Stanford Back Pain Education Day 2016 – Q&A Panel #1

Stanford Back Pain Education Day 2016 – Q&A Panel #1


BETH DARNALL: So
the question was that if you have an individual
who isn’t depressed or doesn’t have major mental
health problems, is there value in being
proactive about seeking mental health care,
specific to pain, as a preventative strategy? And the short answer is yes. So what we know is that one of
the biggest predictive factors about whether a pain-free
individual actually acquires chronic pain
following an injury, or an acute back pain
episode, or after surgery– which is essentially
a controlled injury, if you think about it– one of the biggest predictive
factors is catastrophizing. And so we tend to think
and feel a certain way when we have pain, even if
we don’t have pain right now. But we all experience
pain from time to time. I hate to call out the
profession of dentistry, but imagine if you
go to the dentist and if you experienced
pain in that procedure. Well, you don’t necessarily
have chronic pain, but how you tend
to respond to pain actually has a very
large impact on whether or not you develop
chronic pain later on. And that just
suggests that, again, going back to this concept
that we’re participating in our experience. So if we can learn
skills on the front end to best control these factors
that will amplify pain, that will lead to
its persistence in our nervous system,
then essentially we’re, again, training our
brain away from pain. So we’re doing some
studies on this topic right now at Stanford. This is investigating
an intervention that I developed to
treat catastrophizing. And the idea is, can we
optimize people before surgery, as a preventive strategy to
ideally prevent the development of post-surgical chronic pain? We’re testing this now in
women who are undergoing surgery for breast cancer. We are about 3/4 of the
way through the study and hope to have final data
at the end of this year. And we’re crossing our fingers
that we will have discovered an effective pathway to
optimize people before surgery, as a preventive strategy. But the data suggests that this
is a pretty logical approach. SEAN MACKEY: Anything
you want to add? HEATHER POUPORE-KING: So I would
say that we know that anything that impacts your
nervous system– which we all have stress, right? Or is it only me? So if you have– even if you don’t
have pain, I think you can benefit from taking
that proactive approach. Cognitive behavioral therapy
is an excellent strategy to learn tools to manage stress. And then, acceptance
and commitment therapy is all about learning to
live a full, vital life. So working toward
what matters to you. So I think, although
CBT and ACT are really helpful for the
treatment of chronic pain, they’re also used for other
things like stress management. SEAN MACKEY: And let me
just add on to that very, very briefly, since
I’m not a card carrying member of the
psychology profession, as a physician who doesn’t
currently have pain. And I attended two
different groups of Mindfulness-Based
Stress Reduction, because I kept sending
patients to it, and they kept getting better,
and I wanted to know why, the curious person in me. So one I did on
my own, one I did with my son, Ian Mackey, who
was about this tall at the time. He’s now 6′ 2″, 6′ 3″. You see him floating
around here. And I think MBSR,
everybody should take it. Mindfulness-Based
Stress Reduction is being put in the schools,
it’s being put in the colleges, our surgeons are now
taking it over here. I didn’t take it for pain,
but it helped improve my life. And I think it helped
prepare me for– I ultimately did end up
with a low back pain episode when I didn’t train
well enough for a 10K. And I paid for it for many
months, and it helped me there. And then we have a bunch
of other questions. So I kind of saw your
hand go up really fast. BETH DARNALL: We have
a microphone now. SEAN MACKEY: Yeah. And we will get to you. I got eyes on you. Please. AUDIENCE: Thank you. This is wonderful. And I’m not using the mic,
I’m using my teacher voice. SEAN MACKEY: We need
you to use your mic. AUDIENCE: You need
to use the mic. OK. It’s a two part question. Are you planning to
include stem cell therapy and/or marijuana in
any of your programs? And the other one is,
how do you incorporate acupuncture mindfulness
in the pain management? SEAN MACKEY: I heard
the marijuana question. I didn’t hear, what was that
thing right before marijuana? AUDIENCE: Stem cells. SEAN MACKEY: Oh, stem cells. Stem cells. So we are starting to
do a little bit more on this regenerative
medicine aspect. And Dr. Ottestad,
I think Dr. Leong– Dr. Leong will be here– can also perhaps address
issues around that space. It’s a promising area. It’s an area where
there is a lot of– still a little bit
of quackery going on. In other words, we don’t
know what really works and what’s just snake oil. With regard to marijuana,
our clinic policy has been, at this point, we do
not prescribe marijuana. We don’t understand exactly
what is working and not working with marijuana. I will share with you
that when I was president of the American Academy
of Pain Medicine recently, that we put out a position
statement on it though, requesting that it be
rescheduled as a schedule II because right now it’s
very, very challenging to study marijuana,
and we strongly believe that it needs to have
the same type of research as applied to others. And then I think the
question was acupuncture, and what was the other? Mindfulness. So mindfulness? HEATHER POUPORE-KING:
So one thing that I forgot to
mention during my talk is you have a yellow
sheet of paper that you received
when you checked in. It has all of the classes
that I mentioned listed, and it also has the
Mindfulness-Based Stress Reduction class that’s offered
through our integrated medicine clinic. I will tell you that
all of the groups, the cognitive behavioral
therapy group and the acceptance and commitment therapy group,
we have a mindfulness component to those groups as well. But the MBSR class
is actually offered through the integrative
medicine clinic. SEAN MACKEY: Thanks. BETH DARNALL: I just wanted
to follow up the last piece, the acupuncture. We offer acupuncture at the
Stanford Pain Management Center. Dr. Jiang-Ti Kong is our
expert physician acupuncturist. She is also conducting
acupuncture research currently, so we’ll be talking more
about this later in the day. But you can visit the Stanford
Systems Neuroscience and Pain Lab website, and
you can see if you qualify for various studies. But if you do qualify
for this specific study, you get free
acupuncture treatment. SEAN MACKEY: All stated. And then if you could pass the
microphone two rows up in front of you, the nice lady here– forward, forward. [INAUDIBLE] us. There we go. BETH DARNALL: Nice teamwork. AUDIENCE: Hi. Are you sure I’m a nice lady? BETH DARNALL: We’ll see. SEAN MACKEY: Yes. JORDAN NEWMARK: We’re
all friends in this room. AUDIENCE: Indeed. OK. My question has to
do with there being a correlate between
the experience of pain and early childhood trauma, or
repeated trauma, life traumas. And the treatment
of anxiety and those medications prescribed
for anxiety, and how they suppress
the respiratory system, but at the same time, the
person who is not only suffering from chronic
and/or debilitating pain, also having that
challenging aspect of maybe it could be considered
post-traumatic stress. And so the medications
for treatment of these two different conditions,
and how they interface, and how maybe that presents
a more challenging dilemma for both the patient and
the treatment people. Is there anything
to say about that? SEAN MACKEY: There was
actually a couple of parts, a couple pieces to that. One is the adverse
childhood events, and the second part was the
complexities around medication, PTSD, anxiety. On the adverse childhood
events, the data is becoming overwhelming that
what happens in childhood, what happens with our
children, greatly shapes their central nervous
system for vulnerabilities throughout the
rest of their life. Not just pain, but addiction,
anxiety, depression, occurrence of PTSD. So those do get
set up very early. We’re now trying to do
studies to better understand to what extent that
can all be reversed, and I’m optimistic
that it can be. But it is a vulnerability,
and one we should acknowledge. Two. One of the key messages
I think you wanted– we hope to take away
from here, particularly around the medication,
is nothing here is black and white. The message here that you
heard from Dr. Newmark, it’s not that you should
not do, because this is a very complex situation. What do you do with
a person who has PTSD, who has a
generalized anxiety disorder, who also has pain? We’re not saying
don’t use benzos. What we’re saying is,
make sure that you as the patient, the person
or people living with pain, are weighing the risk
and the benefits, and that you’re
making an informed decision with your clinicians. AUDIENCE: May I add
something, just one aspect. If you have maybe a subconscious
or vulnerable predisposition to fear because of
early childhood trauma, that influx of fear that shows
up when you least expect it and it continues,
isn’t that also sort of a powerful medication that
is actually not helpful to you? I’m not sure if I’m
being clear, I hope I am. BETH DARNALL: I
wanted to just add a few words that maybe address
a couple of components of this. I mean, one is the idea that
adverse childhood events can contribute to a tendency to
be fearful and also have pain. Medications have their place
in both the treatment of pain and also in
psychological conditions. It’s critical that we don’t
rely on medications alone, because particularly in the
cases of persistent anxiety and also post-traumatic
stress disorder, there can be a tendency to
either over rely or maybe become dependent
on the medications. So one of the pathways to help
people reduce their anxiety is to actually help
increase their confidence, then they can decrease this
fear and anxiety themselves. And that’s really the realm
of behavioral medicine and psychology. So post-traumatic
stress disorder, when it co-occurs
with chronic pain, it’s really hard
to treat the pain when we have this anxiety
flaring all the time. So I recommend that
people work with a anxiety specialist, a psychologist. There are non-pharmacological
strategies that should be optimized. And medications may be one
part of the treatment plan. I’d just like to
give a shout out to Eye Movement Desensitization
and Reprocessing therapy, EMDR. This is used by the
Veterans Administration. This is evidence-based medicine,
applied to our warriors coming back from
combat who have PTSD. There’s also
evidence that it can be helpful for chronic
pain and people with co-occurring
anxiety disorders. SEAN MACKEY: I’ll tell you what,
just to allow some other time, we would be happy to
chat with you more afterwards during the lunch
break, if that’s helpful? Why don’t we go right to
the next lady, and then we’re going to go
next in the back, just so we can queue up the mic. AUDIENCE: I was having
a successful experience with low dose
naltrexone, but I had a physician recently
suggest that it could cause my brain not to be able to
produce endorphins on its own after a while. And I stopped taking
it because of that. And I really liked
it a lot, and I’m curious as to what the long-term
effect on the brain’s ability to produce endorphins
on itself could be. SEAN MACKEY: Yeah. Briefly, so low
dose naltrexone– naltrexone is a drug
that’s been used to treat opioid and alcohol
addiction for decades and has a longstanding
safety profile. Used at small doses,
tiny little doses. It’s thought to work by
reducing nerve inflammation. We’ve published two
papers here in our group– Dr. Younger lead this
effort out of our group– on fibromyalgia low
dose naltrexone, and we got great results. And we’re running a
clinical trial right now, a research trial with
complex regional pain syndrome and that drug. What I can share with you
is that for those people that it’s worked, it’s been
absolutely transformative, and we’ve seen really
little to no side effects or long-term effects. We don’t know, at that
low dose, whether it blocks the opioid receptor. And even if it does, almost
who cares if it’s really improving your
quality of life and it’s not causing
untoward effects. And so, you know, we’d
be delighted to chat with your physician about that. It’s probably one of
the safest medications that I have prescribed. I have no financial
relationship with this drug. It’s generic. It’s been off label and
off patent for decades. And then one last
question in the back, and then we’re going to
get you out for lunch. Yes, the lady in blue. All the way in the back. AUDIENCE: Hi, there. My name– is this working? My name is Sammy. I actually work with
a couple of you, so this actually applies to
all of you, psychology as well, some of you who have worked
in the surgery department. My question is have you noticed,
with the chronic low back pain or chronic pain
in general, have there been more diagnoses with the
mental and behavioral health field with the
chronic low back pain, either as newer onset diagnoses
because of the chronic pain that has surmounted, or because
of psychological disorders that there has
been a correlation from either triggers or
whatnot because of the pain? SEAN MACKEY: So let me just
take a little piece of this and say, what we’re
trying to do at Stanford, we’ve developed an informatics
platform that we may chat about later that
really characterizes most patients that
come into surgery. It’s called CHOIR, and it’s
actually in the Stanford Pain Center first, where we
get a big picture look at you across physical,
psychological, and social domains. We put it into the pre-op
clinic to actually capture these characteristics of
PTSD, anxiety, and depression, because we know they’re
huge predictors of who’s going to do worse after
surgery, particularly after back surgery. And we’re just starting
to use that information. So I think it’s one
of the innovative ways that we’re addressing it here. And then– BETH DARNALL: I’d just like
to say that the data suggests bidirectional relationship. So what you’ll see is that
people who have anxiety, depression– and I’m talking
about formal diagnoses– much more likely to acquire back
pain, but other types of pain as well. It’s all pain. And then, once you
acquire pain, you’re much more likely to experience
anxiety and depression as a consequence of the pain. So it works in both directions. It’s always important
to be mindful of that, and then to treat all
of it because all of it impacts every aspect of your
life and your experience.

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