Can you tell us how you became interested in the field of chronic pain?

I have a tortured path to getting here. For the first five years of my career, I was practicing psychiatry and then I found myself missing more hands-on medicine. At the same time, I was becoming more interested in pain through patients that I was treating for depression and anxiety who also had chronic pain. I saw what other doctors were doing for them and I became interested, so I went back and did an anesthesiology residency and then a fellowship in pain. And I’ve been doing that ever since.

How did your background in psychiatry play a role in the way you treat chronic pain patients?

On the biological side, there’s a huge overlap between the medicines that are used in psychiatry and those that are used in treating pain. That’s because of the way these medicines alter the nervous system.

Pain is the ultimate example of the mind-body experience and it’s important to help patients attack it from both angles. My background allows me to be a little bit more convincing when I’m talking to them about it.

Do you have any areas of chronic pain that you are specialized in?

I will take patients with a variety of diagnoses, but my focus has been on neuropathic pain, especially CRPS or complex regional pain syndrome. I would say that is probably 60% of my practice.

How do you determine which medications are best for each patient with chronic pain?

If they have neuropathic pain we typically turn to antidepressant or anticonvulsant medications. In almost all kinds of pain, we try to avoid the use of opioids not because of the risk of overdose or addiction, but more because in the long run, they fight against the treatment of pain. They activate glial cells and they make the pain-transmitting nerves more sensitive to pain.

We use a lot of ketamine in either oral or IV forms. Each case has to be tailored to what the diagnosis is, what the patient wants, and how sensitive they are to side effects.

Can you tell us more about ketamine and why we’re starting to see it more often in the treatment of chronic pain?

Ketamine is an old drug. It first came into real medical use in the Vietnam War as a field analgesic. We have since then discovered that ketamine is an NMDA receptor antagonist. That means it’s blocking a receptor on nerve cells. When unblocked, the receptor allows calcium into the nerve cell which causes the nerve cell to become more sensitive. By blocking that receptor, we’re blocking the inflow of calcium and we’re blocking a lot of the sensitivity that develops in chronic pain. The IV form is more aggressive, but taking oral capsules is also an option. Those are not manufactured. They have to be compounded by compounding pharmacies.

You stated that you tend to work more with patients who have CRPS. Can you tell what type of medications you are often prescribing for these types of patients?

CRPS is a neuropathic condition which means the nervous system is malfunctioning. We use antidepressants and anticonvulsants a lot. We use oral ketamine quite a bit and in severe cases we can use IV ketamine through multiple infusions. We also like to use another compounded drug called low-dose naltrexone. This blocks different receptors which can lead to the activation of the nerve cells. By blocking these receptors, it acts as a nerve anti-inflammatory.

How would you describe your overall approach to treating chronic pain?

First, we have to get a history and a physical to really understand as best as we can what’s going on and then try to reach a diagnosis. It often takes a while to reach a diagnosis and sometimes we never find a diagnosis.

I then discuss with the patient the different tools that are available. Some of those will be pharmacological and some are interventional procedures like nerve blocks or implanted devices. Other options include occupational therapy, physical therapy, and pain psychology. I encourage the patient to use many of those techniques because I think attacking it on multiple fronts is the best way.

When you interact with these patients, do they often already have beliefs about how their pain should and shouldn’t be treated?

It does vary a lot from patient to patient. Frequently patients have already made several efforts at treatment and they haven’t gone well. Eventually, they make their way to Keck USC and they have come to terms with the idea that there is not some magic bullet out there. Usually, by the time they come to me, they are more receptive to a multipronged approach.

What influences the way that someone experiences chronic pain and what causes it to worsen?

I don’t yet have a Nobel Prize so I can’t answer that in great specificity other than to tell you that many things contribute to chronic pain. When patients get scared, anxious, or depressed, all of those things contribute to pain. There may be underlying neurological issues that we frankly don’t understand very well. We don’t fully understand why the nervous system can spin out of control and the pain becomes worse and long-lasting.

We know a little bit from animals. For instance, if an animal experiences an injury and we then take a look at their spinal cord, we’ll see that the inhibitory neurons in the spinal cord tend to die off when there is a big blast of pain. It’s called excito-neurotoxicity.

That’s just an example. It’s both biological and psychological.

What changes do you believe should be made within the healthcare system to improve the way we treat patients with chronic pain?

We need to improve education. The average graduate of medical school gets about nine hours of formal education on pain yet pain is the most common complaint by far. I think if we look at other clinicians like nurses, pharmacists, dentists, psychologists, and all the other various clinical fields, I think you’ll find even fewer hours of education devoted to pain.

In my opinion, that’s the biggest change that needs to be made. At USC Keck we’re trying to make our little drop in the bucket by creating graduate programs for any clinician as well as Masters degree programs on pain. I wish such things would pop up all over the country.

Do you see any value in providing patients with pain neuroscience education?

Yes, but not in great detail. We don’t want to blow them away with all the details or scare them. I want them to have some idea of what’s going on which allows them to better understand why the doctor is making the recommendations that he is making. For instance, if a patient comes to me with neuropathic chronic pain and they’re on opioids, I will talk to them about getting off of opioids and explain to them that the opioids are increasing the activation of glial cells and this leads to irritation of the nerve. The analogy I like to use is it’s like driving down the highway with one foot on the gas and one foot on the brake. 

For patients to understand a little bit about mind-body issues is very helpful. I think it makes it clear that when we recommend pain psychology, it’s not because we think they have a mental illness. It’s because we think that the mind has tremendous power over the body and that they can harness that to some degree.

How often do you find that patients are willing to take steps to decrease their opioid use?

80-90% of the time. They’re usually pretty receptive.

What does the process of getting them off of opioids look like?

We usually work with the doctor who is prescribing the opioids because we don’t take over their prescriptions. Together with the patient and that doctor, we try to come up with a schedule of slowly tapering down the opioids while we taper on or titrate other medications. One of the most successful for us has been oral ketamine.

What is your advice for someone who has been newly diagnosed with chronic pain?

Number one is to find a good pain doctor that they feel comfortable working with and number two is to be careful with what you read. There are good things and bad things out there. I’m a fan of a book put out by an author named Alan Gordon called “The Way Out”. That’s one of the better books on mind-body techniques for treating chronic pain. Working with a good physical therapist is important, but you need to find a physical therapist who is used to working with these kinds of problems. Working with someone who usually works with injured athletes will not be helpful for chronic pain.

What is your advice for someone who has had chronic pain for over ten years and feel like they have tried everything there is to try?

It sounds like they need a second opinion or consultation to see if that’s true. They may need to look at what the nearest university pain center offers.

Can you tell us about any success stories that you have had with patients who have experienced significant improvements in their quality of life after treatment?

There are tons. Different people respond to different things. We have had some patients who have come in practically bed-bound for years. We take a multidisciplinary approach that involves pain psychology, physical therapy, and occupational therapy. In the beginning, it is fairly intensive, with patients having two or three appointments a week and it is gradually slowed down over months. We often have to rearrange their medications, get rid of some meds, start new meds, and slowly taper them off of opioids. A lot of these patients are no longer bed-bound. They’re leading active lives and they’re able to function so that pain is not the focus of their lives. That kind of scenario is not rare.

Some patients need more aggressive treatments that are available at universities, but not in the community. These include ketamine or lidocaine infusions or implanted devices. Some of these patients do really well.

I would say we do about nine ketamine infusions every day. We’re one of the largest ketamine centers in the country. Out of all the patients we do ketamine infusions on 10% drop out and 90% stay on. Some of these patients do fantastically well and some say the treatment makes them feel 10-20% better, but they tell me it’s the only thing that has made them better so they continue with it. I would say the majority of patients feel 50 to 80% better.

It is somewhat similar to nerve stimulators, both peripheral and spinal. Peripheral nerve stimulators are growing rapidly in terms of their use. Many patients who use these have significant improvements in their quality of life.

Some of the new stimulator devices involve implanting a wire wherever the source of the pain is. Spinal cord stimulators are also good technology. I would say that roughly two-thirds of patients who get nerve stimulators are happy. They experience levels of improvement typically ranging between 40-80%. Then there are a third of patients who don’t get that level of relief.

You wrote a book called “Confronting Chronic Pain”. What can you tell us about this book?

It’s aimed primarily at patients, but also clinicians who don’t have any background in pain and want to learn more. Since it’s written to be understandable by patients, I try to lay out the basics of what kind of conditions cause chronic pain and what the different treatment strategies are. It’s like a mini textbook for a nonmedical person.

Is there anything that you want the general public, medical practitioners, or people with chronic pain to know?

In the medical world, I want people to know that this is a specialty in its own right and it deserves more focused attention in medical schools as well as nursing, pharmacology, and psychology schools. We’re not going to see a big change in how people with chronic pain are treated until their treaters get more knowledge.

Takeaways:

• Opioids fight against the treatment of chronic pain by making nerves more sensitive to pain.

• Oral ketamine and IV infusion ketamine can be used to successfully decrease certain types of chronic pain.

• Our healthcare providers and other medical professionals need more training on chronic pain.

• People with chronic pain may benefit from learning more about mind-body issues.

• Find a good doctor and physical therapist who both specialize in chronic pain.

Thank you so much to Dr. Steven H. Richeimer for sharing this valuable knowledge with us. He is an amazing doctor and he is working with USC Keck to provide more specialized education to providers and other healthcare professionals on chronic pain. His work will significantly improve the way chronic pain patients are treated. If you would like to learn more from Dr. Steven H. Richeimer, check out his book “Confronting Chronic Pain”. You can find it on Amazon, Barnes and Noble, and other book stores.