Hey Guys! Last week, I did an interview with Dr. Kim Hecht, a physician at the Susan Samueli Integrative Center who specializes in the treatment of pain. She has helped a lot of people with chronic conditions and has a large amount of knowledge on acupuncture, pain reprocessing therapy, and other strategies that can be used to significantly reduce pain.
Takeaways:
- Acupuncture and trigger point injections work really well for a lot of people. They don’t work for everyone, but they are worth trying.
- Low dose naltrexone can be used to treat several different types of pain conditions.
- Chronic pain is a learned behavior that changes the brain.
- Pain is really complicated and there are a lot of different ways to treat it.
Can you tell us how you got into the field of treating chronic pain conditions?
I was really passionate about integrative medicine to start with and it opened my eyes to different approaches. When I was in college, I was already interested in how the mind and the body interact. I was a psychobiology major and I had the opportunity to learn how stress in individuals affected their T-cell count. It was really fascinating to me. I explored different opportunities and I found the UCLA Center for East-West Medicine. They were doing a combination of acupuncture, trigger point injections, and massage for chronic pain. I was very impressed with the results that patients were getting. That made me more curious about other approaches.
I did one year of acupuncture at Emperor’s College and then I became an osteopathic medical student. It was there when I began to feel very drawn to helping people with chronic pain. Then I came to UCI where I studied physical medicine and rehab. Now I’m here at the Susan Samueli Integrative Health Institute and I have been able to help people through all different types of approaches that I’ve learned through the years.
I myself have suffered from various different types of chronic pain syndromes over the years. I have treated myself for irritable bowel syndrome, interstitial cystitis, and in 2019 I developed fibromyalgia. Having gone through a lived experience of chronic pain in various formats, I was able to connect more deeply with my patients and give them a perspective that other individuals treating chronic pain don’t have.
It’s very different if you have experienced it yourself. I think that patients do appreciate having a slightly different insight there. What are some strategies that you have used to treat your pain?
Initially I had low back pain with sciatica in my mid 20s and doing acupuncture was very, very helpful for my pain. That’s why I was interested in being at the Center for East-West Medicine. I was able to look at a lot of research showing how acupuncture increases endorphins and can improve pain that way. Helene Langevin, who’s the head of the NCCIH, has done some beautiful studies looking at how the twisting of the needle affects the fascia.
That coincided with my experience, as an osteopathic medical student where I actually got treated by my peers for my back pain. That helped as well, but the treatments were always kind of temporary. I would somehow exacerbate my back pain again depending on the activities that I did. In medical school, I got reconnected with another former graduate from Western and she was doing injections and trigger points. She was injecting into acupuncture points and I found that there’s a 70% overlap between trigger points and acupuncture points which is really interesting to me. She did some injections with lidocaine in my back and I think that helped desensitize things. The back pain was completely resolved.
In terms of the irritable bowel syndrome, there are apps that now offer hypnosis for it. There is also a lot of work around Pain Reprocessing Therapy. Ted Kaptchuk did a placebo study where he gave people sugar pills and told them that it would help their IBS. And it worked.
For me, I was able to self regulate my emotions of stress and anxiety. That calmed my overall system and really helped with my irritable bowel syndrome. On top of that, I learned a lot about diet and supplements and the microbiome. It was a combination of things that really helped me.
Then I developed fibromyalgia which was right around when my daughter was a year old. Usually when you hear stories of people developing chronic pain, there’s a certain series of events that lead to it. For me, I was a mom of two, my son wasn’t sleeping, I was working two jobs, and then one day I became ill with a virus infection and I ended up in full body pain and fatigue. As an integrative practitioner, I thought that I needed to go on a special diet so I tried that.
My favorite thing that I like to recommend to my patients is a medication called low dose naltrexone. I really love that medication. When we think about the problem that we have with the opioid epidemic, it’s that people are getting chronic exposure to these opioids. Their bodies are developing a tolerance and their brains are down regulating the receptors for their opioids. Naltrexone is an opioid blocker and it is traditionally given to drug addicts in high doses. In low doses, it temporarily blocks the endorphin receptors so that your body thinks you have a deficiency. This way you make more of your own natural endorphins or at least upregulate the receptors so that you can respond better to the endorphins that you make. I have found that more and more providers are recommending low dose naltrexone and that really helped with my fibromyalgia along with some dietary changes that I made. But what made the biggest difference for my pain was Pain Reprocessing Therapy.
Wow, you’ve done quite a few things. You’ve covered diet, low dose naltrexone, and Pain Reprocessing Therapy. It sounds like you have taken a very biopsychosocial approach. I think that’s really a great way to approach any type of chronic pain. I’m curious about the low dose naltrexone. I work in an ER and I don’t see that medication getting prescribed for chronic pain.
They wouldn’t prescribe this medication in the ER. The ER is definitely its own animal for patients who have chronic pain. You have to realize that after six months there is some kind of central sensitization that is occurring. There was a beautiful study done by Hashmi in 2013. I don’t know if you’re familiar with that study, but he looked at people who had low back pain, initially for two months. He would then reevaluate to see if they still had back pain at 12 months. Each time they put these people under functional MRI. At two months, the brain lit up in areas that you and I were taught about in nursing and medical school. The thalamus, insula, and the somatosensory cortex lit up. When these people still had pain 12 months later, different areas of the brain lit up. Most notably was the social-emotional learning circuit. One of the prime areas that you may be familiar with is the amygdala which is what I call the threat detection center. We also saw the prefrontal cortex and the insula lighting up.
We have figured out that chronic pain is about learning. It’s a learned behavior. I almost want to say that our brains have become kind of addicted to the pain as well because it lights up a little bit in the basal ganglia when they look at some of these studies.
We really haven’t looked at what happens in the brain when you’re taking low dose naltrexone. In my clinical experience in recommending this to innumerable patients, I have found that a subset of patients (not all of my patients), respond to it. They find that their pain is relieved and their mood is improved because they’re probably stimulating their own endorphin release. Their inflammation goes down and sometimes their inflammatory markers and their autoimmune markers actually improve.
When we look at what we prescribe in the ER and to inpatients, how patients perceive the medication is very important to what their reaction will be. If a patient perceives that their providers isn’t caring, he’s screaming in pain, and they give him tylenol instead of morphine, this particular patient is likely not going to get pain relief. I actually gave a lecture to some of the palliative care doctors at UCI, who had also been ER residents before. They asked me, “How should we talk to these patients?” It comes down to that biopsychosocial model. You want to convey that you care so that people feel safe. That is almost the most important medicine that you can give in the emergency room. Give the patient a sense that they were heard and that you are there to help them. Even if they just went through an experience where they almost died, you want to make them feel safe. But that is a very different experience for people who have chronic pain day in and day out for decades.
That’s why I recommend to my patients the low dose naltrexone. It has been studied in people who have Crohn’s disease and in pediatric populations as well. They have even done colonoscopies showing that there is healing after low dose naltrexone.
When I evaluate my patients with chronic pain, I am also looking to see if they have organ dysfunction that’s causing a visceral somatic reflex that is giving them pain. One of my patients had terrible mid-back pain and she also had terrible acid reflux. Once she got medication for that, it improved her back pain. When you dive deeper, you discover that she’s also a very anxious person. If you’re very anxious, your digestive system is going to be on high alert and may start over secreting hydrochloric acid.
I also had an individual who had sciatica and he was sent to me by a spine surgeon. He had a history of ulcerative colitis and he said that it was in remission and he was on medication. I told him, “Let me give you some supplements to help heal your gut lining, plus the low dose naltrexone, which has been studied for inflammatory bowel disease”. He also did the pain reprocessing therapy and his pain went down to a one. That was in the span of three months.
I take it case by case and I look for what may possibly be the biggest contributors to pain and I try to address those first. It really is the biopsychosocial model with injections, supplement, and diet.
Yeah and everyone’s going to be very different depending on the cause. You have touched a little bit on central sensitization and we previously talked about peripheral sensitization. Could we talk about what those are and how they are treated differently?
When we think about peripheral sensitization, that is kind of what pain management likes to treat like carpal tunnel for example. You might have compression here at your wrist which is compressing blood flow or compressing that median nerve. So maybe we open it with surgery or inject it with a steroid to decrease the inflammation. What I have found throughout the years is that there are other forms of entrapment that are less widely known and not addressed in conventional pain management. Sometimes nerves become entrapped or they are damaged by some kind of systemic disease process like diabetes. People can develop peripheral neuropathy. This can be caused by having too much sugar in their bloodstream and that sugar damages the blood vessels. Then there is less blood flow to their hands and feet causing a burning sensation.
So peripheral sensitization can occur from a disease or it can occur from something mechanical like a pinched nerve. It gets kind of blurry once you end up having chronic pain. One of the conditions that I treat is called cluneal neuropathy. There are these superficial nerves that come down from your spine and they cross over your iliac crest and into your buttocks. I remember that I had one patient from Las Vegas who used to fly about once a month to see me for the injections that I do. I use this particular brand of peripheral nerve blocks called perineural injections. I inject these afferent nerve fibers with 5% dextrose, 1% lidocaine, and a steroid as well. What I found is that by desensitizing these nerves on the periphery, there are less signals coming to your spinal cord and some patients find that their system starts to calm down and they have less pain.
The other way that I address peripheral sensitization is by trying to address the underlying problem. In someone with diabetic neuropathy, the problem is their diabetes. They might have poor circulation so I recommend supplements or devices to my patients that improve circulation and improve their diabetes status overall.
When it comes to central sensitization, the process that I was talking about with the Hashmi study, there are circuits in your brain that have become overactive. You may have strained your back, but then after a year of having pain in the same area, you have developed an almost Pavlovian response to different triggers. These triggers could be movements, something environmental, or something within the body.
One of my patients told me that when she gets to the front door of her house, that’s when her headaches start. So I asked her, “What’s going on when you get to the front door of your house?”. And she says, “I start thinking that I have to wash the dishes, wash the clothes, clean up the house, vacuum, and it gets kind of overwhelming”. That’s a trigger. There’s nothing wrong with her head. Her brain is thinking that it’s entering something dangerous so it gives her a headache so that she doesn’t do it.
Central sensitization usually manifests as much more diffuse pain. It can move around and it’s associated with persistent pain. We have a researcher at UCI. His name is Dr. Richard Harris and he has done some research on people who have different types of pain, whether it’s rheumatoid arthritis, fibromyalgia, or something else. He gave people with chronic pain the fibromyalgia questionnaires and what he found was that the more diffuse their symptoms were, the more it affected how they responded to the different types of acupuncture. The people who had more diffuse pain responded to laser therapy or a more gentle modality. I think that understanding the different phenotypes of pain does help us to determine which type of therapies will work best for each patient. Dr. Richard Harris has done a lot of research on acupuncture and he’s doing more research at UCI as well.
That’s really cool. I know that UCI offers acupuncture to the patients. It’s not used very often in the ER.
We also offer it to the general inpatient and then outpatient as well. We have a variety of different acupuncturists with different modalities of treatment within acupuncture.
Do you find that acupuncture is more successful for specific types of chronic pain or do you find that it can cover a wide variety of chronic pain conditions?
That is a very good question. I have seen acupuncture work for a lot of different things and I have seen it not work for a lot of different things. I can’t explain all the different reasons why it works for some patients and not others. Medicare covers acupuncture for low back pain. We do see a lot of patients with low back pain and it is very helpful for them when they receive it. I think it can also be helpful for headaches, dysmenorrhea (period cramps), pelvic pain syndrome, irritable bowel syndrome, and a lot of different musculoskeletal problems.
It’s not a panacea and it is usually used in conjunction with other therapies to make it more effective.
Do people tend to respond well to acupuncture after one session or does it require several sessions to make a difference?
It really depends on the problem. For certain patients that have an acute sprain or injury, it might prevent them from going down the chronic pain route. It might take a couple of sessions to actually improve the pain. But it’s not a one-size-fits-all approach. Some of my practitioners would say that they are calming down the nervous system, but once the patient goes back into their life where they hate their job or they’re in an unhealthy relationship, the pain comes back. This may be because their muscles tighten, their posture is in protective mode, or they’re doing repetitive actions that are constantly injuring themselves. If you sprain your ankle and then get acupuncture, it might take away your pain, but if you have a habitual way of walking or you’re in a sport with a high risk of injury, then the pain might come back.
So we still have to address the root cause at the end of the day.
Yes and I would say that there are multiple causes.
Can you tell us about the Susan Samueli Integrative Center and how it differs from a pain management center?
Let’s start with where we are as an institute. We have definitely grown through the years and we are much bigger and broader than we have ever been before. I have many acupuncturists and they actually rotate through different sites at UCI, including inpatient and various outpatient clinics. We have naturopathic doctors. I don’t know if you’re familiar with those types of doctors, but they have received different types of training that have a bigger emphasis on lifestyle and they have a stronger understanding about supplements, hormones, and the microbiome. We have many physicians that have training in functional medicine and they look into the root cause of conditions. They may look at how stress is affecting your cortisol pattern or if you have micronutrient deficiencies that could be contributing to your pain. They may even look at your social life.
We have psychologists and some of them do something called neurofeedback. That’s where we use an EEG to measure different brain waves and we help patients to work on modulating the activity in their brain through different types of exercises that might be helpful for various problems including pain. Anxiety and depression can aggravate pain so having a psychologist can be helpful. Some of the naturopaths do something called biofeedback. This involves looking at different physiological features like heart rate or heart rate variability which is the beat to beat variation between each heartbeat. We can look at skin conductions and muscle tension and then teach people different techniques to modify their own physiological responses which may improve pain. This may include deep breathing, mindfulness, or guided visualization. Biofeedback has been studied and shown to be helpful for headaches. There are even a few studies looking at biofeedback for hot flashes. It’s just another modality to help people learn how to regulate their own system.
We also have physical therapists who have very specialized training, like in visceral manipulation or cranial sacral therapy. They are doing more manual therapy with the patients as well as talking to them while they’re doing it. We have massage therapists and health coaches. Health coaches really help individuals make behavioral changes. For example, if you have a goal to lose 20 lbs to see if that will help you with your knee pain. If you’re getting up each night for a snack because you’re feeling tired and down, they’ll help you understand your emotions related to that particular behavior and how you can substitute something else for the snacks. They help patients set their own goals for themselves and create a road map to help them get through things. A lot of my patients with chronic pain have benefited from seeing our health coach as well.
We also have specialized physicians such as an integrative gastroenterologist. There is a lot of overlap between irritable bowel syndrome, chronic pelvic pain, migraine, interstitial cystitis, and other types of pain syndromes. It’s really good to address the gut when it comes to chronic pain.
It’s different from other pain management clinics because we really work as a team at UCI. Some of my patients with chronic pain need a spinal cord stimulator. In pain management at UCI, they’re much more procedure based. They might do different types of epidurals, nerve blocks, or spinal cord stimulators to help the patients. When they come to us, their pain may still be high and they may have a history of anxiety and depression. They may benefit from neurofeedback.
It seems like you offer a lot of different options at the Susan Samueli Integrative Center. More than what I’ve seen at most places that treat chronic pain. That’s really amazing.
You interact with a large variety of chronic pain patients. When you’re interacting with someone who is brand new to chronic pain, what is your go to advice for this person?
I usually bombard my patients on their first visit with a lot of different things to let them know that pain is complicated. You can’t just assume that because someone has low back pain, their L4-L5 is destroyed and that it’s pinching on a nerve and that’s causing sciatica. It’s usually more complicated than that.
What I usually do for my new patients is start them off with thinking about Pain Reprocessing Therapy. I’d be curious to know how you did it for yourself. I usually tell them that depending on the environment that they are in at the onset of pain and where they are psychologically and socially will have a tremendous impact on your experience of pain.
I often introduce patients to the whiplash study mentioned in the book “The Way Out” by Alan Gordon. This study was done in Germany and Germans are very creative when it comes to making different contraptions. They made two cars look like they had hit each other. The front car was on a slope with some pulleys and it was pulled forward so that the tire goes over a bottle that makes a broken glass sound. They made it look and sound like a real car accident which can be a jarring experience. They did psychological evaluations of the participants who had been in the car and they found that the people who had the most fright and the most somatic symptoms initially right after the car accident tested high on the psychosomatic scale. I don’t think of that as a negative. All that means to me is that your mind and your body are so intertwined that your reactions are instantaneously not only in your mind but also in your body.
If people still had symptoms one month after this fake whiplash, they tested higher on life dissatisfaction. From the get go, I have to let my patients know that all of those things play a critical role on your continued experience of chronic pain. It’s a big difference from how I used to talk to patients about pain because I was trained in physical medicine and rehab. I used to look at a knee on an X-ray and say, “Oh that’s bone on bone”. I would tell my patients that’s the worst knee I have ever seen and that their bones were grinding against each other. I now tell my patients that I don’t wish to hex them anymore with these thoughts that make them automatically assume that just because there’s some structural degeneration they have to have chronic pain. A lot of patients come in having this preconceived notion that they have to have chronic pain because they saw other healthcare providers who haven’t been trained in this model of looking at how pain is maintained by the brain.
Arthritis is terrible and I’m not saying that it’s not a component of pain, but what I’m saying is that pain is complicated and there are a lot of different factors. Some patients when they remove certain things from their diet, they decrease inflammation in their system, and their pain goes away.
I can’t say that I give my patients a simple plan of action. I’m really trying to plant the seeds that there are different psychological processes that are at play and maintaining their chronic pain.
We see a lot of people in the ER who have had chronic pain for years and years, often due to several different conditions. When you work with these types of patients, how do you treat these patients?
It’s easier for me because I tell them off the bat that I’ve suffered from chronic pain. That kind of gives me an in-road with them that makes them feel like I’m not trying to convince them that the pain is all in their head. I am telling them that once they have chronic pain, there are circuits maintaining the pain in their brain.
When I worked on inpatient, I remember working with this one woman who had back pain. She had severe back pain after she had fallen down the stairs. I spoke to her and said, “That must have been so terrifying for you to have fallen down the stairs”. She was still kind of in shock and feeling like she had broken something, even though she didn’t. Her pain was severe so I validated for her that she went through a terrifying experience and then I let her know that structurally nothing was wrong. But it would make sense as to why she would feel like this. Sometimes I tell patients that feeling safe about their life and where they’re at has an impact on their pain.
Sometimes I do a gentle visualization with patients. I’ll ask them what color their pain is and to see if we can change it to a different kind of pastel color or something less threatening. You would be surprised that some patients are pretty open to this and they do experience some pain relief. I also just taught them a tool that they can use on themselves to work on their pain.
It depends on the patient though. If they have broken 10 different bones I would say, “You’ve definitely had a lot of damage and you still need to know that your brain has a huge influence on your experience of pain. You’re here in the hospital and we’re looking out for you. You’re going to be okay.” Encouraging a sense of safety can improve their pain.
I think that’s why it’s really important for nurses and healthcare providers to be reassuring and try to create a sense of safety. It can be hard to do this in the ER because it’s a very rushed and chaotic environment.
No but there are a few things that can be done. You can get down to the level of your patient, bring your voice down, and establish some eye contact. It shouldn’t take longer than 30 seconds to tell them, “Hey, I get it. You just went through something scary and it’s affecting you in many different ways. You’re in the ER now and we’re going to work on it. I want you to know that your sense of safety can have a big impact on your pain”.
There was a study where a guy had a nail in his boot. He was a construction worker and 29 years old. He jumped over something and the nail went through his boot. He was in so much pain and he could barely move his foot. They have him fentanyl which is a very strong opioid and then midazolam which is a sedative. These medications barely calmed down his pain. When they got his boot off, they discovered the nail had not gone through his foot, it had gone in between his toes.
When I tell my patients about this study, they often ask, “Are you trying to tell me that I’m faking it?” And I explain that I know their pain is not fake and that the guy with the nail had an authentic pain experience. That shows that whatever your brain is perceiving can have a direct impact on your experience of pain.
I never tell patients that their pain is fake. I tell them that it’s authentic but not all pain has to come from a physical injury.
Absolutely, the brain is so powerful.
Huge thanks to Dr. Kim Hecht for taking the time to do this interview with me. Check out the Susan Samueli Integrative Center to learn more about what services and treatments they offer.
This is so real! I have chronic migraine – there is nothing physically wrong with my brain… there is just a pain signal malfunction… I need to keep regulating my stress levels… great post! Linda xx