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19 Articles in Volume 20, Issue #4
20/20 with Dr. Nathaniel Katz: Pain Research and Future Therapeutics
A 20-Year Timeline: Pain Therapeutics and Regulations
A Comparison of the Alpha-2-Adrenergic Receptor Agonists for Managing Opioid Withdrawal
A Pain Assessment Primer
After the Task Force: A Conversation with Vanila A. Singh, MD
Ask the PharmD: Can opioids and benzodiazepines ever be used together?
Cognitive Strategies and Mindful Awareness for Integrative Pain Care
COVID: Clinical Considerations for Acute and Post-Infection Symptoms
Editorial: Fudin and Gudin Tackle Pain Care History – Asking, Have We Done a 180?
From Hands-On to Home-Based Care: Physical Therapy Undergoes a Paradigm Shift Due to Pandemic
MS-Related Pain and Spasticity: Are Cannabinoids an Option?
New Biological Agents for Psoriatic Arthritis: A Monoclonal Antibody Primer
Pandemic Presents Unexpected Opportunity to Embrace Multimodal Analgesia and the Integrative Care Team
Provider Perspective on Knee OA: Injections and RFA Options
Redefining the “Pain Specialist” of Today
Resident’s Corner: Climbing the Learning Curve in Pain Management
The Evolution of Pain Management: Experts Weigh In
Tips from the Field: How to Enhance Practice Efficiency
Tumor Necrosis Factor (TNF) Inhibitors: A Clinical Primer

After the Task Force: A Conversation with Vanila A. Singh, MD

With a new focus on practice and research, Dr. Singh shares her optimism for the future of pain therapeutics and integrated care – and why patients and clinicians must be in the fight together.

The field of pain management is undergoing changes like never before. With an opioid crisis and a pandemic, people in chronic pain are suffering on multiple fronts. Practitioners are similarly challenged with trying to help a growing patient population, largely from a distance, while also trying to maintain their own health – and sanity – without burning out. The good news is that clinicians’ toolboxes are growing.

Pain research is moving at a rapid pace – to find therapeutic alternatives and to address the growing acceptance of mental health’s role in the pain experience and in pain management. Medical and scientific communities are gaining new understandings about how pain manifests, why it lasts, and which approaches (beyond medication, but also including medication) can make a difference in outcomes. Practitioners are communicating with patients in new ways, not just because of telemedicine, but also because the age of accountability and patient education is among us.

PPM talked to the woman who has been on the frontlines of this evolution, pushing hard for more research while also taking time to really listen to patients about what they need (ie, function) and encouraging clinicians – from primary care to specialists – to wrap their heads around how to deliver integrated care.

Vanila M. Singh, MD, MACM is currently a clinical associate professor at Stanford School of Medicine’s Department of Anesthesiology, Perioperative and Pain Medicine. She has a long and important history as the immediate former Chief Medical Officer at the US Department of Health and Human Services, under the Office of the Assistant Secretary of Health, where she chaired the Best Practices Pain Management Inter-Agency Task Force.

Here’s what she had to say.

Vanila A. Singh, MD

 

On The "Pain-Demic"

 

PPM/Drakulich: Dr. Singh, you recently spoke to the Integrative Health Policy Consortium and the Congressional Integrative Health and Wellness Caucus about the PAIN-demic (which is what some are referring to as the un-ended opioid crisis, exacerbated by COVID-19). For those who don’t know, the consortium is comprised of members from 26 professional organizations and healthcare institutions and serves as a critical watchdog of the federal agencies overseeing US health and healthcare.

You suggested that there are two crucial steps needed to balance COVID and the opioid crisis:

  1. decrease opioid misuse
  2. increase the treatment of chronic pain

Clearly, these steps are complex and involve many factors. How do you see them working together?

Dr. Singh: There is a fear on both sides of the opioid issue – for patients, they fear decreased opioids, and for clinicians, they may fear prescribing them. But to focus on pain, we have to remember that it’s a general term and to try to generalize a multitude of different painful conditions that an individual may have – along with their comorbid conditions, functionality issues, and general physical condition – is not ideal.

That’s why one of my major philosophies is that we approach pain management more individually using a patient-centered approach – and that's not just to say it in words. It may sound good but it’s also absolutely necessary. You can have broad principles, but ultimately the decision has to be on the individual level because no two people are alike, even when they have the same diagnoses. They’re different anatomically and in what their body may accept or reject. Pain care is not one-size-fits-all.

Our goals as pain clinicians have to be quality of life and improved functional ability for people to go back to work, for example, or to achieve other goals So many people have goals that are actually very reasonable.

At the same time, we’re not interested in just decreasing opioids. Opioids alone are not a pain care plan. The pain care plan has to be based on what we see in the patient.

 

On Short-Term Opioids and Other Approaches

 

PPM/Drakulich: The Inter-Agency Task Force recommended that clinicians use a multidisciplinary toolbox for treating pain, including 5 core modalities:

  1. Medications – (eg, acetaminophen, NSAIDs, anticonvulsants, antidepressants, musculoskeletal agents anxiolytics, opioids)
  2. Restorative therapies (eg, physical therapy)
  3. Interventional procedures (ranging in level of invasiveness from trigger point and joint injections to nerve blocks to neuromodulation)
  4. Behavioral approaches (talk therapy, cognitive behavioral therapy)
  5. Complementary and integrative health (eg, acupuncture, stress reduction, yoga, massage and manipulative therapies)

In addition to this multidisciplinary, biopsychosocial approach, the Task Force recommended that optimal pain management needs to address risk assessment (eg, PDMP, drug monitoring), access to care, stigma (also a barrier to care), and education/awareness about pain.

But many people living with chronic pain say they have “tried everything” over the course of many years and found that opioids are the only thing that truly relieves their pain. What would you say to them?

Dr. Singh: Well, most people are really open and reasonable. Their concern is that the “alternatives to opioids” are not going to be effective. Or they may have been doing rather well on their long-term opioid care and are suddenly facing the prospect of tapering or coming off of opioids. And that’s a natural fear any of us would have.

For doctors, they can be empathetic and caring, but clearly they are also thinking about their licenses which are subject to what their Board or DEA may perceive, which puts them in a challenging position.

So, as a general rule with my patients, I don’t want them to feel as though I am being punitive if someone is on a high opioid dose. When I bring up a multimodal approach, it’s not either/or – it’s about needing the medicines, the physical therapy, the integrative health, and discussing the role of each.

Short-term opiates are really great for some, as are long-term opiates in some, because they allow people to function. But all the other parts of the puzzle, whether it’s the interventions or behavioral therapy, all have potential value in indication.

So it needs to be less about judging patients and each other. We need to empathize with each other.

The irony of it is, I feel like I’m here to advocate for a very challenging part of our healthcare. In pain, unlike other disease entities, people feel so much and it greatly affects their quality of life, and it affects their forward-thinking ability, which often poses a very dark picture. I want to see what we can do to help all of these patients in their own individual capacity. Balance, not judgment, is really what I’m trying to put forth. We know that they are going to be bad apples in every industry in every manner – but they cannot dictate where we move forward with science and compassion.

 

On The Reality of Opioid Alternatives

 

PPM/Drakulich: Clinicians are still waiting for effective opioid alternatives. Are there any therapeutics on the horizon that you are particularly excited about?

Dr. Singh: Absolutely! I have to say that one silver lining in the current environment is all of the attention that pain care has gotten. There is money being allocated to a lot of different things, including important research around understanding better the mechanisms of pain. It is so challenging at the very molecular level about what causes pain and if we better understand those mechanisms, we will have better treatments, whether they be devices or neuromodulation or medicines with different routes such as topicals.

In the device area, there are magnetic treatments and therapies that may sound strange but at the molecular level, make sense. And there are some new medications that may actually help by trying to get at where the opioid acts but without some of the downsides, like constipation, nausea, and sedation.

It is a great age of innovation. I may be biased because a lot of those innovative industries were coming to my office when I was in my official capacity and, actually, they still do. And I’m so happy to see it because we haven’t had this kind of advancement in a long time for these folks who suffer. This is how we move the ball, no matter what treatment.

I am hearing a lot more these days from my patients along the lines of, ‘Hey Doc, I’m doing better. I’m able to do X, Y, and Z,’ and ‘I feel like this is manageable now, I feel so much better than I was.’

Five years ago, this was not the case. There are game-changing things happening and I’m a full believer in all of it really. My main motivation is to keep the interest alive to policy leaders. In one sense, we are fortunate that pain is relatable compared to some other disease entities…our mothers, fathers, uncles, aunts, friends, and so forth suffer from pain. Everybody understands some aspect of it and I’m more excited to keep it on the radar.

 

On Mental Health as Part of Pain Care

 

PPM/Drakulich: Let’s talk about mental health. Perhaps one important aspect that has come out of the COVID pandemic is how much mental health affects those with chronic pain, even though research has shown these correlations for many years. Do you think the pain management community is finally taking mental health under its wing, and if not, what more needs to happen?

Dr. Singh: This is definitely one of the biggest and clear things I have noted. For example, we do Botox for migraine and clinic procedures like minor to moderate trigger points for muscle spasms. Suddenly we couldn’t do them when COVID struck and it was hard because our patients who may have been socially isolated already felt further isolated and fearful.

I was really glad we had telemedicine opportunities which we moved to very quickly, as did so many of my colleagues around the nation. Telemedicine was a lifesaver because all of a sudden we had an insight into what the patient was going through.

It is very clear that anxiety and depression come as a result of chronic pain, which people then feed into – it can be a self-fulfilling cycle. We must address that and ensure that people have a means to feel like they’re not at a loss when the worst moments occur. We need to give them the tools to address these thoughts.

I often tell my patients who master these skills that they are actually ahead of all of society – being able to manage and cope with emotions and stress are skills everyone needs.

At the same time, they need to know that pain is not in their head – an old unfortunate stigma that has to be broken. Anxiety and depression are the result of having chronic pain that limits your functionality – it’s a very natural human response. It warrants a real concern about one’s future. And if that does not lend itself to stress and anxiety, then we’re not human.

Do you screen for mental health disorders in your pain assessments? Take PPM's quick poll.

 

On Task Force Follow-Up

 

PPM/Drakulich: The Inter-Agency Task Force has technically sunset with the committee’s work complete. But certainly its impact is not over with —are there any plans to re-engage the Task Force or measure progress in a couple of years?

Dr. Singh: A good question, and one that I often thought of when working on the Task Force. My guess is, since understanding pain and pain management have infiltrated the government, it will be something that’s revisited.

There are bipartisan efforts right now on Capitol Hill to implement the recommendations and, as we talked about, our senators and congressmen are often motivated by their own experiences [with pain].

The Task Force report is broad and deep and I think those principles will stay with us. Even as advancements happen, it will be a great reference point. And I see great efforts underway by different organizations – across the medical spectrum, groups large and small – to implement it.

 

On Personal Advice for Practitioners

 

PPM/Drakulich: Having worked for both the public sector and in private practice and research, and having so much passion for this field, can you get a bit personal and share what your thoughts are for today’s pain practitioner?

Dr. Singh: You know, people are never going to really understand how hard this field is. From a clinician perspective, you have the challenges of getting authorization, to getting enough people who are treating in different categories, to even getting your own colleagues to understand that you’re not just mindlessly writing a prescription.

There are always going to be those who unfortunately have an agenda, but in my view, they’re the minority.

I was speaking to some Fellows specializing in pain recently, and I shared, that for me, the real light bulb went off a few years ago when I recognized that even when it seems challenging and complicated – it only takes one or two visits with patients to come to an understanding about what is happening and to keep them front and center.

Then, everything else will fall into place. If the patient recognizes that you’re for them, you reap rewards. Patients can give you great energy. They become your allies and remind you why you’re in this job in the first place.

Sometimes, this industry can be frustrating, but when we forget the humanity of it all, we lose our passion and our excitement. Trust me, I have those moments, too, but I really feel as I’m getting older, that the patient is where it all lives. If you stop and listen, they’ll be very understanding of our recommendations, and our limitations, and that’s like the best place to be – when you’re in the fight together.

Last updated on: August 17, 2020
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20/20 with Dr. Nathaniel Katz: Pain Research and Future Therapeutics
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