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Pain Management in the Crosshairs: A CAP Roundtable, Part 1

Guests: Dr. T. John Hsieh, Dr. Medhat Mikhael, Dr. Charles Steinmann, and Dr. Jae Townsend
Moderator: Carole A. Lambert, MPA, RN

CAP: We recently had the opportunity to sit down with four CAP members who care for and protect patients as well as clinicians by their expertise and their experience. They are all anesthesiologists who are also interventional pain management physicians. Joining us were Dr. T. John Hsieh from Irvine, Dr. Medhat Mikhael from Fountain Valley, Dr. Charles Steinmann from Newport Beach, and Dr. Jae Townsend from Pasadena. What follows is Part 1 of the edited version of the roundtable. Dr. Steinmann got the ball rolling by sharing a brief historical perspective on the challenges of pain management while he’s been in practice. 

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CS: The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain protects us from injury and disease. Fact is, we always will have to deal with pain. The trick is once the injury or disease is recognized, how do we shut off that response?

In one of the earliest recorded pain treatments, the ancient Egyptians used beer for surgical procedures. For the last few centuries, the gold standard for controlling pain has been morphine. By the time of the Civil War, general anesthesia – ether or chloroform – was used in over 85 percent of all amputations on the battlefield. During the mid-20th century, other mechanisms began to be used, such as local anesthesia, pain blocks, acupuncture, antidepressants, pain pathway inhibitors like gabapentin, and anti-inflammatories.

By the late 1990s, it was still easier for prescriptions for pain medications — such as Vicodin or codeine – to be written that way. At the same time, multiple pressures were put on the physician to prescribe more. Because of the problem of addiction, now we are under pressure to prescribe less. 

TJH: I’ve watched the pendulum swing throughout my career. In 1980, a letter to the editor was sent to the New England Journal of Medicine, stating that treating pain patients with narcotics would not cause them to become addicted to narcotics. This was a revolutionary statement, and that letter — with its observations and conclusions — became the most cited publication for the treatment of pain and influenced how physicians prescribed opioids for the following 25 to 30 years.

But, pinpointing where and when the use and abuse of addictive substances really took off is difficult because our society has historically been a society of using pills. In the years I was going through high school and college, the use of cocaine and ready access to prescription drugs was obvious. It’s very hard to say that physicians promote pill popping when it is such a part of American society. And there is the economic reality that prescription medications are big business, which has to be part of any attempt to deal with substance use and abuse.

At the end of the day, pain is very difficult to measure. It is ultimately subjective and unlike any other vital sign in that there is no real measuring device you can use. When you’re treating pain, it is based on the patient’s perspective and sometimes a lot more complicated than it first appears.

JT: My experience in collecting historical information for a patient going into anesthesia and then receiving post-op care just underscores the fact that every human being is wired differently. So, the wiring of a female is different from a male. A person who has had experience with pain throughout their whole life, or just even early in childhood, has different wiring than an adult who has no experience. As a society, as a culture, I encounter people daily who are about to undergo surgical procedures and have an unrealistic expectation that they’re going to have zero out of 10 pain post-operatively. So as a society, we’ve set ourselves up to have an unrealistic societal expectation that you’re never going to have any pain or suffering. We are a culture of pill poppers.

People have pills for every single thing from slight anxiety or slight depression to minor discomfort. Granted, there are plenty of times that this is warranted and appropriate, and I’m not undervaluing that at all. But we have to undergo nothing short of a cultural revolution in which we, as physicians, educate people that it’s unrealistic to expect no pain. I typically tell my patients that we’re going to have controlled or managed pain after surgery.

Over-prescribing originated due in large part to instances in which physicians were held accountable for patients with uncontrolled pain. Specifically, end of life, death, and dying. There was liability, there was accountability, there were physicians who were sued. In consequence, I think clinicians overreacted and began over-prescribing because they were afraid of having patients complain about their being under-prescribers.

Let me just add that opioid use in the United States has consistently been the same. We just had opioid use that was prescription opioid use. Whenever there wasn’t a lot of prescription opioid, there was a lot of heroin. Now that there’s less prescription opioid, there’s more heroin. People in this culture, in this society, are addicted to opioids and we have to have a societal change. So, back to your question. What do I do as an anesthesiologist to prepare patients? I do a lot of education about realistic expectations. I tend to refer to opioids as the poison. I’ll give you some of the poison, but we’d like to get you off the poison as soon as possible. Sometimes, you need a little bit of the poison, but we’re going to try to minimize it and create a situation where we use all sorts of alternatives, so you need as little as possible.

MM: You know, there is a huge unrecognized role of other medications in the increasing death rates from overdoses. The common factor among all these patients is how polypharmacy has contributed to a lot of the accidental deaths that have happened.

For patients with chronic pain, we may start by adding anti-seizure medications. Then we might add antidepressants. Some clinicians like to use anti-anxiety agents that they believe affect muscle relaxation. These medications contribute to depressing the central nervous system and, as a result, they can depress respiration and can lead to an overdose and death. This point has been addressed in the CDC guidelines, particularly with benzodiazepines and of the synergistic effects of drug combinations. Our patients ask why we want to review and maybe modify their medications when they have been on, say, Ativan and Norco for years without any problems. We tell them that if the patient is at a weak point – on any given day they were dehydrated, they had a flu, they were malnourished, they were sick for any reason – the combination of these medications was too much for them to handle and they ended up with an overdose or dying.

So, Dr. Hsieh and Dr. Townsend talked about the pendulum that has swung from one extreme to the other because the designation of pain as the fifth vital sign puts pressure not only on clinicians, but also on hospitals. If the HCAHPS score showed that patients rated you as controlling their pain well, your reimbursement was impacted positively. But if the pain score was down and the patient was below extremely well controlled, the reimbursement rate was negatively impacted. Now the government is recognizing this wide variation and its impact, so the 2018 changes to HCAHPS moderate the measure.

That shows you how the pendulum has swung. But we clinicians are challenged to care for our patients, to respond to their concerns, to prescribe and refer appropriately, all in an atmosphere of intense scrutiny and potential liability. We all need to continue to educate ourselves and then educate our patients.

CAP: Dr. Steinmann, you have a very active pain practice and you do injectables as well. Tell us about the patient education efforts in your practice and the staged interventions that you use, even in the face of patients’ demands for ultimate treatment.

CS: Well, we try to answer the questions of how to protect the physician and the patients. My approach is, first of all, when you first meet a new patient, you have to document. Having worked with CAP on many cases, the biggest thing is communication closely followed by documentation. Dr. Mikhael has noted a real problem: We’re given a pain patient and a situation where we may not have the time to be able to give him the full education. But it is our duty to communicate with the patient. I think communication is half the battle of a treating a pain problem.

There are things that are helpful for us as physicians. The CURES system is excellent to follow up to find out if patients are having other doctors write prescriptions. An agreement, whether oral or written, between the physician and patient is a good topic for us to talk about as well. But my basic plan is that the last thing I’m going to do is give a narcotic. So, I tend to start with anti-inflammatories.

I tend to use obviously injectables, like pain blocks and even oral steroids, before I would opt to going to any narcotic, even Vicodin. And I’ve been relatively successful in doing that, but then again you have to look at the patient match. I tend to get patients that might be less pill-driven than other physician practices. 

CAP: Dr. Townsend, you are a pediatric anesthesiologist. There’s always been a concern about children being under treated for pain. How do you approach achieving an assessment and a treatment plan for a child in pain?

JT: I do acute pediatric pain management as well as anesthesia. Children are really different from adults, and the younger the child, the more so. For example, a premature neonate has different physiology than a full-term neonate. We know because there have been very eloquent studies done that have proven that children exposed to early painful experiences become adults who have poor mechanisms to control pain later in life. I also am involved with fetal surgery and we’re not really sure exactly when a fetus starts to develop their top-down regulatory mechanisms, but we know they’re certainly not there when we’re operating on one at 16 and 17 and 22 weeks of gestation. So, we’re providing analgesia that crosses the placenta to prevent a painful experience.

Studies have been done comparing children who had immunizations. All kids in the U.S. get immunizations at two, six, and 10 months and it hurts, but who cries the most? Other studies compare boys to girls. Boys who were circumcised with anesthesia were compared to boys who were circumcised without. Boys who undergo circumcision without anesthesia cry longer and harder and score inordinately higher on pain skills consistently through their childhoods. So, we changed our medical practice based on studies like this from the 80s. We started providing anesthesia for little, little children undergoing circumcision. Hopefully, you prevent a lifetime of enhanced pain perception that way. Interestingly, the kids who felt the least amount of pain were girls, and you would think girls and uncircumcised boys would be the same but they’re not. That’s because little girls, when they are born, have high levels of estrogen, and estrogen is very analgesic. Yay, girls!  

Click here for Part 2 of “Pain Management in the Crosshairs: A CAP Roundtable”


Carole A. Lambert is Vice President, Practice Optimization and Residents Program Director for the Cooperative of American Physicians. Questions or comments related to this article should be directed to