Central Line

Episode Number: 154

Episode Title: Advances in Pain Medicine

Recorded: January 2025

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

DR. ZACH DEUTCH:

Hello, everyone, and welcome to the Central Line Podcast. I'm your host, Dr. Zach Deutch, and today we will be focusing on the topic of pain medicine. I'm joined by two experts from Stanford University. Dr. Beth Darnall and Meredith Barron, who are contributors for the March issue. They're going to share their expertise with us today on this important topic. We're going to talk about pain medicine in general, the rewards and pitfalls of practicing it, the outlook for the subspecialty as a whole, and emerging roles of techniques like biopsychosocial interventions. I'm happy to have both these ladies on the show.

First off, I'd like for the listeners to get a little information about you two, your trajectory to where you are now, what your professional duties are, and where did you get your interest in pain medicine? Dr. Darnall, I'm going to start with you, please.

DR. BETH DARNALL:

Yeah. Hi. Thanks. Um, so I am a professor of anesthesiology, perioperative and pain medicine at Stanford University, and I direct the Stanford Pain Relief Innovations Lab. Um, my background is I'm a clinical psychologist, and I was first exposed to pain during clinical internship, and then later on my postdoc fellowship at Johns Hopkins University, where I was working with people with, uh, catastrophic burn, amputation, other major, um, surgeries, and, um, also spinal cord injury. And what was common to all of these populations was that, um, they were in need of pain management, and they were looking for non-pharmacologic ways to, to manage their pain and cope with the pain that they had, and this would work alongside their, their medical plan um, for pain treatment. So that's really where my my interest got started. And I've been working in this field for 20 years now and it's been very rewarding. Mainly because I get to see people get better, to see their suffering reduced, to see them gain an understanding of how they can help themselves and translate that into a better quality of life.

DR. DEUTCH:

Very good. And Dr. Barad, can you share a little bit with us about your background?

DR. MEREDITH BARAD:

Thank you. Um, so I come to pain from neurology. I got interested in pain when I was a neurology resident. Um, and went on to do a pain fellowship, and, and I think the reason why that encapsulates my interest in pain came from seeing many patients in pain, but not a lot of interest in treating pain. A lot of interest in neurology, in treating cognitive issues, motor issues, sensory issues, but not the overall complex physical and emotional event that pain is. And so I found a wonderful pain program at Stanford, did a fellowship there, and I am still there today. I am a clinical associate professor in both anesthesia and the pain division and in neurology, and I focus on patients with headache and facial pain primarily.

DR. DEUTCH:

Okay, so I just have a couple questions just to figure out the structure. I'm curious, based on what you have said about your professional backgrounds, both of you are not anesthesiology people that have come to pain medicine through the fellowship. So just to refresh myself, because the last time I've had direct involvement with this, other than management of a pain practice in a private group was when I was a resident. So specialties that can get into the subspecialty of pain medicine besides anesthesiology or neurology, psychiatry and physical medicine and rehab. Is that correct? Have I left anything out?

DR. BARAD:

Emergency medicine, family medicine, radiology? Um, I think those are the big ones that are all allowed to sit for the boards.

DR. DEUTCH:

Okay. So at your division at Stanford, it sounds like it's at least based on just talking to you, too. It must be well represented across disciplines. Can you kind of give me an estimate? What percentage of the faculty are anesthesiologists by training versus not in y'all's division?

DR. BARAD:

I mean, Beth, I'm just going to guess I would say probably 80% of our division is anesthesia, 75%, something like that.

DR. DARNALL:

Yeah. I mean, I think we have, um, if I may get my numbers wrong, but I think we have eight clinical psychologists in the division of pain medicine. So I don't know from a percentage standpoint, but psychology is is well represented among this multidisciplinary, interdisciplinary approach that we offer in the Stanford Division of Pain Medicine.

DR. BARAD:

I guess maybe just to build on that, Zach, um, we truly believe in practicing multidisciplinary or interdisciplinary pain management. And we we walk the walk and we we want to create a multidisciplinary group. So within our group we have eight pain psychologists, we have neurologists, we have physiatrists. And from time to time we've had different, uh, addiction medicine, internal medicine, psychiatry. And then we try to bring in a fellow group that is also diverse, because every fellow that trains with us brings another piece of their training to our treatment group, and we all learn from each other. Um, but still, the bulk of pain fellows and pain fellowships are are anesthesia dominated. There are some pain fellowships that are in physiatry departments. It's a little bit different, but usually the majority of pain fellows are coming from anesthesia.

DR. DEUTCH:

Understood. Thank you guys for clarifying. And I hope that none of the listeners who are chronic pain physicians are cringing thinking, how could you not know this stuff, guys? Just just give me a break. It's been a while since I've been involved directly in that. And like you, I'm going to avidly read this issue to learn all I can and to and to bone up. And it's and it's good to be able to understand, you know, what colleagues are doing in other subspecialties, because obviously this affects us in ways that we treat overlap. These patients are treated by us in an acute setting and other people in a chronic setting. Which brings me to my next question. So we know pain is a big, big deal in perioperative medicine, especially pain that is poorly treated. We know that acute pain that's improperly treated can lead to chronic pain, which can be severe and cause a lot of dysfunction, patient hardship, time off work and cost to society, and also problems with chronic opioid use. So we can't snap our fingers and make this problem go away. But we are people like yourselves, and divisions like Stanford and other places are working to manage this. So, Dr. Darnall, you’re a psychologist, can you kind of fill us in about what management strategies that you guys are using that are more cutting edge, that you found to be more effective to try to deal with this problem?

DR. DARNALL:

Sure. Um, you know, you alluded to this in your question, Zach, but research has consistently shown that a person's mental state or some psychological factors, such as anxiety or pain related worry or depression, can impact surgical outcomes. How much pain a person has, um, and how long it lasts. And several new studies, all conducted in the last 3 to 4 years, show that we can apply brief skills based treatments to reduce postoperative pain intensity for months. So this has been a very large focus, especially in this era of reducing opioid prescribing after surgery and long term as well. So in an era of opioid reduction, there has been more interest and emphasis on nonpharmacologic or at least non-opioid strategies. So this has been a nice opportunity for psychology to come into the fore, um, because it does address some of these factors that impact pain after surgery. And if we can help people have less pain after surgery, then maybe they can have a better recovery. Need less medications and be able to rehabilitate and get back to doing more. Some of these skills based treatments can include mindfulness components. People gain an understanding of what some of their unhelpful thought patterns are, thought patterns that increase or amplify distress and pain. They learn various techniques to calm the distress that pain very naturally causes us, and overall keep the nervous system in a calmer state. That's conducive to healing. So it basically like these we have different techniques and approaches for the perioperative space. People can learn the information, apply the information and, and basically have a roadmap for how they can contribute to their recovery by keeping their pain and distress low.

DR. DEUTCH:

So I'm not sure if some of what you've already spoken about goes to what I'm going to ask you. But, you know, as anesthesiologists especially, are very familiar with procedural medicine, you know, doing things to people, doing injections to treat pain. But now we're talking about something that's noninvasive like that. So a biopsychosocial intervention. Can you tell us exactly what that means to you and what exactly would it entail when you see a patient in the clinical setting?

DR. DARNALL:

Absolutely. So the biomedical approach is very much what most physicians and anesthesiologists are used to applying, which is basically working with the person purely from that, that physiologic medical standpoint. Um, but the biopsychosocial treatment approach recognizes that there's these other dimensions to the person that have a very large influence, both on the pain that they feel as well as their outcomes. And so that's where psychosocial comes in. So recognizing the psychological factors, social factors. And some people even bring in spiritual factors as well. But from a big picture perspective, the biopsychosocial treatment approach, um, equips people with knowledge and skills that they can use themselves to reduce pain and and suffering from pain. So rather than it being something that a physician is doing to the patient, the person becomes empowered with the information and skills to fundamentally alter their own experience. And with these skills applied over time, they can actually alter the trajectory of their pain and their recovery. Common approaches include mindfulness based skills or cognitive behavioral skills. Both of these target our attention and our reactions to pain and other stressors, so it really helps people gain awareness into response patterns, what's happening in mind and body, and then learning to apply some pretty simple skills, but important skills that can calm the central nervous system. When the central nervous system is calmed, it reduces pain processing in the brain and and therefore reduces pain perception experienced by the individual. So it's it's literally giving them a degree of control over their own experience within the context of these physiologic factors, medical diagnoses and and biomedical circumstances.

DR. BARAD:

Just to add on, Zach, it's it's such a powerful tool for what we can offer our patients. So we call it the three legs of the stool. We give them the interventions that they need post-operatively, we give them the medications that they need post-operatively. And then we give them the skill set, the psychological skill set that they need Post-operatively. And we carry that into our chronic pain management as well.

DR. DEUTCH:

Okay. That was interesting. And obviously kind of a deviation from some of these traditional models. So I'd like to ask both of you, if you don't mind, can you think of a patient you treated recently and just describe how you approach that patient, what you did and how that affected their whole course through a perioperative situation or something like that. Just give me a little quick case study, because I think that would be really illuminating for listeners, and I know I would love to hear it. If you all don't mind, Dr. Barad you can start if you have something you can think of.

DR. BARAD:

Okay, so I had a chronic headache patient who had been to multiple different providers and had a lot of different medication options, um, still suffering from chronic migraine on a daily basis. When our patients come to our clinic, they fill out a rather lengthy questionnaire that looks at a lot of different outcomes other than just their pain experience. It looks at their sleep experience. It looks at their levels of depression and anxiety and isolation and catastrophization so that we can really get a a full picture of how pain is impacting their life. It also asks about, um, a childhood trauma, uh, and events that happened that may or may not have been fully processed during their life. So this patient was very high in all of the psychological markers of anxiety and depression and very poor sleep. We were able to, in addition to giving her the state of the art medications for migraine, which she had not been exposed to previously, and giving her interventions like Botox and trigger point injections, um, and occipital nerve blocks. We were also able to send her to Dr. Darnell's empowered relief class, as well as get her enrolled in one of our CBT classes, and then refer her to sleep, where she got started in CBTI, which is CBT for insomnia. And she said to me when I saw her again about three months later, that of all of the things that she'd been given in the past three months, the most powerful tools were the psychological tools that she had been exposed to because she felt like she had a degree of control over her own physical situation for the first time in her life. That was very illustrative to me. And she was very, very happy and and empowered.

DR. DEUTCH:

And what was the length of this course of treatment?

DR. BARAD:

Well, we started I mean, I have seen her for six months now, but at three months there was a very significant improvement. These patients have chronic pain. They've had a lifetime of of pain. And so we don't expect things to improve overnight. And we don't expect things to improve completely. But she was in a place where she felt like she had some tools in her toolbox to manage her pain. And her degree of helplessness and hopelessness and depression and anxiety were very diminished on our outcomes measures at subsequent sessions.

DR. DEUTCH:

Understood. Dr. Darnall, do you have a similar vignette you can share with us?

DR. DARNALL:

You know, I like to add on to what Dr. Barad was saying and and really underscore that her description is what we commonly hear. One of the most distressing aspects of pain is that it just naturally feels outside of our control. It's like it's something that's happening to us, and it's common for people to feel like there's nothing I can do about it. And the I need the doctor to give me something to treat it or to reduce it. And so that's what we call an external locus of control that actually sets up kind of a bad situation for people. We know from decades of research that helping people feel and be more in control over their mind, their body, their physical experience and their pain is an incredibly powerful and positive prognostic indicator for pain control and for recovery. So what people tell us when we connect them with this type of approach, that again, it works alongside the medical. So it's not to replace surgery or whatever else a physician may do. We offer this psychological approach or this behavioral approach in addition to whatever the medical plan may be, but it helps people, really change the trajectory of a lot of symptoms that can compound pain and suffering.

So Dr. Barad mentioned sleep. Well sleep disturbance is one of the biggest predictors of next day pain. So we we really need to target sleep so that people are are getting that restorative recovery at night. That helps with healing after surgery. It reduces fatigue in the cases of chronic pain. It gives people more energy to be able to accomplish things during the day, and it keeps inflammation and pain lower. So these strategies that can help people sleep, reduce their distress. You know, this combines to help people have overall better health and and less pain. I think what she described as is a really common experience. We also see that when we connect people with this behavioral skills based approach, either before surgery or after surgery, it's common for people to say that it reduced their anxiety, that it gives them a positive focus. It it helps them be in control of mind and body through the recovery period. Um, and so all of this is, is really what we want to do. If we can give people an evidence based skill set to reduce their pain, that naturally counteracts helplessness, feelings of helplessness. I mean, we feel helpless when there's nothing we can do. The antidote to that is to give people the evidence based skill set that they can focus their energy on so that they can steer themselves in a positive direction. And that can make all the difference in the world for people.

DR. DEUTCH:

Okay, so that's some very good insight into the specifics of trying to do a holistic approach to patients, um, for pain treatment. Let's let's zoom out a little bit. And Dr. Barad, this is directed at you. We, most of us know that that the number of people going to anesthesia is very high and, uh, that it's become very competitive. However, relative to that or in concert with that, the people interested in pursuing fellowships is declining. And I believe this is true for pain medicine as well. Um, can you talk about the future of training programs in pain medicine? Good, bad or indifferent? And maybe at the same time, it's your chance to give a little plug for why trainees of anesthesiology or other fields should go into this subspecialty, and what you think recommends it.

DR. BARAD:

Yeah. Thank you. Zach. Um, so we have, similar to every other anesthesia fellowship, seeing a decline in anesthesia applicants. Most recently, between 2019 and 2023, one of my colleagues on the board was me of the American Association of Pain program directors found that the applications for residents specializing in anesthesiology, which is historically the largest specialty in pain fellowships, has dropped about 45% in the past five years. We're also seeing applications drop in all specialties, but not 45% more on the order of 14 or so percent. We're not sure why people are not as interested in pain as they used to be. So one of the reasons why we published this article is to try to invigorate people and get them interested in in this wonderful specialty. In order to write this article, I interviewed the other members of the board of the Association of Pain Program Directors, as well as one of our current fellows, and in our discussions, we recognized that maybe we haven't, as a specialty, been selling ourselves enough. Maybe we've been complaining as a specialty of the problems that we face as physicians, with challenges with insurance and all that stuff on a daily basis. And maybe we haven't been highlighting how great pain medicine is. Um, and so I interviewed all these faculty members all over the country, and it really reaffirmed my belief and reminded me why I went into this specialty. There's so much benefit that can come out of working with this patient population and helping them meet the challenges of pain. And there are both the immediate gratification of doing the procedures, but also the long term gratification of working with a patient population over time, getting to know them and know their family, and know their children and know their grandchildren and learn from them at. As they approach pain and manage pain on a on a daily basis.

DR. DEUTCH:

Well, I think that's interesting. I was not aware of those statistics. And obviously economic principles are obvious. If the job market is very good and people can make very good money without doing extra training, then they'll tend to avoid that extra training. Now what I, yeah, what I've always told residents is the one thing about pain that it gives you, that you don't get in perioperative medicine or critical care is the ability to be entrepreneurial and to kind of be more autonomous, not to be beholden to a certain health system or surgery center or any other facility in which you must physically be located in order to do things. You can create your own clinic, your own procedural areas. You can choose to partner with another place, or you can do it yourself. You can hire your own office staff. You can be your own corporation. You really have a avenues available to you that are really slimly available to people that are doing standard operative anesthesia or critical care. Um, I don't know if you if you talk to trainees about that as well.

DR. BARAD:

I do think that degree of autonomy is really important for a lot of people, and certainly one of the reasons why they may seek out the fellowship.

DR. DEUTCH:

And Dr. Darnall, I'm not a psychologist by training, but I'm curious, is there within your field also these type of divisions in terms of people choosing one path or another once they've obtained their doctoral training? Can you share with us any insight in that?

DR. DARNALL:

Um, yeah, there really is. People have a choice, with the postdoctoral fellowship to take a more general fellowship, let's say that's more broad based and and health focused. Or they could choose to specialize Is in chronic pain management or overall acute and chronic pain management. So we have an APA approved pain psychology postdoctoral fellowship at Stanford that is led by the director, Dr. Heather King. And this postdoctoral fellowship is very much focused and specialized in treating people with chronic pain of all different etiologies and and types.

DR. DEUTCH:

Okay. Now we're kind of coming to the end here, but I have one more question before my one more question, which is you all have presented a very, um, convincing, holistic approach. So I was just wondering if you all could think of. I'm assuming there are other large centers, whether academic or not, that are doing this type of holistic, um, all inclusive, multidisciplinary treatment of patients with chronic pain. Can you comment on that a little bit?

DR. DARNALL:

Absolutely. I mean, there are there are people who are doing it. It really well. So I will say Cleveland Clinic is doing a really nice job of treating pain from a biopsychosocial perspective. They have really innovated programs, and we collaborate with them a lot on providing evidence based and scalable options for people with chronic pain, as well as people, you know, through the perioperative process. And they've nicely integrated in a biopsychosocial approach to spine surgery. So I'm just speaking from a clinical perspective. There are many healthcare organizations in the United States who are innovating and moving in this direction of holistic perioperative pain care. The VA Health Administration is another example. They have integrated into perioperative pathways some of the behavioral or psychological innovations that we have developed at Stanford and are offering those as standard care for different types of surgeries. So I think that there's a lot on the horizon. People have begun to realize that, um, you know, that this biopsychosocial model is is really the way to go.

You know, I have to say, I think that the knowledge and the understanding has been there for a very long time. What we have lacked are, are scalable, accessible interventions that could be integrated at low cost, low burden into healthcare settings to optimize the perioperative experience and post-surgical pain management. Um, but we've been focusing on that at Stanford and, um, innovating options that have been widely adopted in the United States and beyond.

DR. DEUTCH:

Dr. Barad, anything to add to that?

DR. BARAD:

I really agree with everything that Beth is saying. I will say that the founding principles of managing chronic pain are founded on multidisciplinary care. And so many of the top programs have a foundation of multidisciplinary care. But it is hard to access those treatments. It's it's hard to have a pain psychologist integrated into your clinic. It's hard to have a full time pain physical therapist in your clinic. And so we are dedicated to looking for, as Dr. Darnall said, scalable solutions to help pain providers achieve this multidisciplinary care that that is well recognized to be the best way to treat both perioperative and post-operative and chronic pain.

DR. DEUTCH:

Okay, now we're pretty much ready to wrap up, so I'm going to give you both an opportunity. Dr. Darnall, I'll start with you. Reflecting on your experiences working on this issue of the Monitor and your experiences in pain medicine. What do you think stands out to you most about either the articles, the topic, or what readers and ASA members and our listeners would be most useful for them to take away from this topic.

DR. DARNALL:

You know, I think what's most exciting is this last aspect that we were just touching on, which is scalable and accessible options to integrate a biopsychosocial treatment approach into busy pain practices or busy surgical pathways, perioperative pathways. And I think we now have the opportunity to integrate this into eras pathways, into busy clinics that wouldn't otherwise be possible because, um, maybe some clinics aren't able to hire a psychologist, a social worker, other types of professionals and and make that financially viable. One of the things we've been innovating at Stanford is a learning health system called Choir that allows for characterization of the patient experience, to identify treatment targets, and then to deploy targeted, digital, self-paced treatments to the individual, at very low cost and low burden. So what's required is an internet connection. And, you know, so I think we can kind of recognize how transformative this type of a model can be for the everyday pain physician or perioperative, you know, anesthesiologist who doesn't have the ability to solve the business of biopsychosocial care, but who could adopt an automated learning health system that could offer them a plug and play option to be able to treat the whole person needs of their patients and and optimize their outcomes. So I think that's like the exciting, visionary takeaway of of where this is headed. It's already in play at Stanford. And, you know, this is really what's available to others outside of Stanford as well.

DR. DEUTCH:

Okay. So I've got multidisciplinary, biopsychosocial, available, scalable, and useful. Those are my takeaways there. Dr. Barad, it's your turn. What do you think that listeners, readers, ASA members should know and be aware of?

DR. BARAD:

Zach, we didn't even get a chance to touch on the innovation that's happening in pain outside of the psychological realm. For anybody that pays attention to pain, pain is exploding with growth in the interventional realm as well. And really, we're sort of past the iterative process, and we're moving into a time of explosive growth in in this field. This is a dynamic and evolving field. And for young people who are interested in doing something remarkable and really changing the way that medicine is practiced in our country and in the world, I would encourage you to consider pain medicine. And for mid-career people who maybe aren't as happy in anesthesia as they thought they might be., talk to us. We have a lot of people that come back and do a fellowship later in life. And I think that they have a lot of career satisfaction afterwards.

DR. DEUTCH:

Okay. That's well said. Something for people to think about no matter what level of your career where you are. And it's been great talking with you both. This is an important topic which, you know, we came into medicine, into health care in healthcare in order to help people, and alleviating pain and suffering has to be top on the list. And whether we can do it with invasive interventions, non-invasive interventions, or a combination of the above, clearly we're going to be helping people. And that was what our mission was supposed to be.

For our listeners, thank you so much for tuning in. We really appreciate your support. You can always go to asamonitor.org for more information on this topic or other past topics, and we look forward to seeing you again on the next episode of the Central Line podcast.

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