Pain Management

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Dr. James Carter: "I'm Dr. Jim Carter, from Mission Viejo, California. I'm here in Connecticut at the International Pelvic Pain Society meeting which is very actively involved in diagnosing and treating women with chronic pelvic pain, and I'm here with Dr. Michael Brennan. Dr. Brennan is really actively involved in helping women with this severe problem, and I would like him to give us some information. Where were you trained, Michael?"

Dr. Michael Brennan: "I did my residency at the New York Hospital, Cornell University Medical Center in physical medicine and rehabilitation."

Dr. James Carter: "I think I heard Sloan-Kettering mentioned once, what was your role there?"

Dr. Michael Brennan: "Part of our residency training was spending a great deal of time at Memorial Sloan-Kettering Cancer Center, and while I was at Memorial Hospital, I integrated rehabilitative services with the pain service at Memorial Hospital."

Dr. James Carter: "We've heard a lot about physical medicine and its relationship to women with chronic pelvic pain - especially one of the areas is rehabilitation trigger points, this is a word that comes up. I know you're an expert in trigger point therapy, could you give our audience an idea of how you approach trigger points, how you diagnose it, and how you treat it?"

Dr. Michael Brennan: "The principle of diagnosing trigger points really goes back to what we were also taught in medical school which actually talks about patients, about their pain patterns, and physically examining them. We don't have any satisfactory imaging studies available yet to look at trigger points, so the best way to diagnose them is by feeling them. Most individuals can find them on themselves. They're painful nodules within muscles, and muscles bellies, or some connective tissue but when we feel them, we'll palpate them with a level of force and you can reproduce pain, maybe some sensory phenomenon, perhaps even some weakness."

Dr. James Carter: "What's your approach with patients in whom this is a problem? I find patients with trigger points in the levator ani muscles where you can actually feel the cord - you can identify an area of pain. But let's say in the abdominal wall you can find these same trigger points - what is your approach for the treatment?"

Dr. Michael Brennan: "My philosophy stems from a lot of work done by several different physicians including David Simons and Janet Travell from California, Willie Nagler in New York City, and Hans Krause in New York. It's a combination of trying to maximize the function of a muscle, and that's where I believe the pain comes from - a fully functioning muscle, whether it's deconditioned or it's been injured. So I will try and strengthen the muscle that has a trigger point in it. We will do directed therapy use at the trigger point itself, whether it's cold therapy or heat therapy. And then there is a role for the injection of a trigger point using any number of substances, different authors and physicians choose to inject into the point trying to render it less painful. That though to me is not the end all of therapy, if you can get a trigger point to feel better, the next step is to make the muscle stronger, more flexible, and have better endurance to try to stop that trigger point from recurring."

Dr. James Carter: "I completely agree. That's a very good pearl for people to take home, and that is that you get the immediate relief that helps you diagnose the problem but we have to treat not only the precipitating factors but those underlying causes, whether it be problems with recurrent or repetitive actions that take place. I find these trigger points in women who are doing ballet and ballet training, and if they don't cut back a little bit or do something or change some of the things they do - they'll get recurrences if we don't strengthen the muscle and get the muscle rehabilitated. That's why rehabilitation - the name of your specialty, physical medicine and rehabilitation - is becoming so much more critical, much more than just an area you had an accident and were injured, and therefore, need rehabilitation. But something occurred even in your daily life which has resulted in a muscle injury or fascial injury, and you need rehabilitation from there. Now what about the people who - the non-responders - you have to give medical therapy for their pain directly - could you address that for us?"

Dr. Michael Brennan: "That's really getting into an area that becomes very controversial. There are a variety of medications, and we'll call them "analgesics" that can help reduce pain and ease suffering. Depending on where one trains and what one's perspective is - medications are either underused or overused. From my perspective, that's a perspective supported by The International Association for the Study of Pain, The American Pain Society, and The American Academy for Pain Medicine, we ought to think about using certain pain killers - especially those pain killers we initially were taught to fear in medical school - a little more clearly, not just willy-nilly give away pain medication but take them into our equation a little sooner. The medications I'm talking about most are narcotic or opioid analgesics. The use of opioids has been shown in a large data pool of first cancer patients and now in non-cancer patients, to not make people less functional, rather they can enhance function, reduce pain, and really improve the quality of life. That to me is what I consider, as Albert Schweitzer said - "My greatest calling is that I can try and ease the suffering of some individuals." These medicines are very controversial. There are regulatory concerns that we worry about, there are peer concerns - the family members sometimes put upon their family members that have to take these medicines. Also, the patients themselves have great fears. They're worried that they're going to become addicted, they're worried that they're going to have terrible side affects, as I like to say they will become zombies - so they have this zombie phobia. When in reality we know that appropriate dosing improves cognition, improves function, and really can make the rehabilitative component that much easier. It's a lot easier to work with an individual who feels relatively little pain then it is to try to work with somebody from my perspective who has terrible pain."

Dr. James Carter: "So if you had a patient who's pain level is a ten of ten, it's hard to even work with them to find out what the underlying cause is of that pain. Then you've reduced that, and you will use some therapy - some narcotic therapies - to try to reduce that pain."

Dr. Michael Brennan: "Absolutely, especially if other therapies have been brought to bear that haven't been able to bring that pain level down. If they've been on high doses of acetaminophen or aspirin-like medicines or even muscle relaxers and their pain remains fairly high, the next step, in my equation, is to think about using medications such as opioids and analgesics."

Dr. James Carter: "Could you describe your protocol for us for these patients? How you give it
a Marsh/March highly titrate levels?"

Dr. Michael Brennan: "The World Health Organization (WHO) has provided a wonderful model that we can use but every clinician can follow, we call the "analgesic ladder." Basically, the ladder has three rungs. The first rung is that one approaching a patient who has pain - assuming you have the right diagnosis - you would start the patient on an anti-inflammatory liquor with acetaminophen. If that can not take the patient out of pain you would then go to a moderate strength opioid. Typical drugs in that category would include hydrocodone, which is commonly available in Vicodin and Lortab and a number of other formulations. Codeine is another moderate strength opioid. If getting up to relatively frequent dosing and high main line doses of those medicines you still can't effect relief, the next step would be to go to what is referred to as more potent opioids or strong opioids, and those include medications such as oxycodone, morphine, and hydromorphone. So my clinical practice on a day-to-day basis starts really following that ladder. I am often a tertiary of a referral, individuals have seen their family care physician and their gynecologist and have not been able to get adequate relief on mild strength pain medicines. So I'm very aggressive in getting right into some more potent opioids, and right now I think that the use of oxycodone is probably the opioid that I use most frequently for a variety of reasons. Most importantly - it's well tolerated, it has wonderful side effect profile when you compare it especially to morphine, and it doesn't have any problematic metabolites that develop after it's been taken."

Dr. James Carter: "So you look at this as a safe way and as a tertiary individual, the person has been to their primary care, they've been to their gynecologist, they've been taken to trigger points they attempted a number of therapies, they're still rating their pain at a ten of ten. These are people for whom this WHO-type layer is appropriate, and neither the patients nor the physicians should really fear this because this person needs help, this person needs the help of someone like you. I strongly encourage individuals who are suffering like this to discuss this WHO layer approach with their physician and to have them make available someone with your resources and capability. Now you mentioned something about - all these medications doesn't effect their cognition. Could you describe that a little bit for us? You mean it doesn't really hurt their thinking?"

Dr. Michael Brennan: "Correct. One of the things that's very interesting and it's been studied both in cancer and in non-cancer patients is that if you give a pain medicine to a person who's not in pain, they can become sleepy, lethargic, euphoric, or get the high for lack of a better word. However, when you take an individual who has pain and give them pain medicines, and it's appropriately dosed, the incidence of euphoria is very small, especially after they've been on the medicine for two or three days. We can talk about incredible doses of morphine up to two or three grams every six hours and people will not become euphoric, in fact, pain patients might complain that they don't feel euphoric - they feel dysphoric. They don't like the feeling necessarily but they recognize that they have to take it. There's also been several clinical and at least one recently published, very adequately performed, study looking at the psychomotor function. If I took a Percocet or a narcotic right now, I would become sleepy. I would have difficulty writing my name a hundred times and doing a crossword puzzle because I don't have pain. When we adequately treat patients, these studies have shown that at appropriate dosing levels not only do they not get sleepy but their psychomotor function - they're ability to think and do things - actually is enhanced."

Dr. James Carter: "As physicians we've known patients who had cancer, for instance, males with prostrate cancers, women with breast cancer - metastatic to all. I know that these people have such incredible pain that they can't think, they can't sleep, and they can't function. And what you're pointing out is that when people have chronic pain that's at that level - that the provision of these medications to reduce their pain level helps them to think, helps them to sleep, helps them to function better. So it has the opposite effect of what is perceived as what this medicine is going to do. They don't become sleepy, in fact, they become alert because they're able to sleep and they weren't able to sleep before."

Dr. Michael Brennan: "Correct."

Dr. James Carter: "Thank you very much for coming to Connecticut for this program. You're going to be speaking here on this very issue of pain management in the chronic pain patient who hasn't responded to the therapies that we've provided and who is in need of further therapy. Thank you very much doctor."

Dr. Michael Brennan: "Thank you."