Episode 011: No Pain Is The Game

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Brian: Hello, and welcome today's podcast. My name is Brian Fortenberry, and today we're going to be talking about a topic that is very hot today in medicine. It's going to be talking about pain, and treating pain conditions. To join us for this discussion, we have Doctor Rett Blake. Welcome, Doctor Blake.

Dr. Blake: Thank you.

Brian: Before we really get into the meat of our discussion, could you tell us a little about yourself, how you got involved in pain medicine, and some of your background, there?

Dr. Blake: My name is Rett Blake. I am a pain management physician in Chattanooga, Tennessee. I did an anaesthesiology residency, followed by an additional year of pain medicine fellowship training. I run a comprehensive pain medicine specialty treatment center in Chattanooga.

Brian: Well, that is going to be right where we're wanting to go today, because pain is such an incredibly hot topic. Why is pain such a hot topic these days? Why has it become very, very prevalent out there in today's society?

Dr. Blake: I think one of the things that makes it such a hot topic right now is the opioid epidemic, right?

Brian: Sure.

Dr. Blake: And obviously, that is closely related to pain, although those are separate things. We've had increased numbers of opioid overdose deaths. I think it was 64,000 overdose deaths related to opioids, both illicit and prescription. And so, that's certainly been something that is definitely in the public conscious right now. There have been multiple news stories, and every time you pick up a newspaper, it seems like there is something related to that, and what the public is doing about that. So, obviously, the opioid epidemic is certainly well-known to everyone, and part of that, not the whole thing, has to do with pain.

Brian: That is a term and a phrase we are hearing a lot in the news, and in newspapers, about this opioid epidemic. What is being done about the opioid epidemic? Is it just legislation, or is there a part that the physicians can play? What is being done?

Dr. Blake: A lot of different things are being done about that. It seems that there are multiple different task force through the government. Several different groups have been looking at creating new legislation to kind of combat this problem. And the Tennessee Department of Health has been very, very active in this for the past, probably, 10 years, really. This is not a new problem, although it seems to be only recently as well-known as it is now. The Department of Health has been closely involved in all of these processes over a good decade, and so a lot has been done about that, and we can talk a little bit more about that, if you'd like.

Brian: I really would like to get into some of that. Is what's being done, is it more on a national level? Is it on a state level, or even a local city and county level? Or is there a combination of all of that?

Dr. Blake: I would really say it's all of those. All of those issues come into place. Pain gets into all of that, because it's such a common issue, itself. So, now we hear about the opioid epidemic, but pain is also an extraordinarily common problem. There's an Institute of Medicine report that shows that 110 million Americans have severe, chronic daily pain. That's basically a third of all adults in the US, and of course, it's probably the leading reasons people go to the doctors, because something hurts.

Brian: Sure. Discomfort. Right.

Dr. Blake: So, for years, I think we've probably undertreated pain, and now we are trying to look for ways to treat pain, and treat it well, but also minimize some of the unintended consequences of using opioids, that have obviously seen a sharp increase in use over the past 20 years.

Brian: Pain is obviously something that has always existed. It's not like this is new. Why do you think that, even though we've had pain for years and years, now we find ourselves in this situation of an opioid epidemic? And we're seeing a lot of people coming out of the woodwork, complaining more of pain, that you think, surely that has been there all along. Why is that?

Dr. Blake: A lot of different reasons. When you look at the different causes of the opioid epidemic, it would be great if it was just one simple, easy thing that we could identify one problem and then fix that problem.

Brian: Put your finger on that and correct that.

Dr. Blake: So, many, many facets to this problem. In terms of pain, there are a lot of different reasons we have more pain. Obviously, we have a population that lives longer than we did 100 years ago, or 50 years ago. We have higher obesity rates than we used to. We have higher rates of some of the painful conditions, like osteoarthritis, and degenerative disc disease. So, we have more people with more painful conditions. We have more surgical procedures that are performed today than we did 50 years ago, so we have higher complication numbers. Not necessarily rates, but numbers, because more people. And so, we have reasons that more people have pain. We still have a lot of the things that we do to ourselves, in terms of smoking and obesity, that lead to those problems, and people want good and fairly easy treatments for pains.

One of the reason that opioids have been used more frequently over the past 20 years is they may have been underutilized previously. But now we have probably overshot that a little bit, because they offer a quick and easy fix to a situation. Maybe not the best fix, but a quick and easy fix.

Another issue is where physicians have higher demands, or higher pressure for demands, in terms of how many patients they have to see in a given amount of time. They have lower reimbursement rates from insurance companies. And unfortunately, opioids fit that mold very, very well, in terms of being quick and easy.

It's also very widely known in public that opioids treat pain. Probably 50 years ago, nobody took pain pills, almost never. It was something that was only given IV after surgery.

Brian: You were in the hospital if you needed that medicine.

Dr. Blake: But now, it's almost expected, or it has reached a point where patients expect, if they have pain, they should be given an opioid. And there is this basically demand mentality that, again, puts pressure on physicians to prescribe opioids.

Brian: And I think you hit on a point, whenever you say it is the fast and easy way to take care of it. I think, just generally in society, we want quick and easy solutions these days, where we used to kind of learn to deal with more of it in the past. Now, we want an immediate fix. And plus, you have the internet, and you have all of that information out there, that people are showing up, probably, at the offices more aware of treatments than in the past, and can be more demanding, to your point. Correct?

Dr. Blake: Very true.

Brian: So, we know that this opioid epidemic is there, because as you said, we've overshot the mark in prescribing those types of pain medications. That may be the easiest and the fastest way. Is it the only way, though? Are there other treatment options out there?

Dr. Blake: It's certainly not the only way. I would say that opioids are rarely ever the first line treatment for pain. Certain types of acute pain, they may be. An acute fracture, an acute postoperative pain, they do fit into that mold very, very well for short-term periods. But in terms of chronic pain, which is where we've seen them being used more frequently over the past decade or two, again, they're rarely ever the first line, and there are lots of other different options that can be used for pain.

Brian: How do you know which treatment option is the best, or most appropriate for a given patient? Is there a criteria that you go through for that?

Dr. Blake: I would say, the most important thing is to first make an accurate diagnosis. When we talk about what causes pain, there's an infinite list of things that can cause chronic pain, and to figure out how to treat that, you first have to know what's causing it. You have to future out, what is the origin of pain, what are the anatomical structures that are involved, what are the physiologic processes that are involved in causing that pain? And then, again, that's an extraordinarily long list of things that can make someone say "Ouch." But that's probably the first, and possibly the most important, step of treating pain. Again, treating pain well, while minimizing certain unintended consequences.

Brian: So, it is trying to treat the source of the pain, not just the pain itself. You're really trying to break it down and figure out, what's the beginning process, here?

Dr. Blake: Sure, absolutely. That's kind of both the art and the science of medicine. You start by just asking the patient questions. You've got to figure out when the pain started, what circumstances surrounded the onset of that pain, what makes it better, what makes it worse, what have they tried before? All of the different history that goes into that individual person's symptoms, and what happens with their life, how that pain limits them.

Because again, when we talked about why is pain so prevalent, why is it in the news? It's because it's severe. When someone has chronic pain, it can be a truly devastating thing. It's kind of easy to say that people that take opioids every day are just drug addicts, but I think that's untrue. A lot of these people are your wives, and husbands, and co-workers, and friends, and accountants, and friends and neighbors, and they have pain that you wouldn't wish on your worst enemy, and they're doing the best that they can to deal with that.

But when you do have those kind of things, everyone's story is different, in terms of when it started, how it started, and how it limits their life at this point. What is it causing, in terms of their functional limitations, now?

Brian: And to that point, everybody probably presents differently in different people. No two people's pain might be the same, correct?

Dr. Blake: I would say that's definitely true. Every single patient's different. There are certain things that happen frequently. There are certain things that happen with a certain or a fairly regular pattern. But in terms of the severity of it, in terms of every person's anatomical layout, a little different, we're all unique.

Brian: Yeah, absolutely.

Dr. Blake: Everyone's a little different, and you kind of have to figure out exactly what the problems are, and how to best go about treating those.

Brian: The physician, then, certainly has a responsibility, just as the patients have a responsibility, to use the treatment correctly. Physicians, I guess, then, have a responsibility to make sure they're not just throwing medicine at a situation and being irresponsible with that. Is that correct?

Dr. Blake: Yeah, absolutely. And we talk about medicines. Medicines aren't the only way. It's not just a pill, whether it's an opioid or a non-opioid pill, right? There are lots of different injections that can be used. Structural interventions, where we're talking about multiple ... Even in the injection category, more different injections and structural-type procedures than I can list, probably, in this time frame that we have. Also, open and interventional surgeries. Looking at the biomechanics, and behavioral modification. Some of those would be something like physical therapy, massage therapy, looking at smoking and weight loss. Types of, again, behavioral modification. Different braces that could be used. All of those are procedural type of interventions, or again, biomechanics or behavioral modifications, that don't involve taking a pill of any type, just not including opioids.

Brian: And that really might go against what people perceive when they hear pain clinic. A lot of people hear pain clinic, and they think, that's where you go to get pills to fix my pain. But as you're saying here, there's a lot of different routes you can go. Can you use that in combination? Do you often consult with a PCP, or a different specialty, and work in combination to try to help people with these pain issues?

Dr. Blake: Absolutely. When we talk about taking a comprehensive, or a multi-disciplinary approach to pain medicine, it's rarely ever just one person, right?

Brian: Sure.

Dr. Blake: I do my skill set very well, but I'm not a physical therapist. I don't do that well, so I refer to the physical therapist, or the massage therapist. I'm not a psychiatrist or a psychologist, but I recognize how important those things are to treating a chronic pain patient, and so I refer to those people.

You have to work well with the patient's primary care physician, because I deal with just the patient's pain issues, but I'm not treating his congestive heart failure, or his diabetes, or his high blood pressure, or coronary artery disease, where the primary care doctor is the quarterback, so to speak, of all of those different issues, including pain. And so, you do have to be able to work with the primary care physician, the surgeon, if they need surgery, and all of those different aspects of medicine.

You brought up a very good point in terms of, you hear about a pain clinic, you think, that's where I go to get pills. And that's always been a pet peeve of mine, because the field of pain medicine is so much broader than that. And unfortunately, over the past 20 years, you had a lot of these little pill mills ...

Brian: Right. That's the term you hear on news telecast, and newspapers.

Dr. Blake: And certainly, those exist. 10 years ago, Tennessee had a huge problem with pill mills. Folks would open pill mills, they would charge cash for high-dose Oxycodone, which was a largely criminal enterprise. But we've made a lot of progress in that. Not as much as we need to, but we have made tremendous progress. I think the number of pain clinics in Tennessee has gone from about 350 to 185 over the past 3-4 years. So, over the past few years, we've cut the number of pain clinics almost in half. Again, a tremendous amount of progress in terms of getting a handle on that side of the equation.

The other side of the equation is, obviously, now, of the illicit opioids, heroin, and stuff that's shipped in from China and Mexico, that does not involve the medical field. But on the medical side of things, we have made tremendous progress. But it's unfortunate that when people think of pain management, the only thing that they think of is pills, or specifically one type of pill, the opioid, when the field is much, much, much, much broader than that, and involves countless other different modalities of treatment.

Brian: So, as we get ready to wrap up, here, for a physician out there that maybe is in training currently, or thinking about changing the type of practice they have, and they're considering going into pain medicine, what would be some of your key points of advice to these physicians, of what to look for, what to expect, and how to best prepare themselves for a good practice in pain medicine?

Dr. Blake: First of all, you have to really be passionate about treating pain, and really be passionate about treating patients with chronic pain, because a lot of these folks have reached the end of the line. They've had a bunch of different surgeries, they've tried all these other different forms of therapy, and they still hurt, and you have to be able to meet those patients where they are, and try to improve their overall quality of life, and their overall function.

And measuring success for somebody may be getting out and going and running a half marathon. For some people, it may be being able to go to the kitchen and cook a meal. So, if you can get someone who can't go cook a meal to be able to go cook a meal, or go to the grocery store and buy groceries for a week, that can be a tremendous success for that patient.

Brian: And, I imagine, very rewarding, as well, for the physician.

Dr. Blake: Yeah. I love being a pain physician. I find it very rewarding, because you take someone that everyone else has said, "Give up. This is just the way it is for the rest of your life," and you can still give that person some degree of quality of life back. To that, it's very rewarding, but it takes a lot of work, and it takes a lot of patience. Obviously, it may not be the most glamorous medical specialty out there. And hopefully, as we try to police our own specialty, we will separate pain medicine and the feel of pain medicine from the "pill mills" that seem to be, I guess, the most widely-recognized form of pain, which is unfortunate.

But apply for your fellowships, and if that's the field that you feel drawn to, get the best training that you can, and go out there and do the best that you can. I would say, that would be the advice for either the medical student, or the resident that's still considering doing that. And to all the people, most of pain is not treated by pain specialists, it's treated by primary care physicians, because they treat most of the medical conditions out there, because they are kind of the front line of medicine.

And as my advice to all the primary care physicians, don't be afraid to treat pain. They're in a difficult situation where, again, they don't have to just focus on the pain, they have to treat that as well as the diabetes, and the congestive heart failure, and all the other medical conditions. But patients tend to want their pain addressed first, because it hurts the most. The high blood pressure doesn't hurt. The diabetes doesn't hurt.

Brian: That's a great point.

Dr. Blake: But the pain hurts, and they want that dealt with as their number one priority. And that's reasonable for primary care doctors to treat pain, but again, do it in a multidisciplinary approach. Be cautious when we're talking about young patients with chronic pain issues, especially back pain, and if you're not comfortable interpreting the MRI, make sure that you could consider consulting with someone, whether that's a spine surgeon or a pain specialist.

One of the things that we want to get away from is using chronic opioids for the younger patient with mild degenerative disc disease. That's a common problem, and that's one of those things that you hate to see in the office, of someone that's been on opioids for five years, for a condition that they probably should have never been put on opioids for in the first place, because now we still have the back pain to treat, but we also have the opioid dependence to treat, because they've been on it for five years.

Brian: Created a problem ...

Dr. Blake: And so now we have two things. And so, just be cautious about the initiation of opioids, and be cautious about the inappropriate continuation of postoperative opioids. Someone that's had surgery still has pain, and is still using their post-operative pain medicine. And again, postoperative pain medicine is completely normal, but at some point, we have to say, okay, now we have to discontinue this and be willing to start that process of weaning or tapering, and discontinuing those medications, so they don't get inappropriately continued for years.

Brian: Sure. Well, I tell you, this has been fantastic. I mean, I have really learned a lot about this, and I think our listeners, as well, will really be able to gain a new appreciation for what it's like inside a pain clinic. Thank you so much, Doctor Blake, for being here.

Dr. Blake: Thank you for having me.

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