?

Brian: And that's the problem. You have hit it huge and big, and it's numbed the pain, but it hasn't taken care of the target pain.

Dr. Vanterpool: It has not taken care of the problem, exactly.

Brian: So what would your advice be to physicians out there that may have these patients that have these chronic pain issues that have been unresolved or they're trying to manage your chronic pain patient, and they just keep throwing the same old stuff at them and it doesn't seem to be bringing relief? What would your advice to those physicians be?

Dr. Vanterpool: What I'd start off by telling those physicians or providers to take a step back and revisit the history for that patient. A lot of times, our patients have multiple pain complaints, so ask them which one is interfering with their function or their quality of life the most. They may be able to tell you, "Well, my back and neck always hurts, but I can't turn my head to drive, so I really need to get this neck pain under control." Then ask them, "Well tell me a little bit more about when it first started." Go through that SCRIPT history: story, current symptoms, relevant medications, previously tried interventions, any physical therapy that they've done, and tests that they've had. Then get a picture of what you think the cause might be. And then move on to your physical exam and reconfirm. Maybe there's something that you have tried or something that has changed since the last time you examined the patient for that particular complaint.

Once you have that level of kind of history and physical exam, and you've formulated your differential diagnosis, see if there's a targeted pain treatment medication that you may not have tried yet. I can't tell you how many patients that will come into my clinic with clear nerve pain, and they've not been on a nerve pain medication like gabapentin. Or how many patients come in, even more common, with muscle spasm in the back, and instead of starting them on a muscle relaxer and on an anti-inflammatory, they are put on hydrocodone.

And it's not a knock to providers who are extremely busy. I mean, there's so much pressure to be able to accurately assess patients and not miss any life threatening things, so I completely understand. But I think if we can expand our focus to make sure that we try to get to the root cause of the pain, and then as best as possible, try targeted pain treatments first, we can make a big difference. We can help kinda balance that Tennessee Chronic Pain Dilemma that we talked about, which is to reduce opioid use, effectively treat pain, but most importantly, improve the function of our patients.

Brian: If it is a physician that maybe is dealing in a specialty that doesn't deal with a lot of chronic pain stuff, maybe they need to refer them out to somebody like yourself that is very skilled in those areas, and knowing exactly how to target what's causing that pain as well.

Dr. Vanterpool: That's definitely an option to refer out to pain specialists. One thing to consider, however, is that we should all as physicians continue to expand our knowledge base. And one thing that I'm pleased to promote on behalf of both the Tennessee Pain Society and also in collaboration with the Tennessee Medical Association is a Pain Management Boot Camp that is going to be made available online to subscribers. What that involves is six one hour sessions that the listener can review, that involve pain assessment, treatment, diagnosis. These are all going to be CME available via the TMA website.

Brian: So yeah, we can put some information regarding that in our show notes, because that does sound like something that would be very beneficial to our listeners out there, not only to get the CMEs, but get that education that you were talking about that's so essential when it comes to pain.

Dr. Vanterpool: Exactly. It will be available through the Tennessee Medical Association, and the Tennessee Pain Society at TennesseePain.org. That's something that I think is going to be very helpful in just expanding our knowledge base in general.

Brian: Dr. Vanterpool, I really appreciate you taking the time, coming in and discussing this targeted pain treatment theory and what you've got going on here. I think it's fantastic. Thanks for being here.

Dr. Vanterpool: My pleasure. Thank you for having me.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcasts. The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time.