274 - Challenges of Treating Chronic Pain (Dr. Roman Magid)

Dr. Roman Magid, a new physician with St. Luke's Rehabilitation and Pain Center, joins Dr. Arnold to discuss the process of treating chronic pain, challenges patients and providers may face, non-opioid and non-medication treatment options for chronic pain, and so much more.

To learn more about St. Luke's Rehabilitation and Pain Center, visit https://www.unitypoint.org/locations/unitypoint-health---st-lukes-hospital---rehabilitation--pain-center

Do you have a question about a trending medical topic? Ask Dr. Arnold! Submit your question and it may be answered by Dr. Arnold on the podcast!

Do you have a question about a trending medical topic? Ask Dr. Arnold! Submit your question and it may be answered by Dr. Arnold on the podcast!

Submit your questions at: https://www.unitypoint.org/cedarrapids/submit-a-question-for-the-mailbag.aspx

If you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Transcript

Speaker 1: 0:08

This will talk on challenges of treating chronic pain. I'm Dr Dustin Arnold, chief Medical Officer at Union Point Health, st Luke's Hospital. Treating chronic pain can be a complex process involving many different factors. Joining us today to discuss this process challenges faced in ways to treat chronic pain is Dr Roman McGeid, a new physician with St Luke's Rehabilitation and Pain Center. Dr McGeid, welcome. It's a pleasure to be here, thank you. So you're in with Dr Matthew, that's right. Who's the best dress man in healthcare? What's that like being with the best dress man in healthcare?

Speaker 1: 0:43

It makes you used to feel right.

Speaker 2: 0:44

Does it?

Speaker 1: 0:45

Yeah, I mean unequivocally best dressed man in healthcare. No, we'll welcome. Welcome to the community, welcome to medical staff, and we're happy to have you here. You know, I think pain has been a challenge, with the opioid epidemic, the pushback against OxyContin, the hillbilly heroin, I mean there's been a lot and I think the pendulum probably swung too far and doctors just became avoidant of patients that had chronic pain and I think they struggled for a while and might probably still struggle. But tell us what chronic pain is and your approach to it.

Speaker 2: 1:34

Yeah, so starting out with, you know, simple definition is, you know, chronic pain. If you Google this is pretty much what you'll find is when the pain exceeds the timeframe. The usual timeframe for a condition or a disease process and a rule of thumb is that's about three months or so, and that's obviously not always the case and some conditions, cancers and the like, you know you're you expect to have pain, that's you know that's going to stay along with the condition, unfortunately. And that's three months is kind of a helpful metric there and it is a challenge, right, and I think one of the helpful things to to know, especially in light of the opioid epidemic, is that that's not the only tool we have. It's a useful tool, especially for acute pain and in those first few phases, but there's a lot of other things that can be, can be done or or worked on outside of that that are still very helpful.

Speaker 2: 2:32

But it's part of the part of the challenges is what pain even is, and it's it's more than just a physiological sensation. It's an emotional and sensory experience related to the potential for actual or possible pain. So, in the same way, where you know if you can put your hand on a hot stove. You're thinking about all the other times you've got burned. Sometimes it's enough to to see like the impending hot thing about to touch you and you're already experiencing pain. Sure, before, even you know, before it even happens. And that's part of the challenge. And with chronic pain you can. There's these ruts of of emotion, you know, of emotions, of memories of suffering that gets built on so that it really becomes a lot to unpack when one's dealing with it.

Speaker 1: 3:18

One of my pet peeves with chronic pain is repatience. You know, I, I'm, I'm, I'm, I'm. Everyone's pain tolerance is for them, right, it's not for anyone else. So when they say, oh, I have a high pain tolerance, or they, they have a high pain tolerance is they have their pain tolerance. It's not high, it's not low, it's theirs. Yeah, that's a pet peeve of mine, so I'm glad I got that out of here. What, what's your Approach to the patient with chronic pain when you first meet them? What, how do you approach to? I'm sure it's setting expectations? Yeah, is a big role, so tell us about that.

Speaker 2: 3:52

It's setting expectations, and it's also what I like to do is I like to let people talk for a little bit and let it off their chest, because I think for a lot of people they feel like they've been blown off so many times and that's not always the fault of the provider. A lot of time there's and it's not really the it's not really anyone's fault, I guess is what I'm trying to say, because there's so many other things at play. There's a search for an underlying medical condition, sometimes one that can be found in a sack Satisfactory way and treat it, and sometimes one that that can't really be. You know, there's not always an sort of an easy answer for why people are hurting. So I like to let people vents for a little bit.

Speaker 2: 4:30

Let people talk, tell me what, what they're feeling at some point. Obviously, you know it's cutting them off or really guiding. Guiding then and and letting people feel like they have a space to be heard, and then we're gonna work on it together. So I think that's that's what. When I often see patients, they have this in their head that no one's listening to me, right? No one's.

Speaker 1: 4:50

You know, I've seen 15 doctors and they've all no one's done anything for me.

Speaker 2: 4:55

People put me on all these medications and none of them work. No one understands how my body, you know, and stuff like that, and they're not necessarily wrong in saying that, because that's what their experience has been. Because people go to, people go to the hospital, people go to the doctor because something's hurting, not because there's an An issue. The pain is the issue and and our job is to figure out what else is gonna.

Speaker 1: 5:16

Yeah, yeah, you. I doubt You're the first doctor to see these patients you know what I mean? Yeah, they've seen my lot and it's so easy.

Speaker 2: 5:32

For to add a medicine when you see someone.

Speaker 1: 5:34

Yeah, I. When I previous lives, when I did outpatient medicine, I was so proud of myself when I didn't start a medicine you know they came in and either as a musculoskeletal injury, or we just talked through it, or you know and I, they didn't need a medicine, right?

Speaker 1: 5:50

You know that? Because I just felt like, okay, this is one more, and it doesn't take very long for these patients to be on 17 medicines. When, when you know, and three of them are conerex, side effects of others, I mean that that is, that is just the way it is unfortunately, and it's a challenge.

Speaker 2: 6:08

I mean, I think there's this sort of barrier professionally to take medicines off sometimes because you don't want to step on somebody else's toes, oh yeah.

Speaker 1: 6:15

Chesterton's fence. You know, ck Chesterton said if you see a fence it might not look functional, but somebody put it there. So there was one time there was a reason. So you're right, you don't want to start taking people off stuff because there might have been a very important reason why they're on it. It just might not be apparent to you at that time. That's a great observation.

Speaker 2: 6:36

But you know, and it's interesting, but I think that's sometimes my frustration where not putting someone on a medicine is a great thing when you can avoid it. But I think sometimes from the patient's perspective, you don't see that as the patient, I don't really see the thought process in the work that goes into managing my med list, managing and not putting my medications Because I'm going to the doctor, I want a pill, I want something to take, you know, make me feel better. So what? We didn't do anything all this time. So we sat in the waiting room and had a 10 minute visit and nothing happened. I don't get it. That's, you know, that's a frustration. So I think trying to communicate that can be really challenging to people sometimes. Of like, here's what we're like to give people a sense that, hey, we did something today.

Speaker 1: 7:25

There's no new medications.

Speaker 2: 7:26

But we're doing something here as a plan, here something actionable.

Speaker 1: 7:29

I think that's great advice. I've always felt there's two types of patients. There's ones that want a fraternal relationship with their physician.

Speaker 1: 7:41

And they start with their各 silverwareaid side. They want to make decisions together. And then there's the paternal relationship, where they just want you to tell them what to do. I mean, they're just like, yeah, doc, whatever, and you have to be able to balance those two. You can't treat a fraternal patient paternally or vice versa. It sounds like you have a good grasp on that. But let's talk about. You had mentioned when we started that there's other things to give besides opioids. So what are some of those things?

Speaker 2: 8:10

And not all of them are medicines too. I mean, that's the other thing that I try to remind myself to is starting with the medicines, since we're on dead. There's nonsteroidal anti-inflammatories, nsaids, and there's a variety of those, based on how strong they are, how likely they are to, how likely they are or are not to irritate your gastric lining, how long they last in your system, et cetera, and picking and how accessible they are. Does it need a prescription or something over the counter? So nonsteroidals are great. For some people. Tylenol is super, can be super helpful, and I think sometimes that takes a little bit of education to convince people that it helps because it's easily accessible and everyone knows it. I tried taking Tylenol. It took 500. It didn't help me at all and sometimes it's not the right dose. Sometimes a thousand, three times a day right, and that's still a safe. I have to say that a lot that's still a safe dose.

Speaker 1: 9:00

Yeah, it's still a safe dose to take.

Speaker 2: 9:02

A thousand ago, you know what I mean. But just upping the dosage and taking it regularly for a couple of days can really be a huge help and that doesn't have a risk of kidney injury, of gastric injury. Topicals capsaicin cream, declofonexial is huge. Voltaren right, voltaren, yeah.

Speaker 1: 9:25

And then they mix it commercials. Yeah, you know.

Speaker 2: 9:28

But yeah, but Voltaren's I mean Voltaren's excellent stuff and topicals are great because they're usually to apply, they're not interacting with any of the other medication, those 17 other meds that someone might be on. And there's a whole host of ice. It's great ice and heat, and sometimes that's a process of experimentation. I feel like people have their favorites when prescribing. People like ice more, some people like heat more and at the end of the day it's really whatever's happening. So, from kind of things to apply to yourself or to take, those are the things I'm often thinking about. Then there's physical components of just mobility. You know, say, motion is lotion for your joints, for your body and there's a motivating process there too.

Speaker 1: 10:12

I've never heard that. I really know that motion is lotion. It's really catchy. Yeah, it is, I mean it's accurate, you know.

Speaker 2: 10:18

But yeah, getting people moving is huge and that has its psychological and emotional ramifications too More blood pumping not just to the areas that are hurting, which helps with healing, but also to your brain also. I feel like, at least for me, if I'm stuck in a rut, I have to force myself, like you know, to do five push-ups, just something, walk outside and those things you know. I feel like that the mobility aspect of feeling better really intersects a lot with some of the social and psychosocial elements too. You're forced to go, say you might interact with a couple people where you otherwise would have been alone all day at home sitting on the couch, and those things. Beyond the physiological help, there's also those other aspects of social, of feeling Like you did something with your day, feeling like you you saw your neighbor. Physical therapy, occupational therapy, speech therapy, more formalized, very, very useful too, and partially for those also again, they're very obvious physiological reason.

Speaker 2: 11:20

You're strengthening the things that are weak, you're stretching the things that are tired, but you're also talking with somebody that you were. You're forced to interact with some other people around you. Oftentimes you're in a group of people, which can be helpful. Pt can be tricky in the sense where I think a lot of people have had some sort of physical therapy. I feel like I see two groups. There's the people that have had physical therapy and it didn't work for them and sometimes it truly didn't work. Sometimes it's not the right things were being targeted In another course of PT, our physical therapy or occupational therapy. Targeting different elements, maybe when you to work on balance, maybe a different group of muscles really is what needs to be targeted and that can make a huge difference. And then there's folks that will kind of feel like I can work out at home especially the more athletic people.

Speaker 2: 12:11

Well, I know how to work out. Why do I need to go to PT and do what feels like a lame workout when I'm benching 500 pounds? Why do I need to do this? And for the same reasons, convincing someone they need a teacher for something. Why don't you do guitar teacher? I play guitar.

Speaker 2: 12:27

I don't play the guitar by the way, I'm very, very bad at that, yeah, I don't play instruments, but yeah, but try to convince someone that it's helpful to have a teacher, someone to fine tune, which you're already doing, Because if you especially for the person that is athletic or already engaged in sports and is hurting and it's something musculoskeletal if you were doing everything right, you wouldn't be hurting in the first place, Right? So there's something needs to be fine tuned, something needs to be adjusted. We talked about motion medicines. Sometimes there's bracing, sometimes wheelchairs, orthotics, things that can be helpful to support one. Just motion isn't enough. Sometimes the emotional components, and I think there's a lot of stigma and resistance.

Speaker 2: 13:10

And this is probably the big one, especially for chronic pain, is seeing a psychologist getting therapy or a licensed social worker, someone that's administering psychotherapy, can be really, really huge, because that can with the emotional aspect of pain, the psychological aspects of pain that we talked about not too long ago, those oftentimes are this underlying component of the chronicity of it.

Speaker 1: 13:38

And I've not that I've had a lot of patients, but ones that have met with a psychologist Dr Tommen and his team.

Speaker 2: 13:45

He's great yeah, and his whole team.

Speaker 1: 13:47

I've never had a patient come back and go. That was wasted time. They always come back and go. Oh my gosh, that was so worth it, so that is a huge component.

Speaker 2: 13:57

Mind over matter.

Speaker 1: 13:59

I mean, that's not just a saying. There is some truth to that.

Speaker 2: 14:02

from that standpoint, I feel like there's this acknowledging of weakness that has to happen, like a little bit of humility that has to happen with acknowledging you know what. I'm gonna give this a shot Because I feel like for a lot of people, and honestly, myself included, where the initial reaction is well, my leg, my back, is hurting. This has nothing to do with my head, I'm fine. What do you mean? There's something You're saying, something's wrong with me, and is this argumentative defensive, right, right, all that comes up, you know.

Speaker 2: 14:26

So I'll be the first to say not necessarily for pain, but I've gone to therapy before. That's been very helpful and it doesn't mean you have to go all the time, but at least to have some actionable things too, to think about, to work on and just keep in mind. You know it can be on a PRN and an as needed basis, potentially right, and just anything that brings those walls down, like going there. Once you're there you realize the value of it, right.

Speaker 1: 14:49

But actually getting there, I think, is the challenge. One of the human traits that we all have is you. Just being alone is not good. Yeah, trying to do it alone, trying to think you can solve the problem alone, you know solitary confinement's the most brutal punishment a prisoner can get, you know, I mean there's there is something to that human interaction on multiple levels and we shouldn't minimize it absolutely. Well, how can a listener get an appointment with you?

Speaker 2: 15:20

That's what, again, the appointment is to call. Call the office, the office with American rehabilitation medicine at St Luke's 380 points, with Dr Matthew and myself, would be the best way to get an appointment with me outstanding.

Speaker 1: 15:34

Last question what, why did you? How'd you end up in this specially?

Speaker 2: 15:39

it. You know the. The short answer is that.

Speaker 1: 15:43

There's really no short answer, it's a long.

Speaker 2: 15:46

It's a long process to get here, but my my training is not not just in pain medicine, but it's in physical medicine, rehabilitation. So it's really anybody with a physical disability and where where I step in is Oftentimes with it with it, with the people who aren't Acutely ill. Right, you're in the hospital. You're not the people who you know who, thankfully, have survived but aren't necessarily a place where they can go home and aren't Functioning to the best of their ability. So my role is to help increase function, help increase quality of life and Help people get home, and I found that along the path of figuring out what I wanted to do within medicine Was immensely gratifying to me was being able to work on that and working with people to get them back to their lives, beyond just being alive.

Speaker 1: 16:33

I Think we see that up in the inpatient floor. We have where you your unit you work on is the staff really appreciate they get to see people get better over. Four weeks or six weeks or whatever a time. They're there where the other floors that are so Brief of a stay you don't never necessarily get to see that, you know, and that's a big deal and that's not to say that people don't get better on the other floors.

Speaker 2: 16:55

No, I know, but you know it's a blessing to be able to spend absolutely time with us, absolutely it really is.

Speaker 1: 17:01

They really develop friendships. Dr McGee, thank you so much for joining me. This has been great information. Once again, this is dr Roman McGee, physician with St Luke's rehabilitation and pain center. For more information, visit unipointorg. Thank you for listening live well, talk on. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcast were available on Apple podcast, spotify, pandora or wherever you get your podcast. Until next time, be well.