Medically Speaking #11

Welcome to today's episode of Medically Speaking. I'm super excited about today's episode. Today we have two of our pain management physicians with us from South Regional, Dr. Sunil Agarwal and Dr. Lissa Heuwenlohe. So welcome guys and super glad to have you guys join me today on today's podcast. Thank you. Great. So let's just start with introductions a little bit. And so maybe Alyssa, why don't you go first? Just tell me a little bit about about yourself, like where you're from, where you went to medical school and did your training and those type things. So I went to medical school in New York. I'm from New York in the city. I did a lot of my training in New York. So I started off at Mount Sinai and then I ended up in California for my fellowship at Loma Melinda, and now I'm here. Nice. Glad to have you. Sunil, tell us a little bit about yourself. Yes, I was born and raised in Michigan. My parents immigrated from India about 40 to 50 years ago, went to the University of Michigan for undergrad, went to Wayne State for a graduate medical program, then did medical school at Cincinnati, and then I went back up to the University of Michigan in Ann Arbor to do an internship in general surgery, and then I did a research fellowship there in opioid prescribing. So there's an organization called the Michigan Open, and there I got interested in pain medicine and then came down to Atlanta, did my residency in anesthesiology at Emory, and did my fellowship at Emory as well in pain medicine. Wow. Yeah, definitely some awesome training, and we're super glad you guys are in Greenwood bringing your skills to the community here. That's just awesome. So let's just start with kind of a broad overview a little bit. I think there's some misperceptions sometimes when we talk about like pain management and those type things. And maybe just like from y'all's perspective, like tell me about your field. Like what do you do? Sure. So chronic pain is usually three months, at least three months of pain. So for people who have pain chronically or recurrent pain, those are the patients we primarily try to help treat. And we try to use many different ways to help treat them. So So the way I think about it is we use medications to help treat them. We use complementary therapies, physical therapy, acupuncture. Supplements can also be helpful. And then interventions, so things like injections and other implants or nerve-burning procedures, things that are a little bit more involved can be also helpful for those patients. Yeah, we really try to see patients as a whole person and treat all the different aspects of them as far as their pain. So sometimes we think of pain management as I have a problem in one part of my body and that's what I treat, but we really try to look at the whole person. Gotcha. So would you guys say you really take that holistic approach, right? Like kind of looking at not just the pain but the whole person as well as their other medical issues besides just the pain that they may be dealing with. How common is chronic pain? Yeah, chronic pain is very, very common. You know, over time, people just develop problems, and those could be either related to arthritis or musculoskeletal pain or nerve pain. So these things happen over time with injuries from either a long time ago or even more recently. And so it's a very common condition. It's one of the most common medical problems that we encounter today. Are there any common things that you see a lot in our area of South Carolina in regards to chronic pain, any particular? I think the most common thing is back pain. That's probably everywhere. Back pain, neck pain, knees, major joints, hips, shoulders. Gotcha. So tell me a little bit about it. Do you guys work with other specialties to kind of coordinate pain management? Like, say, you mentioned, like, back pain or neck pain, shoulder pain. Do you coordinate with the spine team, like the surgeons in those departments or orthopedics, for example? Tell us a little bit about how that might work. Yeah, absolutely. So we have a multidisciplinary approach to addressing pain. So we work really closely with the spine center, with the neurosurgeons over there, with the PM&R doctors over there as well. We work with the orthopedics team as well. So a lot of times, you know, a patient who can't have a procedure, we have things to offer them, or a patient who has had a procedure, we have things to offer them as well. We also work with our podiatry colleagues, who they help address some of our patients who have foot pain that we can't help, and then vice versa as well. We work with physical therapy, and so they play a very crucial role in how we help treat patients with chronic pain. Mm-hmm, mm-hmm. yeah so there's i know there's different types of pain right there's like uh i say nerve pain for example like people have neuropathy from diabetes or other chronic impingements in their back or whatever and then there's more like like shoulder like bone pain and um and cancer pain and and and different types maybe tell us a little bit about maybe the different types of pain that you treat and how your approach may be different depending on what the patient has so if they're having more like that arthritis bone pain that will be a certain type of treatment maybe depending on what joint it is their age and all the different things that are going on with them we might refer them to physical therapy and try to start with a stepwise kind of almost like a laddered approach so least invasive to most invasive would mean physical therapy maybe some topicals over the counter medications and then if they need it we could do injections and if they're really not really getting a lot of relief sometimes we refer to those other practitioners like surgeons if we're talking about neuropathic pain it just really depends on where again where the pain is but a lot of the same kind of modalities so we'll start with you can even do physical therapy for nerve pains topicals and then we do do some injections depending if you're talking more about nerve pain like a radiculopathy that would be more like a spine injection and then we can even do things where we do implants like a spinal cord stimulator people have peripheral neuropathy in their feet if they have just one nerve bothering them sometimes we can put in a peripheral nerve stimulator so we have a lot of different options yeah so those are I think she covered the majority of the options that we have available you know for people who also have narrowing around the spinal cord there's a procedure that we do that relieves some of the narrowing there's a ligament that lives in the spinal canal outside of the epidural space where we can actually peel away at that ligament. And that's a non-invasive procedure that patients can go home the same day and get relief with that narrowing around the spinal cord. It's called the MILD procedure. Okay. Okay. Talk to us a little bit about the role of opiates in pain management. I know as an ER physician, I see someone comes in with acute fracture. It's not uncommon for me to write them a few days of something a little bit stronger, Lortab or something like that to really take that edge off acutely. But what's the role or is there a role in opiate pain management just in general? And in which cases might you use that more than others? Sure. So I always explain it as every intervention has a side effect. There's a risk and a benefit to everything. So with opioid medications in the short term, they can be very helpful for an acute problem. If someone breaks a bone, has a surgery, opioids can be very helpful in getting them through that acute process. But in terms of long-term use of opioid medications, that's where the risks start to outweigh the benefits, where people start to have side effects from these medications, where they lose their effectiveness. And it's not just things like addiction or overdose that are important things to consider, which they are, but they can affect the body as a whole, so they affect the hormones, they affect the bone health, they can actually make your pain worse because your body starts to get used to these medications and can cause a concept called hyperalgesia, where your pain is actually amplified while on these medications. And so it's important to approach pain with multiple different angles, multiple different viewpoints and perspectives to try to make sure that we're targeting the pain in as many ways as possible, not just one therapy. Gotcha. So is there a role for opiates in chronic pain management? Other things may not be working, or what's your thoughts on that? So my thought is, you know, if we try to exhaust more conservative options, if those are not effective, then opioids are a last line. They are something that can be helpful, but until we try the other options, they're not usually a first line of therapy. Sure. I know you've already touched on some of the other options, but maybe dive in with me a little bit more. So you mentioned acupuncture is something that you might try. Maybe let's talk a little bit more about some of those, I guess what maybe some people would think of the alternative treatments. I'll dive into that a little bit. And how does that play into your practice? Yeah. So we, you know, it really depends on what patients have access to but there is a lot of evidence for acupuncture for um even things like mind body practices or therapy so that's going to be like mindfulness meditation yoga tai chi is really big a lot of evidence for that so um really talking chronic pain we're talking about chronic pain yeah yeah so um those are some there's a lot of different categories and i think we touched on supplements a little bit too a lot of different like herbs topicals different things that people can try that are known to be safe um massage can be really great pool therapy getting in the pool a lot of people with arthritis people have a lot of weight on their joints on land if they get in the pool they can move better and really get that workout that they need to kind sustain their body and get that strength around those joints um what else what else am i missing chiropractor chiropractor is great um you know maybe it's not the cracking is not for everyone but um chiropractor does there's a lot of overlap between a lot of different um uh like between physical therapy and chiropractors so they will give out exercises and they will do some of the the manipulation myofascial release then physical therapy will kind of do some of that too dry needling things like that and i always recommend that patients do stretching at home try to have good form when they're lifting things especially because low back pain is one of our more common commonly seen conditions and then we also have wearable devices that people can use at home things like a tens unit which is a transcutaneous electrical nerve stimulator basically a sticker that you put on your muscle and you can stimulate that muscle to help with myofascial or muscle pain. Gotcha. So how does someone get an appointment with you guys? Can they just call or do they typically need to go through some type of a primary care doctor or other physician first? How does that work? I think it depends on their insurance, right? If they have to go through their primary care, but I think they can call. I think for the most part, they see a primary care doctor first. The primary care doctor will then refer to us if that is, if they're having, if they meet the criteria for chronic pain. So if they've had pain for three months that has not responded to more conservative therapies. We also see a lot of patients who've seen the surgeons first and who've had a procedure in the past who have pain after the procedure and get some referrals from our surgical colleagues as well. Do you guys work much with our cancer center? We've started to work more with the cancer team. There are certain procedures that we do to try to address cancer pain and medications that are commonly used to help with cancer pain and also treating pain that results from therapy from cancer treatment. So a lot of times people who have chemotherapy, they can develop neuropathic pain or nerve pain. So there's certain medications that we are comfortable prescribing that can be used to treat that. I have started treating patients with stage four metastatic cancer who are receiving palliative care with neurolytic procedures. So we actually burn nerves that are responsible for the sensation that they have from tumor bulk that could be pushing on those nerves. Gotcha. Gotcha. Oh, let's touch on pain goal setting for just a little bit. This is something I remember from back in the medical school days. It's like sometimes, you know, it's easy, I guess you've been dealing with something and maybe to have sometimes an unrealistic expectation on like what you're going to be able to do. Tell me about the role of pain goal setting or goal setting in the work that you guys do. Yeah, I think expectations are really important. Just making sure that, you know, we're on the same page with the patients and understanding where they're at right now and what their idea is of where they can get their pain to. I think people hear pain management and think, I'm going to go from a 10 to a zero and it's going to happen right now. But you're right, if you've been dealing, the longer you've had something, the harder it can be or more challenging it can be to get it to kind of go down, it's not always the case that we can get pain to go away completely. So kind of setting that expectation. And there's a lot of different reasons why that could be. I think just really making sure anytime we initiate a medication or procedure or send a patient to therapy, really just making sure that they understand what the expectation is as far as what they're supposed to be getting out of it and what work the patient should put into it as well. And another thing is not just thinking about it in terms of a pain score or pain number, but it's also functionality. So are you able to do the things that you love doing that you used to be able to do prior to your chronic pain and providing quality of life? Yeah, I think it's so important to, like you guys said, to kind of have that expectation of like, what do you think you're really going to get out of this? I mean, if you come in and you think you're going to be completely pain-free, it's probably not realistic, but we can take you down from an eight to a four or something like that and, uh, and make it to where you can manage it and do the things you love to do and have some quality of life. That's really what you guys, I think, bring it along in a big way of what you do is you help people get some quality of life back. And that's a big deal. Sometimes it's even just sleep. People just want to sleep. Exactly. One of the reasons I got into pain medicine was, you know, a lot of medicine is focused on longevity. So how old we are living too, but not necessarily focusing on quality of life. So that is something that I take pride in trying to provide my patients is a better quality of life. 100%. And I think you guys do that. I definitely think you guys do that. Okay. Well, I guess one other thing I wanted to touch on is just community partnerships and relationships. to me that's super important that at the hospital we're looked at no not just like we do this health care thing that's all we do but we're really more broadly involved in the community and want to really be looked at as a as a community partner tell us a little bit about some of the things that you guys are involved in in the community or whatnot um we're starting to partner with the y um we like i was saying before we want patients as many patients as possible to get into the pool and try pool therapy or aqua therapy. So we'll be starting that up soon where patients can go there for their therapy. I think it's going to be like a group class, but special for our pain management patients. Okay. Yeah. And we partner with the different physical therapy options available in the area, not just in Greenville, but also Abbeville and neighboring counties. We are also trying to connect with acupuncture resources with massage therapy and chiropractor resources as well so our patients can have access to them. And then we're also partnering with our psychiatry colleagues who can help with cognitive behavioral therapy and they're doing group sessions for patients who can benefit from that. Tell me about cognitive behavioral therapy. What is that and how does that work? So there's definitely a strong relationship between emotional state anxiety state and pain and so a lot of times when someone is in a more stressful state they have greater pain and so by helping address their emotional state and their anxiety state you can actually help improve their pain cognitive behavioral therapy specifically helps trying to help with patients in their coping mechanisms and trying to understand their pain understand how they can address their pain in their daily living and helping patients formulate their own expectations and goals too and it kind of makes these things tangible for the patient cool so just kind of changing subjects just a little bit you guys are both relatively new on our medical staff having just started with self regional in the fall just curious like what was it about self regional and Greenwood that attracted you guys to come here Because you guys, with your training, New York, gosh, Emory, you know, you guys could probably have gone anywhere. What was it that said, you know what, I think I'd like to try this out at Self Regional? Putting us on the spot. I really liked the atmosphere. I liked, I mean, from the time I met just the staff and, you know, my first interactions with Self, it was clear that there was something different about being here. I like the small community feel, but there was a lot, you have a lot of resources at this one hospital and the patient population. And then also it's the South, you know, everyone is so sweet. And I come from New York City where everyone's yelling, which is great, but it's nice to practice medicine in the South, I'll say that. Cool, cool. Yeah, and for me, you know, from the top down, leadership here, it's a physician-led hospital. And I think that is a great opportunity for providing health care, physician-led health care. And so that was something that was really interesting to me because it's not a common practice. There's a great opportunity for pain medicine from leadership. It sounded like there was a great opportunity to develop the pain medicine center and partner with our neurosurgery colleagues to form a spine center, which I think we're in the process of doing. We are, yep. And also the patients here, there's definitely a need for addressing chronic pain. This is a place where people are very friendly, people work very hard, and in South Carolina, historically, they haven't had appropriate chronic pain management. And so I've seen studies where opioids have been largely overprescribed in the southeast, and so I feel like it's a great opportunity to help address that and help provide people with proper pain management. Great. Good answers. That's awesome. Well, gosh, is there anything else you guys want to share or tell the community about what you guys do or really anything else you want to touch on? Maybe just a little, like, blurb about pelvic pain. Sure, yeah, please. You know, it can affect men and women. A lot of times, you know, people can think they're having back pain, so it presents as back pain, but it can actually be pelvic pain. And we can treat it the same way we treat everything else with the stepwise approach. But some nuances would be that we would send people to something called pelvic floor PT or physical therapy. And so we've been trying to really find some resources around. You know, we have some people that may do a little bit here, but finding some dedicated pelvic floor PT people in the community. Yeah. Okay. Cool. And, you know, it's our priority to provide care with consideration of being safe. So being safe first and foremost, and then secondarily trying to help address pain. Safety is really important, and so it's important to keep our patients safe, make sure that they're getting appropriate management with the medications that they're on and consideration of their other medical conditions. And so those are all things that we consider when we're coming up with a creative plan to try to address pretty complex problems. Awesome. Great. Well, gosh, guys, thank you all so much for joining us on today's podcast. And we hope you guys picked up a few little nuggets today about our pain management center. And thank you for trusting Self Regional Healthcare for your healthcare. Thank you. Y'all have a great day.