Stanford’s Ming-Chih Kao, PhD, MD, on “Medications: What’s Good for Back Pain and How to Stay Safe”

Stanford’s Ming-Chih Kao, PhD, MD, on “Medications: What’s Good for Back Pain and How to Stay Safe”


MING-CHIH KAO,
PHD, MD: And thanks everyone for being
here at Back Pain Day. Of course, we’re
now in the middle of the second half
of the day and I just want to ask everyone to
reach into the goodie bag that you received this
morning when you checked in. The reason is we have
a handout in there. It says chronic pain on the
front and if you’re watching the stream at home, this
is available on our website stanfordhealthcare.org/pain. Or if you’re watching
this recorded video and binge watching it, you can
find it on our website as well. Now, why do I want
to pull this out? It’s because I like
to help everyone kind of understand the context
of what we’re discussing here. Here we are talking
about comprehensive. For the course of
the day, we’ll be talking about a comprehensive,
multi-modal pain management for chronic low back pain. And that includes– AUDIENCE: Doctor, [INAUDIBLE] MING-CHIH KAO,
PHD, MD: Excuse me? AUDIENCE: [INAUDIBLE] louder. MING-CHIH KAO, PHD, MD: Louder? OK. Will do. Thank you. So we have been talking about
multi-modal pain management. And the purpose of pulling this
out and really understanding the various components
of pain management is so that I can
properly place in context the true role of medications
in pain management for chronic low back pain. I’d like to start with a case. It’s actually a
hypothetical case. It’s an amalgam of
various patients I’ve seen over the
years, and there are some patients
who are particularly sensitive to medications. And so this guy who
has chronic back pain, I’m seeing in my
clinic, would tell me that he has tried so
many medications and none of which he can tolerate. Now, there are
some medications he liked, as in they
were helpful for him, but the side effects
were too overwhelming and he had to stop. He could take it for a few
days, but be could not continue. He would tell me that he
would take the lowest dose formulation of this medication. He would open up the capsule. He would count the
granules, 120 or so, and he would take
a fraction of that. So with it, he had
less effect for sure, but he also had
less side effects. By altering the balance
of effect and side effect, he was able to take this
medication chronically, and he would tell me that he
had more relief after that. Now, by this point, if
there’s any pharmacists in the audience, you’re
probably fainting. I’m not recommending that
we do this in general. What I would recommend
for this patient is that I would prescribe
a compounding pharmacy prescription so that this
ultra low dose medication can be made available to him. So why do I bring this up? A case like this illustrates
the various aspects of pain medication used in
a chronic setting that’s very unique, very unique,
poorly appreciate it and I think very important
for all of us to understand. So I’m going to
circle back to some of the fundamental principles
underlying medication using chronic pain management. I’m going to take another step
back and just talk a little bit again about the epidemiology of
back pain, which Dr. Mackey had covered this morning. We know that back
pain is increasingly common on most Americans. This is data across the
last 15 years or so. And each patient with
chronic low back pain is increasingly likely to
receive opioid medications as the primary
mode of treatment. And we heard from Dr.
Newmark this morning that it is not an
ideal solution. In fact, just a
few weeks ago, all clinicians physicians,
nurse practitioners, and physician assistants
across the country received the letter
in their mailbox from the Surgeon General
himself, Dr. Vivek Murthy. In this letter, he outlined
and reminded all clinicians around the country that opioid
medications have their role in acute pain
management, but when used in chronic pain setting,
it causes more problems. It contributes to misuse,
abuse, diversion, and addiction. And he recommends
that clinicians be wary of these issues and
then manage chronic pain more appropriately. The question now
becomes, of course, from the clinician’s
point of view, our interest is to help
patients, not to get patients into trouble with medications. From individual
patients’ point of view, the interest is well-aligned. Patients do not want
to take medications that are not helpful. So if both sides agree on
this being not the solution, why do we reach for it? Why do we reach for
the wrong solution? It’s because it’s the easy one. I’ll explain a
little bit more why. In fact, there are 200
medications in pain management. Only about 20 are
opiate medications, and opiate medications work fast
when used in an acute setting. They’re obviously helpful,
but many other medications in pain, the 180 that are
left that are not narcotic, that are not opioid,
that are not addictive, are harder to use as a
group because, first of all, there are so many. In fact, if you
really do the math and you find that
for every medication, any given patient can
be on it or off it. So if we do that across the
board for 180 medications, the number of combinations
of medications we can try for
any given patients is actually more than number
of atoms in the universe. So I wouldn’t recommend
an exhaustive search in this process. So this is why, in my
opinion, opioid medications have been used as a primary
medication for chronic pain. Now, among the none
opiate medications, my guess is many of
you have at least tried some of these medications. These are some of our
most common ones, right? Starting from the top left, we
have gabapentin and pregabalin to the bottom right, we have
topiramate oxcarbazepine. Each and every one
of these medications has unique side effects,
has unique effects, has unique mechanism and each
of which has its own role. Now, they do cluster into a
certain functional groups. So some are anti-inflammatory. Others are muscle relaxants. And they can all work together. So on the left here
is a little graph we put together that
summarizes everything we know in the literature
about the neurobiology of consciousness. The reason I put this
up here is because it’s so– pain pathways
are so complicated. If you studied
consciousness, you would find that
the main vein that runs through the pathway
for consciousness all have to do with pain,
pleasure, motivation, and action, the very fundamental
recipes for survival. So what that means is there are
many, many ways in which pain– well, these pathways can
malfunction, therefore, causing pain. The flip side of that is there
are many, many places where we can intervene. Hence, we need all 200
medications at our disposal. We’re diving a little
bit more to some of the pathological
mechanisms of chronic pain. Now, other speakers today
have touched upon this, so I’m not going to
talk about all of them except to point out the
middle, the one in the middle, the central sensitization. That’s really the
key to chronic pain initiation and maintenance,
to the beginning and ongoing continuation
of chronic pain. Now, the 200 medications each
will treat different aspects of these mechanisms. I don’t think we
have enough time to talk about 200
medications today, but we’ll talk about some of
the principles in which we can make this a more
feasible problem to solve. So choosing non-opioid
medication’s is hard because there are many
and because each is different. So when you see
your pain doctor, that’s the task your
pain doctor is facing and that’s the task that
you’re facing as well. How can we make it easier? So, of course, educational
efforts around the country are led by Dr. Mackey and
the National Pain Strategy. That’s one key part
of the solution. But what I would
like to also give you today would be a set
of recommendations that you can walk away with that
when you work with your pain doctors on an
ongoing basis, this will help you find the right
set of non opioid medications that can be helpful for you. All right, so first, we’re
going to address the very common refrain from some patients
about pain medications perhaps hiding their pain. Now, this is a very– in many
ways, a conceptually reasonable concern because the mental
model we have of pain typically is, for example,
say a paper cut. If I sustain a
paper cut, it hurts because there’s a nerve
that’s irritated by the cut. And on the model
here on the left, we have a neuron, a nerve
that’s trying to transmit signal to the neuron on
the right telling it that there has been a small
injury with a paper cut. On the receiving end,
it has received– the nerve has received
the signal so, therefore, now it knows there’s an
injury and, therefore, experience of pain. That’s an acute pain
setting and it makes sense that we worry about
hiding the pain because we would like to know if we’re
sustaining an actual injury. But that’s not what’s
happening in chronic pain. Chronic neck pain, chronic back
pain, all sorts of chronic pain work differently. It relies on the concept
called central sensitization we mentioned earlier where a
steady, consistent, persistent barrage of pain signals coming
from the nerve from the left is now impacting the nerve on
the right in such a way that by virtue of its
consistency and persistence, causes changes in the
synapses, therefore, initiation of centralized
pain so central sensitization. This is the core
of chronic pain. It’s characteristically,
qualitatively different from acute pain. So non-opiate medications
do not hide the pain. What they do do is to reduce
the amount of signals that’s being passed from
the left to the right so that this process of central
sensitization, first of all, can be reduced. In fact, can be undone. So as in reduction of your
chronic pain over time. All right, we talked
a little bit earlier about the dosage of medications. In fact, we find
this very frequently in our clinical practice. Every patient reacts differently
to the same medications at the same doses. Each medication is unique
in terms of its mechanism. Every patient is unique. All of us have six billion base
pairs of DNA, and each of us can be different in many
of the 40 million ways we can be different, the
so-called genetic variants. So the bottom line
of that is there is a degree– there’s only
so much that clinicians can predict what
your response will be to any given medication. So, therefore, there will be a
little bit of a trial and error process that’s involved
in finding the right set of medications for you. What we usually
recommend and when you work with your pain
physician and the clinician, you can go for
this as well, which is to start medications at a
low dose and increase it slowly. Start at a low dose so
that you can figure out if you can tolerate
this medication, and then increase it slowly
so that you give your body a chance to get used to it. And what’s also important is
to record your side effects and your reactions
to medications to your prescribers. That will help the prescriber
move on either continue the medication,
changing its dose, or finding an alternative. So these are
important information that you’re prescribers
will find very valuable. All right, so here’s a
very interesting concept, I think, in chronic
pain management that I find counter-intuitive. Our mental model of
taking pain medications is for example, reaching for the
Tylenol, reaching for the Advil when something hurts. It’s more analogous to the
way we take antibiotics. If there’s an infection,
we take antibiotics. If the infection is cleared,
we will stop the antibiotic. But chronic pain medication
and the non-opioid medications are typically taken more like
a blood pressure medication. As in, you take your
blood pressure medications regardless of your
blood pressure on a given day
for the most part. And you would take it
daily for days, for weeks, for months in order to
derive the most benefit. The same principle is true
for chronic pain medications that are non-opioid. In fact, many medications
that work on the consciousness pathway we talked about earlier
rely on the body’s response to the presence of the
medication in order for it to be effective. As in, the medication
itself doesn’t cause or it doesn’t help
with pain management. It’s more so the body’s
response to it that helps it. So, therefore, the
timeline for that is in the order of
weeks to months. For some medications, we say you
have to try it for two months before we can come
to a conclusion about whether or not it’s
helpful for you. And that’s an important concept
because– so first of all, I’m sorry. It does prolong, it
does prolong the process of finding the right solution. Yet on the other hand,
some of these medications that work slowly are some
of the best medications we have in pain management. So the more you can work with
your pain physician on this, I think the more benefit,
the more value you get out of that interaction. This is my public service
announcement slide. You remember we
talked about how pain is such a fundamental
driver of our consciousness. Pain distracts us. Pain sucks away all
of our attention, keeps us from doing the
things we want to do. Same thing is true for all
the other parts of health care as in I see many patients who
are so engrossed with going after their pain
that they neglected their colonoscopies, neglected
their mammographies, neglected to check their cholesterol,
check their blood pressure. These are fundamental
aspects of health care that you have to
keep– pay attention to so that, overall, you
have your health as well, well-maintained. So it’s an important
thing to pay attention to. Lastly, we, again, reach back
to this map of chronic pain management of multi-modal
pain management and ask, why do we even
take medications at all? It takes– it’s a
complicated problem. The easy solution is
opioids, but opioids give us all kinds of side effects. The heart or the non-opiates
medications, on the other hand, are extremely hard. We talked about how it’s
more than the number of atoms in the universe. Why do we even bother
with this tough problem? It’s because medications
are not in and of itself. It’s a means to an end. It’s a means to help
you participate more in physical therapy,
to participate in psychology, to
optimize your nutrition, to get better sleep at night. And it’s a tool so that
you can participate in the rest of the
multi-modal pain management. If you keep that
in mind, I think you’ll get a lot more value
out of working with your pain physician. And thank you. [APPLAUSE] AUDIENCE: You show this slide
of the non-opioid medication. AUDIENCE: The clock
in front of you. MING-CHIH KAO, PHD, MD: Yes. AUDIENCE: And also, I noticed
gabapentin, in my experience, is the one that has
most been suggested. Is it because there’s the
most studies on it or why? Or it’s just my experience? MING-CHIH KAO, PHD,
MD: It is certainly. It’s, I think, for all the
factors you have mentioned, it is one of our
go-to medications. Can we have this slide
show back on, please? Now gabapentin, we
talked about how we have 200 medications
in pain management. Gabapentin is always
number one on that list because of its effectiveness
and because of how safe it is. We have a joke that the only
way to be harmed by gabapentin, because it’s so safe, is to
be hit by the truck that’s carrying the gabapentin. So– [LAUGHTER] AUDIENCE: [INAUDIBLE] MING-CHIH KAO, PHD,
MD: Oh well, it’s so safe that the only way
to be harmed by gabapentin is to be hit by a truck
that’s carrying it. I’m sorry. But we talk about
it because we want to emphasize how safe it is, and
it’s our first go-to medication in most instances. Of course, in particular
for chronic low back pain, we will want to offer patients
a non-narcotic alternative. That’s a great
question thank you. And the way I see
these medications is recognizing the fact– AUDIENCE: Should
I say it louder? MING-CHIH KAO, PHD, MD:
Let me repeat the question. Excuse me. The question is really
is about alterations, alterations in non-narcotic
pain dosage in response to changes in levels of pain. Whether or not we should
increase versus decrease pain medication doses as
the pain fluctuates on some good days and bad days. My response to that is I would
prefer that my patients change doses in a deliberate way
as in having discussed with the physician, with
the prescribing physician, so that there’s a plan. So on some days, well,
we can increase the dose over the course of a couple
of weeks, for example, or reduce the dose over the
course of a couple of weeks. And that’s because I don’t want
the patients to find themselves pain– really spending
an entire day trying to measure their own
pain and, therefore, trying to gauge the amount of
medications that they take. I want these medications
to be– well, I want patients to spend
more time doing things that they like to
do and be more– do functional activities. I would say these
small changes in doses are less likely to be
immediately helpful, and it’s much better to
maintain a consistent dose. Now, with that being
said, I will occasionally offer patients an extra
dose of benign medications, for example, like gabapentin. It does not apply
across the board, but some medications
are good and can be taken on an additional
as needed basis so that patients can do
more physical therapy. Usually I ask them
to take it 30 minutes before activities for example. AUDIENCE: When you said that
when we take pain medications, we should take them like we
take blood pressure medications, that you should
take it every day, my understanding was
I take medications when I have pain
that’s basically interfering with my life. But you’re saying that
it’s important to take it consistently. MING-CHIH KAO, PHD, MD: Yes,
the question is a good one. It was– I was speaking in terms
of the most medications in pain management there are
non-narcotic in nature. So medications just
like gabapentin and many of the medications on this
list, they work most effectively when they are taken
on a consistent basis because they induce changes
in your brain circuitry such that the pain is reduced. Does not apply to every single
medication, I should emphasize. And thank you for
bringing this point up that you should really check
with your prescriber, your pain physician, your pain clinician
regarding your medications and how to take them properly. AUDIENCE: My second
question was it’s like– it seems like
pain medications and anti-inflammatories, NSAIDs
are kind of mixed together and yet, I think
they’re very separate. Can you explain why on this list
you have both NSAIDs and pain medications, or what I
consider pain medications, as if they were the same thing? MING-CHIH KAO, PHD, MD: Got it. AUDIENCE: So I’m
saying what is– MING-CHIH KAO, PHD, MD: Right. So I think your
question is about what is unique about NSAIDs, the
anti-inflammatory medications, and do they even belong on
the list of pain medications? I would say that it is true
that NSAIDs as defined, they’re non-steroidal
anti-inflammatory drugs. Their primary action is
reduction of inflammation, but many of them also
have analgesic properties as in reduction of
pain in and of itself. So much so, that if you look
at the NSAIDs as a class, some medications have more
anti-inflammatory effect and less analgesic
and other medications in a different direction. So each and every one of
them has a different balance. And for that
reason, because they do have independent
analgesic effects, I have listed that
in this table. NSAIDs are important
to point out because even though many of the
NSAIDs are over-the-counter, they do have their
side effects when taken chronically over the
course of months and years. So, therefore, these
medications need to be discussed with your
pain prescriber regarding the way you take it. Thank you. PRESENTER: You can
see all the interest there is in medications
and so we’re going to bring Dr.
Kao again a little bit later when we do a
panel Q&A towards the end. In the meantime,
we’re going to turn it back to Dr. Darnall who’s going
to introduce our next speaker. DR. DARNALL: OK, great. Thank you so much, Dr. Kao. [APPLAUSE]

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