Can you tell us about your backstory? How did you get involved in pain medicine?

I was a medical student at UC Irvine and I did a lot of rotations. One of the rotations I did was in pain medicine and I loved it. I thought it was a perfect mix for me because you get to talk to patients and you get to do procedures. You get to develop relationships and make a difference in people’s lives and outcomes. It just made sense to me. I always wanted to be more of a master of one thing as opposed to the jack of everything. I thought pain medicine really allowed you to focus in on that complaint as opposed to all the different chief complaints that patients come in with. From there I went and did training and I did anesthesia. I did a fellowship in pain and neuroanesthesia which I think is a big part of pain. Then I came back and I’ve been at UCI for about ten years now.

You had mentioned that you’re involved in perioperative and intraoperative techniques that can help prevent chronic pain after a surgical procedure. What can you tell us about that?

There’s a couple of different things to talk about in that context. One thing is patients that don’t have pain at baseline and then now come to have surgical insult for the first time. There’s a lot of apprehension related to that. If you don’t take the appropriate measures, then patients that never had chronic pain syndromes can develop chronic pain. 

After surgery, you have a lot of genetic stuff that happens at the cellular level and a lot of spinal cord changes. We have these things called modulation which are pathways in our spinal cord that can either be turned up or turned down. If you don’t appropriately try to tailor that right at the time of surgery, then patients can develop not just acute pain, but chronic pain syndromes that will last for a long time.

The second population, which is actually more exciting for me, are patients that already live in a lot of pain. They’re already on opioids and they’re already in, let’s say, nine out of ten back pain. Now they’re going to have back surgery. What kind of metrics can we take for this so-called normal pain that’s anticipated?

The good news is that there are a lot of patients like this and we’ve instituted a few things here at UCI that we like to term perioperative optimization. We have actually started a perioperative pain clinic. If somebody has baseline pain scores that are very high, they can come to either myself or one of my colleagues and we’ll go over the latest literature and figure out what to do so that they are teed up not just before surgery, but during surgery. We like to catch patients on post op day zero meaning like right when they are either going into surgery or when they’re coming out. We don’t want to wait two or three days and then get called by the surgeons and be told that the patient has been suffering already for two or three days.

Before a patient goes into surgery, what are you doing to optimize pain levels for the patient?

One of the things we like to do first is get an understanding of where the patient’s original pain came from. We want to know if there are any psychosocial factors. We want to know what kind of opioids the patient may be on and who is the prescriber. Let’s say that someone is on gabapentin at 600 mg three times a day. You don’t start the surgery on no gabapentin. Let’s say you’re on a long-acting opioid and you don’t take it on the day of surgery. You’re already behind the ball.

We want to get all the safety stuff out of the way. If you’re on opioids, we want to make sure that you have Narcan. We want to make sure that you’re educated on perioperative sedation that can occur because you’re going to get new medicine. 

A big that we like to do is really hone in on what we call “expectation management”. Basically if you’re already in a nine out of ten pain, what are you expecting after surgery and what would be a success for you? If someone says they’re in nine out of ten pain the day after surgery, normally we think that’s a failure, but then somebody who was in nine out of ten pain before surgery, maybe that’s a success.

We also like to do a lot of education. The numeric pain score isn’t going to mean all that much to us. It’s really going to be based on functionality. We want to educate patients on their goals after surgery like being able to walk, eat, or be able to talk to family. If we can succeed in those goals, maybe we have succeeded as opposed to saying that the pain was at a zero which might not be realistic if you’re going into surgery with a lot of pain already.

One of the things we like to try to do is a preemptive opioid wean. If somebody is on 6 percocet a day for the past year, then even if they could go down to three percocet a day for the week prior to surgery, then when they go to surgeru and take six percocet a day, it’s like getting a higher does than you were most recently getting.

We also like to start medicines that might need to get started. Let’s say that someone is only on opioids but not muscle relaxants. We may deem that they need to see a pain psychologist.

We like this idea of prehabilitation. Everybody talks about rehabilitation, which happens after the insult, but they can go to a physical therapist even before and figure out who they’re going to be seeing. Establish the range of motion stuff that they can and be ahead of the game. We do this with ACL injuries all the time. You don’t necessarily need to wait until after the surgery.

Then there are special populations. There are patients with intrathecal pumps, which are opioids being delivered into the spinal cord, spinal cord stimulators, or they may be on long acting medications like methadone or buprenorphine. We can give recommendations on how to take those perioperatively. The older recommendations used to be that they should stop buprenorphine, but the newer recommendations are to continue buprenorphine throughout the surgery and we want to make sure that the surgeon and the patient are on the same page. Just like someone who has hypertension or diabetes, they need to know which medications to take or not to take for a better perioperative outcome.

When patients are coming out of surgery, how often are you seeing it where somebody went into surgery with no prior chronic pain and then after the procedure, they now have chronic pain?

It’s to make that decision right after surgery because we like to define acute pain as a symptom of a disease whereas chronic pain is the disease itself. If you’re catching someone anywhere from a week to two weeks, even less than three months out, then we really try to call that acute pain. Some people even say six months. It’s when you get beyond the three to six months that you’re now dealing with chronic pain and it really depends on the surgery and the patient risk factors for developing chronic pain.

For the most part as anesthesiologists, we try to prevent that from occurring and there are techniques that start from the periphery of where the nerve feels the pain all the way up to where the brain will cortically comprehend the pain. We like to do things like regional blocks where we give the patient a shot. Let’s say they’re going to have hand surgery. We’re not just going to give them a Norco. Instead, we will use an ultrasound to find the nerves that are coming out of our neck and then they bundle in the clavicle area which is what we call the brachial plexus. Then we can deposit a bunch of numbing medications similar to what the dentist would use to numb your tooth. We can even leave a tiny wire there and the wire is like an angel hair pasta that dribbles numbing medicine right at the area of the nerves. That can give the patient ongoing pain relief by continuously blocking the pain fibers.

If we’re doing these so-called preemptive measures, there are two words that we want to talk about. One is called preemptive analgesia. Analgesia means pain relief. Preemptive means before the pain comes, you give them pain relief. This way the spinal cord never gets excited. Another term is preventative analgesia, which means either before, during, or after the insult. What can we do to prevent this from occuring? Remember, our spinal cord is very plastic, meaning it’s able to make changes. If you normally don’t have pain, there are not a lot of nerves that are in charge of pain, but we have what are called wide dynamic range neurons that can serve multiple functions. Let’s say they get called to duty because there are a lot of pain signals. Now all of a sudden your spinal cord can be what we call wound up or ready to go for any pain and those patients can develop chronic pain syndromes. We are trying to prevent that with some of these measures.

To answer your question, I don’t know exactly what percent will develop chronic pain because every surgery is different, every surgeon is different, and every patient is different. We do know that if you are developing a lot of pain right after surgery, it’s much better to have that addressed earlier than later. There are numerous things that you could do that are much more effective in the beginning of that cascade as opposed to six months or a year later.

 Would you say that there are certain types of surgeries that put patients at a higher risk of developing chronic pain?

Every surgery has some risk, maybe not a cataract surgery, but there are definitely surgeries that or more or less likely. There were 176 or something surgeries that were commonly performed and they were ranked on how often they were leading to chronic pain. Things like spinal surgery, ankle surgery, and orthopedic surgeries were more likely to develop chronic pain as opposed to soft tissue surgeries. Patient risk factors also play a big role in determining the ultimate outcome for the patient.

If you have a gnarly trauma related injury and the trauma surgeon is not able to be really careful in terms of where they go and they’re just trying to save your life, you will have a higher susceptibility for chronic pain as opposed to someone coming in for a controlled surgery.

You have mentioned that there are risk factors that patients can have prior to surgery that may increase their risk for developing chronic pain. What are these risk factors?

One of them is having baseline pain. A prior history of substance abuse, mental illness, poor coping, poor social networking and support systems, and poor insight. Then there are genetic factors that are not within our control. We have variability in our perception of pain and the pain experience is multifold. Only one fold is the sensory fold, one of them is cognitive, and another is emotional. Patients that have poor emotional IQ and have a lot of baseline anxiety and depression are at a higher risk. If a surgeon says to a patient, “This is a gnarly surgery and you’re going to have a lot of pain” then there’s already a placebo effect because you’re now expecting a lot of pain. If I tell you, “You might have pain for a few days, but you should be fine in a week or two”, then you might have less pain after surgery.

Let’s say that you have a patient who has had chronic back pain for 10 years and they’re getting back surgery, what advice would you give to this patient in order to help them not have an increase in pain after the surgery?

It would be tailored to the patient. We want to know what prior experiences they have had with surgery and what their daily activities are at baseline. I think a lot of medicine and the art of medicine is giving the patient the empowerment to understand that we will do what we can to get through this, these are our tools, and we will be dynamic with them. We can take a lot of measure before surgery. We might put them on a different opioid that is more likely to help with nerve pain. We might start them on antiinflammatories.

For every patient, the first thing you want to do is make sure they have optimized all the non-pharmacological stuff. This may mean nutrition optimization, physical therapy, yoga, assist devices like back and knee braces, music therapy, pain psychology, and acupuncture. Then you want to try to optimize the non-opioid pharmacological stuff as much as you can. That includes topical agents, tylenols, anti-inflammatories, neuropathic agents, antidepressants, and muscle relaxants.

The analogy I like to give is when you make a cookie, you don’t want to just add chocolate chips, which is the opioid. You want to add flour, sugar, milk, and eggs and all the different things come together and you have a cookie that tastes better.

If someone has renal disease, you don’t want to give them an anti-inflammatory and if they are old and confused, you don’t want to give them something that is going to worsen the confusion. At this point, you might consider opioids. Short acting opioids would take precedent over long acting opioids. If the patient is a good candidate, you might have to consider a long acting opioid as well. That has to do with safety and some of the CDC recommendations in terms of which opiates are safer versus more dangerous.

Another area that you have mentioned interest in is virtual reality being used to treat chronic pain. What can you tell us about this?

It’s similar to the cookie analogy we were just talking about. We are always looking for new and innovative ways to treat pain and you want to be at the cutting edge with it. One of the modalities is virtual reality. Our brains are very primitive so it’s easy to distract ourselves. If you go to the dentist and you’re getting work done, they can put on Netflix so you can watch it and not pay any attention to what they’re doing with our tooth. Virtual reality is you actually being immersed in a different environment and you’re like an avatar so it’s a completely different experience. When you’re in the hospital, you don’t really want to be having a procedure done, so virtual reality allows us to escape and not realize where we are. You could be walking in London or playing a video game or do something that’s not actually in the realm of pain. There are a lot of articles on this, but for various reasons, one of them is to distract yourself from acute pain.

Let’s say a child is about to have an IV started. You can give them virtual reality classes to help distract them or an adult for that matter, even a laboring woman. This has been done specifically at UCI. We brought virtual reality glasses for three populations. One of them is pain patients. If they’re going to do a painful procedure or any procedure and a patient seems anxious, they could use it. We also brought it for chemotherapy infusions because nobody wants to be unnecessarily having chemo. Then we use it on burn patients.

There’s a lot of stuff out there. I’m sure you have talked about it in your blogs, but unlike mindfulness and meditation, virtual reality has a lot of programs that are designed to build on each other to optimize your relaxation techniques.

We can’t be stagnant. If there is new technology and it is safe then we should embrace it.

The next area of interest for you is opioids. What can you tell us about opioids in your line of practice?

I talk heavily on opioids, I do all the lectures for any new doctor that joins UCI or any new fellow or resident. I go over opioid safety and safe prescribing. We give community talks on opioid safety and national talks. My colleague and I worked on the curriculum for all of the medical students. We teach another course on opioid safety for providers that not intentionally but without faults of their own may have made some errors in prescribing habits. We teach them the correct ways of prescribing opioids.

The non-ideal way of prescribing opioids is working with someone who is what we call a legacy patient which is someone who has been escalated on opioids for a very indefinite amount of time. Now they’re just tolerant and dependent, without any particular cause. This what we’re trying to prevent.

First of all, not everyone needs opioids. You know, if you roll an ankle, you don’t get opioids. If you had an early surgery or cancer or something where the benefits outweighed the risks. You’re starting point should be to have a goal and a care plan established with the patient. We have to consider how long should the patient be on opioids and what is the goal. You want to go over with the patient what the risks and benefits are. Sometimes it will be obvious that someone should be on opioids and other times you may want to try all other measures before trying opioids. 

When trying opioids as your so-called starting, you always want to start low and go slow. You want to do an ongoing assessment to really verify that we are making tangible improvement in functionality and there are different ways of doing this. One way is just asking the patient, but there actually objective measures you can do where you use scales and other stuff to see that patients are actually having an improvement in functionality. You may also want to consider the various modalities we have for risk stratification. You definitely want to get a urine drug screen on somebody just because you don’t want to be biased. You also want to check the registry which will tell you if they have been receiving opioids from other doctors and if so, how much have they been receiving? There are tools that can tell you how high of risk the patient has for developing opioid use disorder. 

Make sure you educate them on narcan or naloxone and not just them, but their loved ones or family members. I like to give the analogy of being on an airplane and you have a peanut allergy. It would be nice to know that your family has epinephrine, even though you don’t plan on taking peanuts. We have to understand that opiate overdoses are often times accidental. In fact, I think 80% of overdoses are accidental in nature. The theme is frequent follow up, make sure that the benefits outweigh their risks, and having an exit plan if there needs to be one, depending on the nature of the patient.

A lot of patients might have a palliative condition and in that case you might have different goals than somebody who wants to be off of opioids in two months because they had back surgery but they don’t want to stay on the opioids.

Within the next five years, where are you seeing the chronic pain research taking us? Do you see any changes taking place in the future?

As a whole, pain management is rapidly evolving, knowing the various dangers associated with opioids. A lot of folks are trying to optimize other stuff so a bunch of new interventions are being patented and going through the FDA process for approval. For example, if someone has a specific genetic predisposition to a drug, we can work on tailoring that drug to be prescribed instead of another drug.

The opioids that are being used are becoming safer and safer and we’re making it more accessible for providers to prescribe those opioids. There is a lot of research out there on augmenting safety. We’re also working on coming up with an objective pain measure because if you tell me if your pain score is an eight out of ten and then tomorrow it’s seven out of ten, that’s helpful and allows me to trend the pain, but it’s hard for me to really know what that means relative to the next person that says they have seven out of ten pain. If there was some way for me to truly know what that meant like you would with blood pressure, heart rate, or temperature, then we would know how aggressive our measures need to be to alleviate the pain. What makes it a little bit harder is that there’s a lot of emotions and other components that are within the realm of pain that are harder to objectively quantify.

Let’s say someone just went through an intense surgery and they were having a lot of pain, but now their pain has significantly decreased. Are there any recommendations for preventing that pain from coming back?

Our bodies heal and the natural mechanisms are to have pain for protection. That’s what we call nociception or the sensation of pain. We know that if you keep someone on opioids for way too long, that can actually change neuronal pathways and cause more pain. We call this opioid induced hyperalgesia. So we want to start and back off of opioids and we want to get the patient out of bed, functional, ambulatory, and back to normal as soon as possible.

Everyone is different, but ultimately if you are starting to get better there’s no reason you should put in your head that you’re going to have chronic pain. The vast majority of patients do not necessarily develop chronic pain. The more important question is if you are still having chronic pain, what should you do? That’s when you should seek consultation to prevent yourself from developing chronic pain.

If you’re getting better, you should taper off of opioids. It’s not uncommon where patients who have been on opioids to all of a sudden start developing hand or knee pain, even though they had never had hand or knee pain.

Do you know of any chronic pain resources out there that are useful to people with chronic pain?

One thing to recognize is that every particular pain condition usually has a resource group. You can find a support group that can help you with whatever your condition is, for example, a CRPS support group. I don’t want to necessarily say that I recommend this or that because a lot of it is the cost. There are a lot of different organizations out there.

Takeaways

• It is important to address pain management before, during, and after a surgical procedure, especially if someone is already dealing with chronic pain.

• Prehabilitation can be done to prevent pain after surgery, For example, by starting physical therapy before a surgical procedure.

• There are risk factors for developing chronic pain after surgery. These include baseline pain, prior history of substance abuse, mental illness, poor coping, poor social networking, and genetic factors.

• When treating chronic pain, it is important to utilize all non-narcotic approaches. These include physical therapy, yoga, assist devices, acupuncture, and seeing a pain psychologist.

Thank you so much to Dr. Navid Alem for doing this interview with me. He is an amazing doctor who is helping so many patients at UC Irvine Medical Center (the hospital that I work at). He is an excellent resource to the chronic pain community and we are so grateful for all the work that he has done.