Stanford Back Pain Education Day 2016 – Q&A Panel #2

Stanford Back Pain Education Day 2016 – Q&A Panel #2


AUDIENCE: My name is
Tim Soltys, and thank you very much for all
of your guy’s time here. It’s much appreciated. My question could
be for any of you and even Dr.
Darnall, Dr. Mackey. My question is when individuals
think about back pain, chiropractic is one of the first
things that comes to mind– whether for a good
reason or for bad reason. I was wondering
if you guys could shed any light onto that topic. And also, if it’s something to
consider as a topic of today has been back pain. DR. KAO: So fundamentally,
chiropractic manipulations are derived based on a
different set of understanding of pathology. What we usually
tell our patients is that if it helps you then
it’s reasonable to continue. But we’ll offer pain management
using different understanding of pain. Now there is one
additional thing to note to all of
our patients, which is there are some practitioners,
some chiropractic practitioners who would perform
high amplitude, high velocity
manipulations of the neck, which unfortunately
has been found to be associated with stroke– perhaps mechanistically
associated with stroke. So for that reason, we
do advise our patients that if they receive
manipulation of the neck to be sure that
they do not receive this large amplitude high
velocity manipulations. AUDIENCE: May I? I don’t know if this is– sorry. DR. KARAYANNIS: No, go ahead. AUDIENCE: Sorry,
I know, very rude. But in response
to that, I’d just urge you to take a look at
recent research that’s come out from the University of Penn
State, Hershey’s Medical Center, as well as the
medical center from Loma Linda University that
states in the title that it’s a meta-analysis
of all other forms of scientific research
that says there’s no causation between
chiropractic spinal manipulation therapy
and dissection. And that indeed, you are
just as likely to suffer a stroke if you go and see
a medical doctor’s office. If you have not heard
of that research, I would encourage
you to look at that. DR. KARAYANNIS: I’ll
just kind of add on to it a little bit on that. That there is some
evidence to suggest that manual therapies
chiropractic, osteopathic, physical therapy,
mobilization, manipulation can help to reduce
pain in disability. And there are some
studies that support that. I think that the
key take-home point is that usually the effect
size or the outcomes are more effective if it’s
combined and integrated with therapeutic exercise
and muscle re-education. So I guess I’ll just
add on to that comment. AUDIENCE: Dr. Mackey,
I have a question. Go ahead. DR. BARWICK: Go ahead. AUDIENCE: Oh, yes, Dr. Barwick. MONITOR: Well, there’s
a question up here. AUDIENCE: I have , um– DR. BARWICK: I’ll
catch you next. AUDIENCE: I have two
siblings in my family that since they were
little children and now into their late 50’s,
they sleep all day and they’re up all night. It’s caused them to lead
extremely dysfunctional lives. And today is the
first day I’ve heard you say something approximating
it might be normal. We just thought they were
really strange people. It’s really messed
up their lives. Is it hereditary? DR. BARWICK: Yes. Oh, I’m so glad you
brought that up, because this is a
under-recognised issue. Now, there is normal genetic
variability in circadian phase. So we feel naturally
sleepy at different times and naturally wakeful
at different times. I have certainly seen people
whose natural bedtime was 6:00 in the morning and
their natural rise time was 2:00 in the afternoon. Now obviously, that
does not work out well for school, certain
forms of employment– because we are able
to retrain ourselves and because you can use low dose
melatonin as a circadian phase shifter, there
are effective ways to treat what you’re describing. The other thing I would
say is for night owls– and it certainly sounds like– that description
you gave is classic. Where since they
were kids, they have had trouble falling asleep,
they didn’t go to bed until parents went to bed. Night owls tend to be– they have very active minds
at night, easily engaged, hard to shut down. so And so, even if they’re
natural bedtime is 2:00, they can just blow
right past it. And especially with
something like the internet, that is a candy
store for night owls. So you do have to work with
them to help them understand how to regulate and
maintain healthy sleep using these circadian cues. There are definitely ways that
they can establish and maintain an earlier sleep window
that will help them, then, be more functional
during the day. But it is normal
genetic variability. AUDIENCE: Is it hereditary? DR. BARWICK: Yes, yes. Not totally
hereditary, but yeah. There’s definitely a large part. You usually see it in families. AUDIENCE: Thank you. DR. BARWICK: Someone– MONITOR: We have
questions up here. DR. BARWICK: Yes. AUDIENCE: So I’m supposed to
be on 24 pain pills a day. [INAUDIBLE] DR. KAO: I’m sorry. I didn’t catch the question. How many pills a day? AUDIENCE: 24. [INAUDIBLE] DR. KAO: OK, so
the question is– I believe you have
noted that you take 24– 24 pills a day for your pain. And the question is whether
or not that is too much? Well, I mean– AUDIENCE: [INAUDIBLE] DR. KAO: That’s prescribed–
so your pain physician has prescribed 24 pills a day. Now, one thing to
note is that there are some medications
for which the doses that are available via the pharmacy
are smaller than what we really need. So therefore one
medication can actually turn out to be several pills. Whereas the actual dose
as given is, first of all, within reason. And second of all, effective
and not found to be harmful. So I would say the
number of pills is more of a function of
the dosage formulation– the ultimate milligrams of
the medications you are given. Now, that mere act
of taking 24 pills sometimes is just a
little bit too much and I would advise chatting
with your pain physician about changing the
doses of those pills. And possibly, looking for other
medications that may require, well, a fewer number of pills. AUDIENCE: Well, I tried
to double [INAUDIBLE] that were on that list, like two. They’ve all gave me
some side effects. DR. KAO: Got it. I would say, in general,
when we work with patients who are have demonstrated
a high sensitivity to pain medications, we
make sure that we start all medications at a low
dose and increase it slowly. Now, the reason why I
listed those medications in particular out of
the 200 is because– well, in fact,
they’re quite commonly used in the pain managing world. We have more specialized,
less frequently used, but very helpful
pain medications that have less side effects. Now, we would typically
go to those medications if a patient, like you,
approached us and told us they’ve tried and failed
all these other medications. DR. MACKEY: And I think
that gets to the challenge, again, with the data
is that, we need to do a better job in figuring
out what works for whom and why. A medication like gabapentin
is usually somewhat sedating and causes people
reductions in anxiety. But every once in
a while, we see people who have a
paradoxical response and actually get more anxiety. I think, we’re going to
go up to the balcony here. AUDIENCE: Hi, thank you. I came today for
me and my sister. And everything
that I heard today would apply for me, at least. The last picture that
I saw of the body crouched over made
me a little sad, because that’s how my
mother is every day. She’s 85 years old. She has an ongoing infection
on antibiotics for life. She takes gabapentin, I guess. She can’t get surgery
for her age I guess. She can’t sleep. So all of those
things apply to her and basically comes
out to quality of life. She’s not suicidal, but she
doesn’t want to go any further. So what do you with an 85-year
old that has no more options? What do you advise? Because, you know,
it’s really painful to see my mom
crouched over that way and not being able to
offer anything to her. Thank you. DR. KAO: So, first of all,
I’m sorry that your mother is in that situation. And thank you for sharing that. It is a situation that
I will occasionally encounter at the clinic. I would say we
typically would spend a lot of time sitting down with
the patients and their family members reviewing all the
things that have been tried, also keeping in mind all of the
other concurrent medical issues that are taking place– in this case an infection– which would limit
some of our options, in terms of pain management. Unfortunately, I cannot
give you a general answer. But I would say, in
the clinic setting where we have extended
period of time, detailed medical records
for review, what we can do is to be helpful by providing
a list of recommendations that patients like this can work
with with their primary care physician or other specialists. MONITOR: We have
one more question. AUDIENCE: Thank you, Dr. Kao. Just curious if you
have any thoughts on any of the
marijuana-derived pain meds that are coming onto the market? DR. MACKEY: I think the
question is, Dr. Kao– is less about whether
we’re prescribing them– which I addressed earlier
before your session– which we’re currently–
other than things like dronabinol and
marinol, we’re not prescribing medical marijuana. But there’s all
sorts of cannabinoids that are being
developed out there and a lot of
interesting research. I don’t know if you have
anything to add to that? DR. KAO: Um, no. DR. MACKEY: I think
what you’re hearing is that there is a
huge gap in knowledge about the effectiveness,
the efficacy, of you know, these compounds and that we need
a lot more research to figure it out. AUDIENCE: For Dr.
Karayannis, if I may? DR. KARAYANNIS: Oh, yeah. AUDIENCE: Hi. Your tai chi and yoga
groups, are they classes geared towards, basically,
pain management, or you do more than that? DR. KARAYANNIS: Could
you be more specific, in terms of what you mean? AUDIENCE: Well, you are a part
of the Pain Management Center, right? So you have those classes
for yoga and tai chi. So what do you do there? DR. KARAYANNIS: So what
are some of the outcomes that we’re interested in
with some of these classes? Well, several– you
mentioned pain management. But there are many different
aspects to pain management, right? So it may be related
to what that person values, what sort of activity
they want to get back to. So it’s individualized
to the person. It may be developing better
awareness of their body. It may be working on a
stress regulation reduction. So there are many
different targets. And I would say it really
depends on the individual and what their goals
and values are. [INAUDIBLE] DR. KARAYANNIS: Did that
answer your question? AUDIENCE: I wanted
to ask a question. I’m sorry, I forgot your name. DR. KING: I’m Drew. AUDIENCE: Drew. Hi, Drew. I’m wondering about what
resources are mentioned to the aging population– speaking specifically
of those people who don’t have the
family support– find themselves not wanting
necessarily to isolate, but their environment
and their circumstances create that isolation. It’s kind of built in. Those people also don’t have
maybe a network of friends that they can go to
outside the home. All right, is there any
advice given or direction given to people who
are facing that? Because many of us are going
into that aging population. There’s a higher percentage
of population that is aging. DR. KING: It’s a
very good question. So for those who maybe
didn’t hear the question, the question was– for those that are aging and
maybe don’t have the same degree of social support
or social network available to them through sort of
the natural channels– they may have had when
they were younger– it’s no less important,
in fact, probably more so moving forward. To some extent, this is,
of course, person specific. But for those who have no real
access to these things, again, I’m going to bring it back
to one of the last things I said in the talk. Which is, the American
Chronic Pain Association has put in a great deal of
effort to put together support groups
that are national, that are meant to
help people get some level of
social connection– even in the classes that
we offer our pain clinic. I think one of the
narratives that we get a lot is that there’s
benefit, certainly, from learning the skills. But also, it’s helpful
to be in a room with other people who kind of
get what you’re going through, even if your pain
condition is different. DR. MACKEY: And the
information on that, once again just to
emphasize, is in your bag from this yellow sheet
that Dr. King provided. DR. KARAYANNIS: Yeah. DR. MACKEY: Whose got a– I think you’ve got an mic. AUDIENCE: I have a
mic right here, too. This is something,
maybe on the light side, but I still would like to know. What’s the best way of
getting rid of jet lag? [LAUGHTER] DR. BARWICK: Be born with
the right genetic code. So there really is genetic
variability, not only in terms of where your
natural sleep window is and how long it is,
but how quickly you can adjust to crossing time zones. Remember, biologically,
we did not evolve to cross multiple
times zones the way we do now. Our system is not
set up to do that. There is no way to recover
from it, except time. And you can, potentially, use– the best thing to do is to adapt
as quickly– probably, sleep deprive yourself
on the flight over, then adapt as quickly as
possible to all the circadian rhythms of the time
zone you arrive at. So the social times, the
meal times, the sleep and wake times. You can use low dose melatonin
to help increase sleepiness if you are out of your
natural sleep window when you’re over there– meaning
your melatonin has not gone up by the time you’re
getting ready for bed. But there’s no great way
to recover from jet lag. Some people are better able
to do it, are more resilient, and others are not. Some people it takes two days,
some people it takes ten. DR. MACKEY: As someone who
flies over 100,000 miles a year, I’ll share with you also
that I will not drink alcohol the first couple of nights when
I cross more than three time zones. I bring a little bright
light box with me that’s LEDs and expose myself to
a lot of bright light where I land at that
site in the morning. And try to get on that
same sleep schedule as quickly as possible. And I found over about
the last 10 to 15 years that I’m doing a lot better
with jet lag than I used to. But I’m not one of those
genetically gifted people that change immediately. DR. BARWICK: And remember,
you can use light. So you want bright light– it is
a powerful learning cue– when you need to be awake. But you want dim
light, dusk cues when you are trying to sleep. So if you’re trying to
recover from jet lag and need to be awake and
active– lots of bright light, keep the sunglasses
off, get outdoors. If you can’t get outdoors,
bright light therapy, as Dr. Mackey was saying. If you’re getting
ready to sleep, dim light for at least three
to four hours before bed. If you’re still outside,
put on those dark glasses. And with alcohol,
It’s interesting. So the thing to keep
in mind with alcohol, it relaxes people,
so it allows sleep drive to unfold more easily. Unfortunately, as it’s
metabolized it breaks down and one of the metabolites is
aldehyde which is a stimulant. So the classic
pattern for alcohol is you fall asleep more quickly. And the second half
of night you are awake or restless fragmented sleep. AUDIENCE: Thank you
for a great day today. It was wonderful
learning so much. My name is Sangita and I’m
an oncology nurse and also a national chair for education. Our patients face a lot
of pain related issues. And my question is
that here, I think, we are all very lucky to
have had all these lectures– and so are Stanford patients. What about the rest
of the country? I know they don’t get access
to wonderful education and resources and
supportive care. Can you share resources,
information, and ideas about what we can share with
the rest of our colleagues so that they can share
it with their patients? DR. BARWICK: This is
being live streamed. DR. KARAYANNIS: I give a nod to
our colleague Kate Lorig, who offers the Chronic Pain
Self-management Program nation and worldwide. And you can access and find
programs in the community to access those pain
education classes that are usually offered very free– or usually, freely offered. AUDIENCE: Which is the–
what’s her name again? DR. KARAYANNIS: Well, the
center that you would look at– they might be in one of
the resource packets– but it’s called the
Stanford Patient Education and Research Center. And Dr. Kate Lorig has done a
lot of work on incorporating a lot of self-management
programs to the community– into some of these
places that don’t offer– DR. MACKEY: So Dr.
Lorig has helped disseminate self-management
programs throughout the globe. They’ve just recently gone live
with a searchable database. So if you look for her– first of all, Lorig,
L-o-r-i-g, and look for the self-management. There’s a web page there. And it was just brought
to my attention, it’s up and running as of
at least several days ago. You can type in your
zip code anywhere, it will show you which
self-management programs are in that area. But also in directly
responding to your question– we are live streaming this. It will be archived and it will
be online for anybody to see. We’re currently having
people watch this from all over the
planet right now. And it will be there
for enduring materials. We’ll take one more question. So– AUDIENCE: I have a
general question. So other than pain
medication, it’s obvious that sleep and nutrition
and psychology and everything else works really well
for pain treatment. But is there a dialogue
with the medical insurance companies to ensure
that they are aware of these treatments as an
alternative to pain medication? And that there’s actually
a long-term benefit of doing these things– a cost
benefit of doing these things, instead of being on
long-term pain medication? DR. MACKEY: That’s a great one. I love that one. And I’ll tell you, that
fits in part and parcel with the early
morning session when we talked about the
national pain strategy and around the area of
service and payment. And what we’re trying
to do is restructure how payment is made. We know that these
therapies will work. They’ll provide benefit. They have very few to
little side effects. They’re pretty cheap
in the big picture. And we need to get a
better payment for them. I’ll share with you that working
with the American Academy of Pain Medicine, you know,
one of the major professional organizations around
pain, we’re taking this seriously and working
with insurance companies to try to get the word
out, and other professional organizations are, as well. And then I’ll also tell
you as I point down to our excellent coach
here, Dr. Beth Darnall, she’s working with one of the
nation’s largest health care networks to better develop
pain psychology education and interventions
within for instance, Intermountain Health, a very
progressive health network. And so the tide is changing. It’s not happening
immediately but I’m optimistic that we’re
making good progress. So with that I want to
close out on that question. We’re going to cue up some
of the research slides. Can you give the
panelists one last thanks. [APPLAUSE] Let’s turn our attention
briefly to research that we’re doing
at Stanford to try to help make a
difference in your lives and those elsewhere
who suffer from pain. Our Mission Statement–
what we’re driven by, is to predict, prevent,
and alleviate pain through science
education and compassion. What that means is we’re
trying to understand what are the factors. What are the
characteristics that makes somebody who
has an injury go on to develop chronic
pain after an injury or after surgery to prevent it? Because as we said earlier,
it’s much better to prevent pain than it is to treat it. We want to then put those
preventative measures in place so that people don’t end
up getting chronic pain or they don’t end up getting
catastrophic high impact pain. And then, we’re all about, also,
researching novel treatments to alleviate pain and combining
that, again, with education. And doing that in a
compassionate way. Probably one of the largest
studies that we have ongoing is an NIH Center grant
through the National Center for Complementary
Integrative Health. This is their center for back
pain that it is supporting. And here, what we’re
doing is studying the impact of several free– my favorite four-letter F word– free treatments for pain. And the actual
purpose of this is not to try to prove whether
one treatment works better than the other– cognitive behavioral
therapy, acupuncture, mindfulness-based stress
reduction, MRI feedback, our single session
catastrophizing intervention. It’s not to prove whether one
works better than the other. It’s to try to
understand the mechanisms of these treatments–
to understand why they work better, how they
work, and for whom they work. Throughout this
discussion today you’ve heard repeatedly that well,
this treatment works for me but this one gives
me side effects. We have to recognize
we’re all individuals. We’re all different. And what we’re trying to do is
characterize your uniqueness. And then use that
information to be able to tailor the treatments
for your particular needs. One of the treatments
that we’re focusing on is this catastrophizing–
this intervention that Dr. Darnall created who
will now tell you about it. BETH DARNALL: So in my
talk earlier today I spoke about
catastrophizing and how it can exert this negative
influence on pain and also negatively impacts the
trajectory of pain– whether pain gets worse, whether
we even develop chronic pain. So the idea– there was
a gentleman, I believe, who asked a question
about whether we could use these preventative strategies. And these are strategies to
prevent the development of pain but there are also strategies
to treat chronic pain. Typically, I mentioned that
cognitive behavioral therapy is effective for addressing
the psychological factors that impact pain. And this is typically– when you go and work
with a psychologist, you will either work one
on one over the course of multiple sessions to
learn specific skills that are going to help
you best regulate your thoughts and your
emotions and some other factors in your life that are serving to
worsen your experience of pain. So you can do this
individually, but also cognitive behavioral therapy
is taught in classes. And so these are
some of the classes that we offer at the Stanford
Pain Management Center. If you’re a patient
there, you can enroll in eight or nine week sessions. So it’ll be maybe a
cohort of 10 or 15 of you in the group at one time. And each week, you
cover various aspect of skills and
information that are going to help you,
again, regulate what’s happening in your nervous
system as best as possible. So what I did was I
took information that’s across these eight sessions and
created a very compressed pain psychology class. It’s two hours long. So it’s a single session. And this is
particularly useful– I bet you can imagine– because
you only have to come once. And most people find that
incredibly attractive, because when you’re living
with a chronic pain, it’s hard to get to all of
these medical appointments. And it just sort of
goes without saying– a lot of co-pays, et cetera. So my work is very much
focused on dismantling barriers to high quality pain care that’s
going to best empower patients to have as much control
over their own experience as possible so that they need
fewer doctors and fewer pills. So in thinking about this,
well, there’s eight sessions. What can I do? Really distilled out these
key components, compressed it into a single session. And then we started studying it. We delivered it in
the clinic with people just like yourselves. It wasn’t just back pain. It was all kinds of pain. But what we found,
surprisingly and fortuitously, was that the class is effective
for reducing catastrophizing. So you really don’t need
eight sessions necessarily to treat catastrophizing. Just by having key information
explained and given some key skills and
developing a personalized plan that the majority of people
can apply this information and begin gaining control very
quickly over their psychology, over these psychological
aspects of pain. Such that, over the course of
two weeks and one month later, we see that
catastrophizing scores have dropped precipitously,
and for a lot of people, just really far down in
the subclinical range. So I know that there’s a lot of
bad news about catastrophizing. But what I want you to hear
is that it’s treatable. It’s just important to get
access to the right treatment. And that’s what this
work is focusing on. And we recently–
myself and Dr. Mackey– acquired a large
grant from NCCIH. This is a division of the NIH. And we are now studying the
effectiveness of this class compared to that longer
course, Psychology, that’s eight sessions. And we’re conducting a
randomized controlled trial. This is only for
people with back pain so we really selected
the number one pain condition in the United States. And we wanted to study
very focally how people with back pain respond to this. And because we know
that catastrophizing– it has such a profound
influence on back pain– we are hoping to be able to show
that this very accessible, cost effective, essentially
free treatment, could make a very important difference
of the lives of individuals with back pain people
just like yourself. DR. MACKEY: Well-stated. As I mentioned earlier
on, we spend a lot of time opening up
windows into your brains to understand how pain is
processed and perceived. We are trying to understand
the mechanisms of what happens when our brains alter
in an abnormal way around pain, and those individual
differences around it. We have worked to develop
objective biomarkers of pain based on brain imaging data. With ultimately
the goal for that to be able to use that
brain-related information to predict, for
instance, two things. One is, before somebody
goes into surgery or ever has an injury,
whether that person is likely to develop pain or
a substance abuse disorder if they’re given opioids. But more importantly, I
think for many of you, is to use that
information combined with other information
from something called neuroprognosis. Where we want to
get to is the point where we can take all this
information together and figure out your unique physiologic
makeup as well as your unique painful condition. And then with a high
degree of prediction, be able to determine what
treatment will work for you under what circumstances. And we’re trying to
do this to advance the mission, again, of precision
medicine or precision health. And then one of the
projects that I’m most excited about these days,
which has become somewhat of a life mission,
is to answer the call from the Institute of Medicine
that I shared with you earlier that we need better data. And so very briefly, we
know that the data quality we have right now is terrible– that we don’t know, again,
what works for whom and why. We oftentimes in
medical situations don’t track how
you’re doing across physical, psychological, and
social domains of functioning. And on top of it,
it’s made worse that just about every treatment
that we have for pain was developed using something called
randomized controlled trials, in which we take very
homogeneous groups of people. That means for every 100 people
that we enroll in a study, we had to screen 1,000
or more to get them. The problem is the 90% of
people that get screened out, they’re like real people. The 10% that come into
the clinical trials often don’t look like
a real-world person. They’re on no medication. They’ve got no other
pain conditions. And so what we’re trying to do
is to answer the question of, really, what treatments work. So we’ve done this through
the development of CHOIR. It’s an open source and free– again, our favorite
four letter F word– informatics platform. It’s a learning
health care system that we’re giving
away to other sites with the idea of trying to
change health care nationally. We integrate this into
clinical environments and with this we’re able to
track all of our patients. Every single patient that
comes into the Stanford Pain Management Center over time
to determine if a treatment is actually working. And also use this to
target therapies for them. And so this one,
by the way, it says funded in partnership
at Stanford and NIH Pain Consortium. That’s a little bit old. We received money from the NIH
last– about two years ago. Right now, it’s all being funded
through generous philanthropy. And I think one of
the key last message is– you saw this
slide before– and I think what has been
driving our vision is that all the research that we
do in the Stanford Pain Division is with you in mind. There are incredible
researchers here at Stanford that are doing
basic science research. And that research
will ultimately lead to really cool
things in the future. We tend to focus on
Translational Sciences here. In other words, we want to
understand the mechanisms within humans and then be
able to directly and more rapidly translate that into
things that will work for you. We’ve done that successfully. There’s been some discussions
with low dose naltrexone and we published the first
papers of it and its type. We’ve done other work in
novel uses of botulinum toxin, transcranial
magnetic stimulation, this single-session
catastrophizing intervention, and there’s many more. So that’s what we are all about. And with that, we need your help
to help make this move forward. If any of you are interested
in doing any philanthropy, there is the contact
information up there. With that let me pause. I think that we are closing
things out right about on time. We’re actually a
little bit ahead because we’re supposed to be
doing the Q&A session right now. But I think this is a good time
to be saying our thank you’s. BETH DARNALL: Yeah, and
right before I do that I just want to mention
that we are going to have these individual
talks archived. So if you want to go back
and review them at any time– and this is for everyone
who’s in the audience and also the live stream, as well. We will work to make all of the
information that was presented today widely available
and accessible to you and to anyone else. So please pass it
along, as well. We want to get this critical
information as broadly disseminated as possible. And, yeah, I think Dr.
Mackey said it well. It’s a time for final thanks. And I really want to thank
all of you for your time and attention today and being
with us right to the end. And I also want to
thank our sponsors one last time, the Division of
Pain Medicine at Stanford. And also Stanford Health Care.

Leave a Reply

Your email address will not be published. Required fields are marked *