Dr. Brian McDonough:
Hello and welcome to Primary Care Today on ReachMD. I'm your host, Dr. Brian McDonough, and I'm very happy to have with me today Dr. Adrian Popescu. He is the pain medicine program director at the VA hospital but he also, in addition to that, has his physical medicine and rehabilitation background and he has a position at the University of Pennsylvania.
And Dr. Popescu, I just want to thank you for taking the time to join us because we have a real big issue in health care today. I know I see it on the front lines. A lot of people are coming in, they're experiencing pain, they want pain medications. So you have people legitimately looking for pain medication. Then you have others who are looking for pain medication because they might want to sell it. Then you have others who are looking for pain medication because they might want to abuse it, and then you have others who are just confused and they don't know whether they want pain medicine or not, they're just saying, "I need help," and we as primary care doctors, and many of those listening today go, "What do we do? What can we do?" And having you on the show is really great because you can look at these issues and try to help us with it. So welcome to the program.
Dr. Adrian Popescu:
Thank you so much, Brian, for having me. This is a truly fantastic opportunity, I think, to talk to my colleagues in primary care. Primary care is pretty much the keystone of the medicine in this country and I think there is nobody that knows better how complex a regular office visit can get when the patient comes in pain, since pain can be a herald for a very serious condition, but also can be something that is less worrisome.
I would start by saying to listen to the patient. The vast majority of the lower back and neck pain has a specific and diagnosable source and most of the patients, the vast majority of them, do not need surgery. I would start by listening to the patient and having a good, good history, going through the different phases of physical exam, reviewing imaging with the patient, reassuring the patient, are the first steps you need to have. Of course for primary care physicians it is a great, great challenge because pain is only one of the seven or eight problem lists that they have on their plan of care as we all know, the time constraints are pretty strict. So yes, pain medicine can help with that. I think it's important to talk with the patient and tell the patient for example there are many, many, many studies showing that 90 percent of lower back pain resolves spontaneously. Only 10 to 15 percent have a readily identifiable cause and only persistent lower back pain is a challenge. I think listening to the patient, talking to the patient, and if needed there are always specialists that can help with diagnosing and treating pain.
Dr. Brian McDonough:
I like what you say right off the top. I mean I can tell just by your approach that you're looking at the patient as being sincere and having an issue, not necessarily saying there's a bias. I will tell you, many of us in primary care, depending on where we practice, might immediately come in with a bias saying oh no, this patient is going to be looking for medication, looking for pain medication, searching for narcotics, has left another practice and come to us, and we don't necessarily have a pain specialist to send them to, all those complaints. You're looking it right off the bat and saying it's legitimate and at least giving them the chance, and I think that's a very important thing to do, isn't it.
Dr. Adrian Popescu:
It's absolutely the most important thing to do and we see this every day in our practice in the University of Pennsylvania. There are patients that unfortunately they do have a condition that requires a more complex diagnosis. Sometimes things are not explained to them and they feel frustrated about that, and they leave one practice and go to the next practice. So I would again, I cannot emphasize this enough, that we should make sure that we establish a diagnosis first and foremost, and with that diagnosis we should establish also goals, and we also discuss with the patient what is the natural history of the problem which is very frequently forgot. The literature about how lower back pain or leg pain or neck pain gets better with pain, with or without a physician intervention, it's very, very often put aside, and we have almost like a jerk reaction to prescribe some type of medicine, be it ibuprofen, be it any other medicines that we have in our toolbox, and sometimes that's not the answer.
Dr. Brian McDonough:
I know, Dr. Popescu, that's one of the things that come up, I talk to our residents a lot, you know, they want to come in with a quick answer because in many cases they're trying to see a number of patients in rapid succession to keep up with the flow, and it's easier to give a pill, many pharmaceutical companies now are pushing different medications they can prescribe as pills. How do you fight that tendency? Because it is a quick solution. It's like hey, take this, you'll feel better, but you may more or less put somebody into a position where they count on that medication as their only relief.
Dr. Adrian Popescu:
That is probably an approach that I would not necessarily take because you always have to think about the patient as a family member ,and when you see that patient try to get a very focused history, try to say, "Your problem is more complex than I can assess right now in the next five minutes that I have to spend with you according to my institution's guidelines." I think a physiatrist or a physical medicine and rehabilitation specialist would be more than happy to see the patient and have a thorough discussion about diagnosis. So the patient should expect a complete examination, a complete history, a detailed imaging review, and not only that but also the pertinent findings of the imaging. There were several studies that showed that imaging does not necessarily correlate with pathology in the cervical and lumbar spine in the neck and lower back pain. Again, we should not treat the picture, we should treat the patient.
Dr. Brian McDonough:
I'm Dr. Brian McDonough and if you're just tuning in you're listening to Primary Care Today on ReachMD. I am speaking with Dr. Adrian Popescu. We're talking about pain, pain management, chronic pain, dealing with these issues, and it's really great to have his expertise because he's clearly talking about things that we need to deal with on a regular basis.
One of the questions I have and I know it comes up for many of the doctors I teach, many of the doctors I work with, and I'm sure it's a problem around the country, is maybe they refer a patient to somebody for pain management and there might be a procedure that can be done or maybe some sort of injection that's done. What the doctors in primary care are looking for is if there's going to be some sort of narcotic medication or pain-relieving medication, they'd like an expert to handle it and they wouldn't necessarily want to, but it's often shifted back to them and the experts will say, "Well no, we don't do that. We only do the procedures." Is that something that is a nationwide phenomenon?
Dr. Adrian Popescu:
I don't know if it's a nationwide phenomenon. I can certainly discuss about what are my expectations, what the patient should expect if they would see a spine specialist or a physical medicine and rehabilitation specialist or a pain specialist, and I would consider the consult as a consult of pain medicine. It's not only the management of the pain but its diagnosis. Again, we go back in a circle and we discuss again about diagnosis which is very, very important. Okay.
So let's talk about an injection or an intervention. The role of the injection sometimes is just to establish the diagnosis. You can expect decreased pain and inflammation, and to maximize physical therapy. The role of the injection is not to empower the patient to press the TV button or to press the remote button. It's to maximize physical therapy, and to restore their function, and to establish realistic expectations.
In terms of the opiate medicine I think it's a false expectation that any pain or any back pain or any neck pain should have an opiate prescription associated with it. There is clearly no evidence of long term therapy with opiates in neck or back pain. Again, going back to the diagnosis, God forbid one of these patients can have a metastatic disease of the spine. So this is a totally different problem, okay, because that is a cancer care, it's palliative care which is a totally different field that would allow and I think most of the primary care physicians or palliative care pain physicians would be comfortable to prescribe opiates for those patients.
But I think setting expectations and having the time to do that with a specialist that a lot of spine disorders, I think that is key in the current healthcare.
Dr. Brian McDonough:
That's an interesting approach because what you're saying is you're trying to get the patient to start to help themselves and I think that is a really key part. I'm sure, I know when I have a diabetic or I have somebody with any health problem I want them to take a part of their own care because they're much more effective because they fell they have a sense of control.
Dr. Adrian Popescu:
You're absolutely right. The key is empower the patient. Establish a diagnosis, find the pain generator, and then tell them what the natural history is, and you'll be amazed at how many patients actually if you take the time in that first visit or second visit to talk to them, they will absolutely understand the issue. A lot of times if they don't, they would like to see a surgeon and my colleagues will tell them the same thing, you do not need surgery. We all have to remember the absolute indications for surgery which is bowel blood or incontinence, progressive muscle weakness, neurological deficit. Pain, not so much.
Dr. Brian McDonough:
Right. I think you're right on that point, that there's other things that we have to look at.
We only have a couple minutes left but one of the issues we also face in primary care and I think I'm speaking for a lot of docs, is the patients who doctor shop. How do you suggest we deal with them? Those that truly are looking for either something to help with an addiction or are looking for something to sell on the street, those types of patients. How do you suggest we handle them? Because obviously we want to take care of those who legitimately have issues but we also have to be protective for the general public as well as the health of those who are asking or those who are trying to kind of game the system.
Dr. Adrian Popescu:
As you probably know, I think New Jersey and several other states, they have a central registration where you can go online and see what other physicians prescribed opiates for a certain patient, and I think Pennsylvania made significant strides to go in the same direction, and it's kind of easy to register and access this database when you have a patient that is a new patient and that was on chronic opiates and had a very stable condition and a stable physician and they are trying to transfer their care. So you can see if they are trying to go from physician to physician which in my experience is not that often that that happens and I would actually try to send him to a spine specialist because I think that's the best that can happen for the patient. Send him to a spine specialist, have a diagnosis, have a good discussion with the patient, and then once you have the consultation form back you would reassess the same issue and you can say, "This is the specialist's opinion, let's focus more on your cardiovascular disease than your age-appropriate lumbar MRI."
Dr. Brian McDonough:
Dr. Adrian Popescu, we've run out of time. I want to thank you for joining and sharing your insights on Primary Care Today on ReachMD.
Dr. Adrian Popescu:
Thank you. Thank you very much and again, the main question is what would you do if your mom would be in the office?
Dr. Brian McDonough:
This is Dr. Brian McDonough. If you missed any of this discussion, please visit ReachMD.com/primarycaretoday. You can download the podcast and you can learn more on the series. I want to thank you for listening and again, Dr. Popescu, thank you so much for joining us.
