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GW Hospital’s Unique Approach to Pain Management
Marian Sherman, MD, discusses the unique approach GW Hospital takes in addressing both acute pain and chronic pain (lasting more than six months). Dr. Sherman explains various opioid alternatives, such as nerve block injections, ketamine infusions, and a combination of small doses of OTC pain relievers. She also explains the important role that each patient can play in their own pain management plan.
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Learn more about Marian Sherman, MD
Marian Sherman, MD
Marian Sherman, MD is an Anesthesiologist and a member of the medical staff at The George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates.Learn more about Marian Sherman, MD
Transcription:
Dr. Mike Smith (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith. The topic today is GW Hospital’s unique approach to pain management. Dr. Marian Sherman is an Anesthesiologist and a member of the medical staff at the George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Dr. Sherman, welcome to the show.
Marian Sherman (Guest): Thank you, very much.
Dr. Smith: Why don’t we start off first by helping the audience understand the difference between acute pain and chronic pain, which is really what we’re talking about, today?
Dr. Sherman: Sure, acute pain is generally thought of as that pain which arises from a traumatic event – and we’re talking about the present. That could be surgical pain – postoperative surgical pain. It could be trauma. I think when we talk about chronic pain, we’re talking about patients who have had the experience of an uncomfortable sensation, both physical and emotional, for a period of six months or more.
Dr. Smith: Yeah, and what’s interesting then is – a lot of people who undergo, say that traumatic event that develops the acute pain – many people don’t have any issues post – the event. Their acute pain is treated, but a lot of people do end up developing chronic pain. Why is that? Why do some people develop chronic pain and a lot of others don’t?
Dr. Sherman: So, I don’t think we understand completely why some people have pain that’s managed appropriately and satisfactorily, and others will go on to develop chronic pain syndrome. I think that we know a little bit about effective pain control in that immediate situation. In other words, if someone experiences a trauma or undergoes surgery if they have excellent pain control in that acute period – meaning the first 24 to 72 hours, we can certainly say that they are less likely to go on and develop chronic pain syndrome. There are different emotional variables that play into the picture, so it’s not simply a physiologic condition.
Dr. Smith: So for the patients that do go on to develop chronic pain, what are the traditional ways that we treat that?
Dr. Sherman: I would say that for a very long while, opioids or narcotics have been the mainstay of pain management, both in the acute setting and the chronic setting. I think that within the past ten years or so, we, as a field, anesthesiology, have been talking more and more about multimodal therapy and we’ve been pushing hard to expand beyond single monotherapy as we call it, meaning using simply opioids to control pain.
Dr. Smith: Okay, so in this unique approach – this multimodal approach, what are some of those other things or strategies that you’re using besides the opioids?
Dr. Sherman: Sure, there are both pharmacological methods, and there are non-pharmacologic methods. There are pills; there are interventions like nerve blocks. If we think of an example of a patient, say coming in for a knee replacement whereas, years ago, if people were thinking about the most common medication used to treat pain after a knee surgery, patients would be prescribed opioids or narcotics. Ten or more years ago, we started focusing on multiple medications used in conjunction with one another so that we can use smaller amounts of each medication, capitalizing on their advantages and minimizing the side effects.
In this example, someone undergoing a knee replacement, we’ll commonly pre-treat with simple medications that many people will find in their bathroom medicine cabinets at home like acetaminophen or Tylenol, and NSAIDs – nonsteroidal anti-inflammatory medications commonly recognized by people as Motrin, Aleve, Celebrex. We’ll give those oral medications before surgery. We’ll also offer to our patients at GW, nerve blocks. What that means is essentially injection local anesthetic in a perineural fashion, which means in the case of this knee replacement, we’ll inject medication around the femoral nerve, which supplies about 50 to 60% of the pain messages that arise from an injury sustained in a knee operation or joint replacement.
So, we use medications preoperatively, we’ll commonly place nerve catheters preoperatively, and for patients who have pain beyond that, which is controlled by the measures I’ve already mentioned, we have additional methods at GW that we can use. We run something called Ketamine infusions. Ketamine is a medication that’s been around for a really long time but has been enjoying a comeback in the last probably ten-ish years. It’s very helpful in the context of a patient who has chronic pain and comes in for additional surgery, either on the body part that’s the source of the chronic pain or another body part, so in other words, the complex patient.
Those are I guess just a few of the methodologies that we employ. Again, Tylenol, Celebrex, other known-steroidals. We can also use gabapentinoids, which are not new medications either, but what we’re trying to do is employ the use of several different medications again to really maximize each medication’s benefit, and by using less of each drug, we can minimize the side-effects that the patient experiences.
Dr. Smith: How much is it a problem that some patients respond well to a certain pain medication and others really don’t and how do you work through that?
Dr. Sherman: Certainly, there is inter-patient variability in response to medications. I think the point you’re bringing up is the importance of once you initiate a strategy, it’s very important to return to the patients’ bedside, evaluate the patient, and measure the effectiveness of your therapy. Patients are excellent resources in offering that information. Patients want to feel better; they want to recover. The importance of their feeling well really impacts their ability to participate in rehabilitation, and that ability, in turn, affects development or nondevelopment of chronic, long-term disadvantage. Really beginning with a common therapy, measuring your effectiveness, and then going back and as we say tweaking a plan based on each patients’ unique experience, whether it’s after an operation or after a trauma is paramount to our success.
Dr. Smith: Dr. Sherman, how – is this really unique to GW Hospital, this type of approach, or are there other medical centers that are approaching pain the way that you guys are?
Dr. Sherman: I think that most hospitals should be employing a multimodal approach to pain management. It’s not a brand-new idea. It’s been around for years – a decade or more, but I think that it’s really getting a lot more attention in the last several years given that there is conversation nationally about our opioid crisis and to the extent that we can minimize our patients’ exposure to opioids, which have been shown to be problematic for many, then we can not only effectively control pain up front after an operation or trauma, but also, help to avoid the development of problems that can arise with opioid overuse or abuse. In terms of how unique is this at GW, I hope that that portion is not unique because I really hope for the vast majority of patients, they’re exposed to medical care or medical care providers who are using this methodology.
I think at GW, what’s really special about what we do is we provide not – when we talk about the knee surgery, an example would be a femoral nerve block, for example – we can provide these types of services not just for patients who are inpatients that we can see every day in the hospital, but we can also place catheters and follow-up with patients who come to GW just for a few hours to have an outpatient surgery. What that means is we’re really relying heavily on our acute pain management team here at GW.
We have a specialized team that really organizes and focuses on the care of these patients in the postoperative period. For postoperative patients who are going home on the day of surgery, we follow them daily with a phone call. They’ve got a number they can reach us at 24/7. I think that’s really unique here at GW. I don’t know how many hospitals offer patients the reassurance and the ability to call anyone – call us at any time of day, any day of the week. We are truly 24/7. There’s a real, live person at the end of the number that we give them to call should they experience difficulties with pain management while at home.
Dr. Smith: In summary, Dr. Sherman, what would you like people to know about pain management?
Dr. Sherman: I would like people to understand that pain management regimens are unique for each patient, that patients who are coming in for surgery can expect to have an informed discussion with their medical providers, be it an anesthesiologist or surgeons about their options for pain control. In a perfect world, we would have time ahead of the day of surgery to talk with patients about their options so that they have a less compressed time frame during which they have to make these decisions.
There are all kinds of ways to manage pain. It’s not just about pills. We can do interventions like I’ve mentioned, peripheral nerve blocks. We can run infusions as we do here at George Washington University. We run ketamine infusions intraoperatively and postoperatively on our standard medicine floors, which is unique. Ketamine infusions are not run everywhere. We’ve had tremendous success with the use of ketamine, particularly in our patients who have chronic pain syndromes who come in for surgeries. We have new strategies on the horizon, so know that here at GW, we are working always for a best-case scenario, and that means looking forward to developing new, and better, and more comprehensive strategies for pain control for all patients.
Dr. Smith: Well, Dr. Sherman, I want to thank you for coming on the show today. You’re listening to GW Healthcast. Please visit GWDocs.com to get connected with Dr. Sherman or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. This is Dr. Mike Smith. Thanks for listening.
Dr. Mike Smith (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith. The topic today is GW Hospital’s unique approach to pain management. Dr. Marian Sherman is an Anesthesiologist and a member of the medical staff at the George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Dr. Sherman, welcome to the show.
Marian Sherman (Guest): Thank you, very much.
Dr. Smith: Why don’t we start off first by helping the audience understand the difference between acute pain and chronic pain, which is really what we’re talking about, today?
Dr. Sherman: Sure, acute pain is generally thought of as that pain which arises from a traumatic event – and we’re talking about the present. That could be surgical pain – postoperative surgical pain. It could be trauma. I think when we talk about chronic pain, we’re talking about patients who have had the experience of an uncomfortable sensation, both physical and emotional, for a period of six months or more.
Dr. Smith: Yeah, and what’s interesting then is – a lot of people who undergo, say that traumatic event that develops the acute pain – many people don’t have any issues post – the event. Their acute pain is treated, but a lot of people do end up developing chronic pain. Why is that? Why do some people develop chronic pain and a lot of others don’t?
Dr. Sherman: So, I don’t think we understand completely why some people have pain that’s managed appropriately and satisfactorily, and others will go on to develop chronic pain syndrome. I think that we know a little bit about effective pain control in that immediate situation. In other words, if someone experiences a trauma or undergoes surgery if they have excellent pain control in that acute period – meaning the first 24 to 72 hours, we can certainly say that they are less likely to go on and develop chronic pain syndrome. There are different emotional variables that play into the picture, so it’s not simply a physiologic condition.
Dr. Smith: So for the patients that do go on to develop chronic pain, what are the traditional ways that we treat that?
Dr. Sherman: I would say that for a very long while, opioids or narcotics have been the mainstay of pain management, both in the acute setting and the chronic setting. I think that within the past ten years or so, we, as a field, anesthesiology, have been talking more and more about multimodal therapy and we’ve been pushing hard to expand beyond single monotherapy as we call it, meaning using simply opioids to control pain.
Dr. Smith: Okay, so in this unique approach – this multimodal approach, what are some of those other things or strategies that you’re using besides the opioids?
Dr. Sherman: Sure, there are both pharmacological methods, and there are non-pharmacologic methods. There are pills; there are interventions like nerve blocks. If we think of an example of a patient, say coming in for a knee replacement whereas, years ago, if people were thinking about the most common medication used to treat pain after a knee surgery, patients would be prescribed opioids or narcotics. Ten or more years ago, we started focusing on multiple medications used in conjunction with one another so that we can use smaller amounts of each medication, capitalizing on their advantages and minimizing the side effects.
In this example, someone undergoing a knee replacement, we’ll commonly pre-treat with simple medications that many people will find in their bathroom medicine cabinets at home like acetaminophen or Tylenol, and NSAIDs – nonsteroidal anti-inflammatory medications commonly recognized by people as Motrin, Aleve, Celebrex. We’ll give those oral medications before surgery. We’ll also offer to our patients at GW, nerve blocks. What that means is essentially injection local anesthetic in a perineural fashion, which means in the case of this knee replacement, we’ll inject medication around the femoral nerve, which supplies about 50 to 60% of the pain messages that arise from an injury sustained in a knee operation or joint replacement.
So, we use medications preoperatively, we’ll commonly place nerve catheters preoperatively, and for patients who have pain beyond that, which is controlled by the measures I’ve already mentioned, we have additional methods at GW that we can use. We run something called Ketamine infusions. Ketamine is a medication that’s been around for a really long time but has been enjoying a comeback in the last probably ten-ish years. It’s very helpful in the context of a patient who has chronic pain and comes in for additional surgery, either on the body part that’s the source of the chronic pain or another body part, so in other words, the complex patient.
Those are I guess just a few of the methodologies that we employ. Again, Tylenol, Celebrex, other known-steroidals. We can also use gabapentinoids, which are not new medications either, but what we’re trying to do is employ the use of several different medications again to really maximize each medication’s benefit, and by using less of each drug, we can minimize the side-effects that the patient experiences.
Dr. Smith: How much is it a problem that some patients respond well to a certain pain medication and others really don’t and how do you work through that?
Dr. Sherman: Certainly, there is inter-patient variability in response to medications. I think the point you’re bringing up is the importance of once you initiate a strategy, it’s very important to return to the patients’ bedside, evaluate the patient, and measure the effectiveness of your therapy. Patients are excellent resources in offering that information. Patients want to feel better; they want to recover. The importance of their feeling well really impacts their ability to participate in rehabilitation, and that ability, in turn, affects development or nondevelopment of chronic, long-term disadvantage. Really beginning with a common therapy, measuring your effectiveness, and then going back and as we say tweaking a plan based on each patients’ unique experience, whether it’s after an operation or after a trauma is paramount to our success.
Dr. Smith: Dr. Sherman, how – is this really unique to GW Hospital, this type of approach, or are there other medical centers that are approaching pain the way that you guys are?
Dr. Sherman: I think that most hospitals should be employing a multimodal approach to pain management. It’s not a brand-new idea. It’s been around for years – a decade or more, but I think that it’s really getting a lot more attention in the last several years given that there is conversation nationally about our opioid crisis and to the extent that we can minimize our patients’ exposure to opioids, which have been shown to be problematic for many, then we can not only effectively control pain up front after an operation or trauma, but also, help to avoid the development of problems that can arise with opioid overuse or abuse. In terms of how unique is this at GW, I hope that that portion is not unique because I really hope for the vast majority of patients, they’re exposed to medical care or medical care providers who are using this methodology.
I think at GW, what’s really special about what we do is we provide not – when we talk about the knee surgery, an example would be a femoral nerve block, for example – we can provide these types of services not just for patients who are inpatients that we can see every day in the hospital, but we can also place catheters and follow-up with patients who come to GW just for a few hours to have an outpatient surgery. What that means is we’re really relying heavily on our acute pain management team here at GW.
We have a specialized team that really organizes and focuses on the care of these patients in the postoperative period. For postoperative patients who are going home on the day of surgery, we follow them daily with a phone call. They’ve got a number they can reach us at 24/7. I think that’s really unique here at GW. I don’t know how many hospitals offer patients the reassurance and the ability to call anyone – call us at any time of day, any day of the week. We are truly 24/7. There’s a real, live person at the end of the number that we give them to call should they experience difficulties with pain management while at home.
Dr. Smith: In summary, Dr. Sherman, what would you like people to know about pain management?
Dr. Sherman: I would like people to understand that pain management regimens are unique for each patient, that patients who are coming in for surgery can expect to have an informed discussion with their medical providers, be it an anesthesiologist or surgeons about their options for pain control. In a perfect world, we would have time ahead of the day of surgery to talk with patients about their options so that they have a less compressed time frame during which they have to make these decisions.
There are all kinds of ways to manage pain. It’s not just about pills. We can do interventions like I’ve mentioned, peripheral nerve blocks. We can run infusions as we do here at George Washington University. We run ketamine infusions intraoperatively and postoperatively on our standard medicine floors, which is unique. Ketamine infusions are not run everywhere. We’ve had tremendous success with the use of ketamine, particularly in our patients who have chronic pain syndromes who come in for surgeries. We have new strategies on the horizon, so know that here at GW, we are working always for a best-case scenario, and that means looking forward to developing new, and better, and more comprehensive strategies for pain control for all patients.
Dr. Smith: Well, Dr. Sherman, I want to thank you for coming on the show today. You’re listening to GW Healthcast. Please visit GWDocs.com to get connected with Dr. Sherman or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. This is Dr. Mike Smith. Thanks for listening.