Central Line

Episode Number: 130

Episode Title: Subspecialty: Pain Medicine

Recorded: May 2024

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. BROOKE TRAINER:

Hi, welcome to Central Line. I'm your guest host for this episode, Dr. Brooke Trainer. I'm here with Dr. David Provenzano, the president of ASRA Pain Medicine, the American Society of Regional Anesthesia and Pain Medicine. We're going to talk about some advancements in pain and discuss the very important issue of patient access. And I'm so happy to welcome you to the show. Dr. Provenzano, thanks for joining us.

DR. DAVID PROVENZANO:

Thank you so much, Dr. Trainer, for having me. It's a pleasure.

DR. TRAINER:

Thank you. So just to get us started, do you mind telling us a little bit about how you ended up in pain medicine, your pathway, what you currently do in your practice and your role?

DR. PROVENZANO:

Sure. Yeah. So I initially started off as a orthopedic resident at Thomas Jefferson University after going to the University of Rochester Medical School. One of our rotations actually rotated on the acute pain service at Thomas Jefferson, and I met Dr. Eugene Viscusi. Unfortunately, I got injured and I had to come back from an injury. And during that time I did research with Dr. Viscusi and when I was cleared to go back, I actually decided to do anesthesiology and then do training and pain medicine. And I went up to Dartmouth and did a chronic pain fellowship after that. So really it was my rotation on the acute pain service. And this was back in the days when you did epidurals for total joints. And I really saw that the power of acute pain medicine, I thought it was really neat field. And and also at that time there were some really cool procedures in chronic pain management that I thought were really fascinating. So I elected to take the path and the pain medicine.

DR. TRAINER:

Awesome. You know, not all our anesthesiologists get that experience, that exposure to chronic pain or sometimes even acute pain early on in their training. So that's great. And I think that's, you know, how you kind of get introduced into it. So I think we all try to grapple with it a little bit at least. And so just speaking broadly, what do you think the role of anesthesiologists should be in managing pain, and why is it important for all anesthesiologists to stay abreast of how the field's evolving?

DR. PROVENZANO:

Yeah. Pain medicine, whether you do acute pain medicine or whether you do chronic pain medicine or transitional pain, I think whatever aspect of anesthesiology that you practice, whether you just practice in the O.R. or you do practice in the pain clinic, you are going to see pain. And I think it's really important for us to take a leadership role in treating that pain. It's very detrimental to outcomes. It has a significant effect on patient care. And so we can really be true leaders on that. And I think one of the big things that we want to do at ASRA Pain Medicine is we really want that whole mindset of pain medicine to be covered, from acute to transitional to chronic. And I think anesthesiologists are so well equipped to do that.

DR. TRAINER:

I agree, I mean, we see the patients from beginning to end, right? So our breadth of being able to care for these patients is expansive. Sometimes I don't feel like we see them soon enough. Right. So let's talk a little bit about some of the more common pain conditions that we may see in some of the advancements that patients can benefit from. And we can start simply because I know this is a very broad topic, but let's start with joint pain, if you wouldn't mind, to help our listeners to sort of understand what's new and inventive out there, that's helpful when it comes to reducing joint pain, this very common pain issue.

DR. PROVENZANO:

Right. So joint pain, unfortunately, probably most of us at one time in our life will experience joint pain. And so obviously you're going to work developing a whole plan for the patient. And often that involves whether it's physical therapy, medication management obviously to try to work with non-opioid forms of pain control. But you may do some topical agents. And then obviously for larger joints such as the knee, we're looking more at some of our ablative technologies to ablade, nerves that innervate those joints. And one of those is genicular nerve radiofrequency ablation. And I think over the last few years there's been a lot of research really looking at how we should do that appropriately. One, how should we select those patients? And two, what nerve should we target? So originally when it came out we were targeting mainly three nerves, uh, the superior medial and lateral geniculate nerves then the inferior geniculate. But really when you look at the innervation of the knee, it's extensive. And there's there's many nerves that can be targeted. So there are studies now going on that are looking at targeting as many as nine nerves. And so I think I'm looking forward to seeing those results. Because the question is is do we need to target more nerves. And if we do have to target more nerves? One of the things that I am concerned about from a physician standpoint is that, I mean, every time we do an ablative technology, there is some degree of collateral damage. And so if we're really have to ablate nine nerves, there would be a fair amount of collateral damage that would occur with that ablation.

So I think that is really fascinating, what we can do now with some of these targeted treatments to go after joint pain. But I still think, again, going back to the basics, I mean, you should always work with your patients on good overall hygiene with regards to health and weight control and physical therapy. But I think we as pain physicians now are getting more targeted treatments.

DR. TRAINER:

So just so I can break it down - genicular nerves essentially are your knee nerves. I think you did say knee pain. But just so our listeners understand and I don't want to speak for you, but what we're talking about is nine nerves around just the knee, for example.

DR. PROVENZANO:

That is correct. That's and it's a very good point. So we're talking specifically about the knee. And so you know most people get medial arthritis of the knee medial joint and arthritis. But people get patellofemoral pain. They also can get lateral joint line arthritis. And so when you look at the innovation of the knee I mean just some of the nerves, you have the superior lateral geniculate nerve, you have the superior medial geniculate nerve. You have the nerve to the vastus medialis. You have the vastus intermedius medial branch. You have the nerve to the vastus lateralis. You have the vastus intermedius lateral branch. You have the infrapatellar branch of the saphenous nerve. You have the recurrent fibular nerve. And then you have the inferior medial genicular nerve and the inferior lateral branch of the nerve. So if you look at all those nerves, the question is how many of you have to target to get a good outcome.

DR. TRAINER:

Yeah, exactly. And they're all coming from different muscle groups and, and innervating that nerve. But you know how much of that is, you know, normal wear and tear over time that we just perceive differently as a population versus real pathology. And I also want to break it down just a little further for the lay folk out there who maybe aren't familiar, even with radiofrequency ablation, like radiofrequency ablation is essentially electrically zapping these nerves, like, and can lead to even more nerve damage down the line, which is what you're talking about, collateral damage. So I guess, you know, when you're asking the patients when explaining this to them, how are you weighing what the long term consequences are over? Like, hey, this is kind of like wear and tear. That happens over time. And, you know, is this a pain you can live with versus like, you know, if I do this radical procedure on you, is this going to dramatically differ your lifestyle and get you back to a functional lifestyle again?

DR. PROVENZANO:

So of course we all get some degree of degenerative changes. The nice thing about like joint pain is that you can get radiographic evidence of arthritis. So that compared to some of the other things we do in pain management where you might have nerve pain and it's really hard to, you know, have some degree of visual diagnosis, you can do that with joint pain. Now the question is, is do people react differently to degrees of arthritis? Possibly. No doubt about that. But I think with knee arthritis as it gets bad, it does get harder for people to do their activities. And also, again, it depends on their overall health and also the status of the muscles surrounding the knee and how much stability they have and whether they have damage to other supporting structures like the ACL and the medial and lateral collateral ligaments.

When it comes to radiofrequency ablation, I don't really view it as a radical procedure. When you ablate a nerve, it's you're causing a third degree peripheral nerve injury, so you're not actually cutting the nerve. The nerve is still intact and it will regenerate. But for a period of time it cannot transmit a pain signal as well. For example, we do this on the back all the time for periods of time. These nerves cannot transmit signals. Eventually they recover and the pain often returns, but for periods of time you give them high degrees of pain relief. You're obviously not going to jump to any intervention unless people have failed. More conservative options. So most of these people have failed physical therapy. They failed oral NSAIDs, or they have a contraindication, NSAIDs. They probably tried steroid injections. And we know when you're looking at the data for steroid injections, the knee I mean, you will try it. But there's evidence, at least in the Jama publications, that you could cause some cartilage damage. The second thing is that unfortunately, the steroid injections don't last long. And then you can go to viscosupplementation, which, you know, some people respond to. Some people don't respond to some of the guidelines don't support anymore. But so really, when you look at the trajectory of that patient, when you go from conservative options through, the more what I would say typical shots. Then you would come to radiofrequency ablation again, which I wouldn't call radical. It's just a it's an invasive procedure. And obviously you have to use care. And I think the question that I would like to emphasize with that is again, is like, if you only to go after three nerves, you're clearly going to have less collateral damage than going after nine nerves.

And the collateral damage that I'm most worried about is really the surrounding muscles. So we know, for example. Everyone's vastus medialis, which is the muscle on the inside of the knee, helps with patellofemoral tracking. Well, if you're ablating, for example, the superior medial genicular nerve, you're going to be in that area. And so that that muscle in and of itself is going to have some degree of damage. Just when you ablate that nerve. Now, hopefully it regenerates. And it's not long standing.

When we look at proprioception, the studies have not suggested when you ablate these nerves that you cause any problems with proprioception. I think probably the most acute risk that you worry about is when you lesion the inferior medial genicular nerve. And if someone has thin skin, there is always the risk of skin burn. But you would assess that before you do the procedure. You would adjust probably your gauge of your needle and also your temperature.

The last thing I would say is that many people, I think, fear exercise as they get older, like I shouldn't run when I get older. But when you look at it, actually runners have in some studies have better knees than non runners. I think exercise is always a great thing. And the same thing for like low back you say people don't run. Wel it really depends on your overall health condition and your injury. But when you look at it actually many runners have better hydration of their discs than non runners. So again you're going to encourage people to do appropriate exercise for them.

DR. TRAINER:

Yeah. And I um maybe over spoke just a little bit there when I said about it being high risk procedures. It's more invasive than for example, exercise, physical medicine, rehab, like you said, moving. You know, you don't move, you die. That's the same, right? We have to move to get up and get going.

I do have another question about the invasiveness of procedures and things like that. There's another advancement that's gaining traction, some popularity for regenerative therapies, and that's PRP. Is this appropriate to ask your opinions on PRP therapies?

DR. PROVENZANO:

I mean, I think PRP and these therapies, I would say the data is mixed for the the arthritic complaints of the knee. Trust me, I would love to move beyond corticosteroids. I mean, we know corticosteroids in the acute period may offer some degree of pain relief, but there can be collateral damage to the cartilage. And so when you look at things like PRP and other possible regenerative techniques, the data is mixed.

DR. TRAINER:

It's sort of like coming at it from a different perspective. Right? Rather than killing the nerves, we're helping them to regenerate in a positive way. I feel like maybe that's also neuromodulation a bit.

DR. PROVENZANO:

Yeah. I mean, I think you're looking at trying to help tissue in the knee become healthy again and stimulate good growth. Correct. First of all, I think people should continue to investigate these therapies. But to sell these therapies to patients, you have to have a honest and forthright conversation with the patient and go over the data. Because most of these most of these treatments, like PRP and other techniques, are out of pocket. So looking at the benefits and harm and the patient and the physician view that the benefits may be worthwhile, any possible risk. And I think you can consider it. But I would say that when you look at like ablative technologies, again, with people with neo, I mean, you look at the studies compared against corticosteroids and viscosupplementation and well published journals, these these therapies are meeting their goal of improving pain. There's no doubt.

DR. TRAINER:

Right. Yeah. And the evidence is there to support that which probably then comes the payment from the insurers to, you know, support that. And, you know, just talking a little bit more about less invasive treatment options. Do you have any idea why the treatment options are becoming less invasive? You sort of touched upon it, but do you mind share some thoughts on how you think pain medicine is evolving and why less invasive procedures are on the rise?

DR. PROVENZANO:

You know, I remember back when I was at the University of Rochester in the late 90s, you know, doing my medical school, and I always like would watch the cardiothoracic surgeons. And I was fascinated by it. And now if you look at the field of cardiology, lots of cases never even make it to cardiovascular surgery anymore. They're done with whether it's stenting or other forms of treatment. And I think we're seeing that in pain management. You know, we have so many people that have a low back pain and it's challenging to treat. And we have people that have low back and leg pain and it's challenging to treat. And I have really good friends that are surgeons in many cases. Some people may have remarkable outcomes with surgery, but unfortunately there's a subset of people that really struggle with surgery and especially with fusion based surgeries. And so, can we provide treatment that is more minimally invasive? Well, I think we are getting there. I would say just as I talked about regenerative medicine, I think that it's exciting to see all these new advancements. But I would say again, before we deploy them in the masses, we need to continue with further research. But I think that when you look at pain medicine ten, 15 years from now, do I think that our present tools will have increased substantially? Yes, I do, and I do think that my personal vision is I hope that we do become almost like the cardiologist did to the heart. We become that to the the spine.

DR. TRAINER:

No, that that sounds great. One last treatment option that I want to ask you about. Um. My institution, we have a lot of experience with peripheral nerve stimulation. Um, we're actually using it in the acute periods, and then obviously in the chronic pain periods as well. I think where I'm at heavily funded research projects ongoing, and we're finding that neuromodulation, which is, you know, electrical stimulation of the nerves, is having remarkable results with mitigating acute and chronic pain and even maybe sensitization of pain. With your expertise and your knowledge? I'm wondering if you had any experience with neuromodulation in your opinions of it thus far.

DR. PROVENZANO:

And neuromodulation is I would say it's a big expertise of mine. You know, unfortunately, in chronic pain, there's a many conditions where people are struggling, where they just are not improving, whether it's complex regional pain syndrome. People that have upper and lower extremity limb pain, they've had back surgery. And you know they're struggling. So I think neuromodulation has substantially improved. I think it's when it's deployed correctly and ethically, it's a really, really good therapy. Now, it's not a therapy that you deploy and that you're done with. I do my own trials and I do my own implants. And I always say to patients like we are basically quote unquote going to be, I would say somewhat in a long term relationship here.

DR .TRAINER:

Married after this.

DR. PROVENZANO:

Correct. Because you are using electricity to treat pain. And just like pharmacology, when you're using oral medications or IV medications, you have to adjust the dose. And I would say one of the major things that we've learned over the last five years is how do we dose electricity and how can we dose it better? And so I think we have substantially improved that. And if I look when I first came out, most of neuromodulation was based on paresthesia-based programming. And the whole advancements in technology was really to get better paresthesia coverage of your painful area. So, for example, you had leg pain, you would try to cover that whole leg with tingling. And a lot of these were based on mapping, but that's changed now. A lot of these new technologies are subthreshold.

DR. TRAINER:

Yes.

DR. PROVENZANO:

Um or they're non paresthesia-based programming. The only caution I would have with neuromodulation is, again, just like everything in chronic pain do I think we get 80% of relief and 80% of people 80% of the time? No, I don't. I think anyone that implants these therapies, I think, realizes that they substantially help people. You have to spend a lot of time programming and helping these patients, and there's going to be ups and downs with some patients, and you're going to have to work with them. That doesn't mean the therapy is not a great therapy. It just means it's the reality of treating a condition that is really, really hard. And we know if you can provide a patient 50% pain relief with a chronic condition, they're like really happy. They're much improved on the pgic. And so I think neuromodulation is a rapidly growing field that continues to improve. It's a it's a really good therapy when deployed correctly. I do think we have to be judicious in our use of it. Sometimes I think there's been some overutilization of it. And I think unfortunately that's led to tighter regulation.

DR. TRAINER:

And that's awesome. That's a great segue. I want to turn to the subject of patient access, but we just need to take a patient safety break. So stay with me and we'll be right back.

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DR. DEBORAH SCHWENGEL:

Hi, this is Doctor Deborah Schwengel. I'm chair of the ASA patient Safety editorial board. Anesthesiologists need to be prepared to handle mass casualty incidents that we call MCIs. But many anesthesiologists are not familiar with the protocols in place to deal with MCIs. Every hospital should have incident command systems that are activated to manage the dynamic and usually novel circumstances of MCI. Every MCI is different. Incident command organizes teams into subteams with clear and manageable scopes of responsibilities. The incident command structure is designed to optimize communication to maximize patient and staff safety. It's very important to remember that certain patient populations are at higher risk during MCI, namely children, pregnant patients, the elderly, and cognitively impaired patients who require careful triage and appropriate referral. Care should also be taken to prevent inequities that affect people with disabilities and people of color. Ongoing education on hospital policies and procedures, as well as disaster preparedness exercises, rehearsals, and simulations are needed to ensure that anesthesiology teams are ready. The time to prepare is now.

VOICE OVER:

For more patient safety content, visit asahq/patient safety.

DR. TRAINER:

Okay, let's turn to patient access. I'm here with Dr. Provenzano and we have been talking about pain management, but I still want to hear from him on patient access. Big discussion point I think in the legislature, in the population, you know, in our own community, in our backyard. So what are your concerns when it comes to patient access to chronic pain services? Are their burdens, and, you know, what can we do to sort of fight back?

DR. PROVENZANO:

Yeah. So I think this is a really big challenge. So I would say majority of physicians are extremely ethical. Let me just put that in the context. Are there some rogue physicians that don't practice evidence-based medicine. Yes. And that's that's been problematic. And I think that's led to some of the regulations. But I would also say that regulations have been a form of cost cutting.

So, you know, I started practicing as an attending in 2006. And I can tell you when I first started, there was no such thing as preauthorization for these procedures. And so now I look at these procedures, such as simple epidural steroid injections. And I may have a nurse, an Ma or someone in my office spending an extensive amount of time trying to get that procedure authorized. And I cannot emphasize enough what a burden this is. And. Honestly, when I do an epidural steroid injection, I look at my Medicare reimbursement. I get paid about $100 for that procedure professionally. If you look at the Medicare fee schedule, you can see that. And if you have someone in your office spending 20 minutes, ten minutes, these procedures become cost prohibitive because of all the pre-authorization that you have to get. So I would say that the idea of having pre-authorization to make sure there's appropriate utilization. Yes, there's a subset of physicians that probably need that. But most physicians, I think, try to do the right thing and it becomes really challenging. And honestly, it leads to burnout between you and the staff to have to get all these pre authorizations for just the ability to control someone's pain.

I think another challenge we're dealing with now in healthcare too is the whole vertical integration. I mean now many physicians are employed by a facility that could be owned by a health care insurance company. And so to me personally, that's a huge conflict of interest. You have the health insurer employing the physicians, developing the guidelines. And I think we all know in reality, it's hard to speak up against your boss. So your boss is the health insurer.

And then Medicare also put extensive regulations on pain medicine now with coverage determination policies. So I would say in the end, it's become much harder to practice pain medicine over the last 18 years, at least personally for me, um, and it takes a lot more staff time to get these procedures approved and it delays care. And then if you go to the AMA and you see some of their slides on this, you will see there's clear impact on patient access and patient care. So this does need to improve. We are working with the American Society of Anesthesiologists. And we've just started the Pain Medicine Coalition. And what the goal is to try to influence federal health care policy where there's appropriate use but really appropriate access that is not burdensome to the patient or to the physician.

DR. TRAINER:

I think many specialties across the board could get on board with this. You know anytime you're going to see a patient, even in home health, you need a prior auth for every medication, for every visit, for every procedure. And it is, like you said, huge burden on your staff administratively and for minimal reimbursement. And so, you know, the middlemen and then, you know, the top guy is the one getting all the benefit from that. Um, not the patient, you know, unfortunately. nd as anesthesiologist, I think, you know, we do have an obligation as leaders in our medical society and our national societies to help fight these issues. And so you did mention working with ASA and the Pain Coalition to start working towards this. And I think that's great. Are you all also working on other things with the medical societies and leadership wise? For example, we talked about some of the new technologies that are coming out, just pivoting a little bit to see what other things can we do as we, you know, lead to get that word out to our patients on what things are out there and how we're helping them.

DR. PROVENZANO:

Yeah, these these are great questions. So I've been involved in advocacy for many years. And, you know, initially it started as writing letters to insurance companies, to government agencies. And and to be frank, it was frustrating. You didn't really see the needle move. And so then. I started to think about it more. Just as you talked about, this is affecting every specialty, every field of medicine. So in order to really, I would say move the needle, And this has been one of the clear desires during my presidency, You have to work with organized medicine, whether it's just ASA or ASRA Pain Medicine. You have to work with your friends because you're not going to move the needle unless you work with large groups of physicians. And so one of the things that ASA has been highly successful at, and you can see this just by the AMA president and that ASRA pain medicine now has been participating in is is the American Medical Association. And if you look at things like prior authorization access, Medicare payment reform, the AMA is really trying to help on these avenues. And I think you can get all groups of physicians to work together on these things. So, you know, having seats at the CPT and ROC, having seats at the House of delegates for the AMA, it's really critical.

And I would say to all the members of ASA and Asra Pain Medicine, when you get a survey to value one of these technologies, whether it's existing or new, whether it's a technique, a block or procedure, make sure you complete the survey, because those results are used by the ROC to generate reimbursement values. And so it's really critical that we participate in that. So in conclusion, I would say we really have to participate with other organizations. We have to work well with other organizations. And we have to work with large consolidations of physicians in order to move the needle.

DR. TRAINER:

Yeah, that is great advice. So where do you see us going from here? Where do you see the specialty of anesthesiology and pain medicine moving, or are there any warning signs that you, you know, that we should be worried about as we move into the future?

DR. PROVENZANO:

I mean, I think anesthesiology is a great field. For seven years of my career, I practiced regional anesthesia, so I did four days of chronic pain and one day in the O.R. with orthopedics. And I loved every minute of it. And I think I just had to start to focus on mainly chronic pain after those seven years. But I think the field of pain medicine in anesthesiology, the future is really bright. I mean, if you look at acute pain medicine, you look at our block development, you look at our drug development, you look at how we're figuring out how to use other technologies that were mainly used in other realms, like you talked about PNS to control pain. And I think we're getting a much better understanding of the causes of pain and why people may go from acute to chronic pain. So that is very bright.

I think the field of chronic pain medicine, our technology continues to blossom. We continue to have new advancements. Again, I would kind of go back to what I said before, though. With any new advancement, you have to develop the evidence and you have to make sure that there's judicious utilization and appropriate utilization. So I would say the future is really bright. I think we have to develop guidelines for deploying these technologies, have some understanding of health care economics, have understanding how we can improve patient access for all these new developments. But I think if we do that, I mean, there's, in my opinion, biased obviously, because I'm an anesthesiologist, but I think there's really no better job.

DR. TRAINER:

I couldn't agree more, biased as well as you know. Um, and before I let you go, I'm going to give you a minute to shout out your own praises to your subspecialty and your listeners at ASRA Pain Medicine, just to shine a light on the various subspecialties. We really are trying to address each, you know, subspecialty in these podcasts. And we just want to hear about your organization, what's unique, what's been going on. I felt like we really had a chance to do that in this episode, and it came full circle. But I just want to give you one last opportunity to just sing your praises about your subspecialty.

DR. PROVENZANO:

Yes thank you Dr. Trainer. So I mean again I'm biased. I love ASRA Pain Medicine and I think the society is it really is flourishing. And I think when you look at resources, with treating the whole spectrum of pain, when you go from acute, transitional to chronic, there's no better society. I think we provide all aspects of what you would need. We have always been stellar in research and education. I mean, I think when you look at any of the ASRA Pain Medicine guidelines, you know, they were ethically developed. They were developed at the highest quality without bias. And I think they become the gold standards for many things, whether it's anticoagulation. And you look at some of our cannabis guidelines. Now we have postdural puncture headache guidelines. And so I think that's a real benefit to the membership.

We have three pillars. We have research education and now we have advocacy. And we talked a little bit about the Pain Medicine Coalition. And again we work at the AMA level two. And we're going to have to advocate. And so ASRA Pain Medicine is and realizes that we're really working hard to do that. I also think, you know, our our vision is to relieve the global burden of pain. While the reality is that many would say that's a grandiose idea. But I don't really think it is. And I think we have great relationships with our sister societies, such as the European Society of Regional Anesthesia and Pain Medicine, and so we really have a global reach. So I think if you're looking at mastering the specialty of pain, continuing to be learning about the new innovative techniques, but with appropriate utilization and strong science, ASRA Pain Medicine is really the home for you.

DR. TRAINER:

And you've heard it best here. That's where it's at, folks. Thank you for joining us. And you can learn more about pain medicine at ASRA.com. Please join us next time for Central Line.

VOICE OVER:

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