Happy second birthday, Portland Pain Solutions.

Sunday, August 13th, 2023

It’s been a year since I wrote anything in this blog, but I’ve had a lot of ideas I want to talk about. Today they seem to be crystalizing, so here we go…

One thing I want to talk about is my strong belief that, based on years of experience , treating patients with discomfort of one form or another, the key to success lies and modifying the way the brain and nervous system processes information. There are a number of ways to do that.

Fix the Problem

Sometimes the best way to deal with pain is to interrupt the source, for example, if you have a broken leg, meditating away the pain isn’t an option. By the time most patients get to me, the easily fixable stuff has already been done. There are certainly problems I see that can get a quick fix though. Patients with joint arthritis of the back and neck often do very well with RF ablation. People can have all kinds of weird trigger points and nerve entrapments that respond to small, carefully guided injections in the soft tissues. Patients with compression fractures can have kyphoplasty, which stops the pain almost instantly.

Modulate the Pain Signals

Sometimes the sensory organs of the body themselves are dysfunctional and the source of these signals. Simply “cutting it off” won’t work. In these instances you need to find a way to modulate (change) the pain signals in the spinal cord or brain. For example, when patients have irritated nerve roots in the spine, this can produce severe pain in an extremity. When we perform epidural steroid injections, this physically interrupts the irritation, allowing the nerves to function normally again for a period of time. In some cases, the results last for years. Another way of modulating the signals is with spinal cord stimulation. This is a procedure in which small electrodes are placed behind the spinal cord and connected to a pacemaker-like device, which functions to change the painful signals in the nervous system before they get to the brain. I find it a point of pride that I don’t do a lot of spinal cord stimulators because I can usually find other ways to manage my patient’s pain. When it’s the right tool for the job, it often works quite well.

Treat the Brain

One of the most interesting problems over of the course of my career has been treating issues of central sensitization, the most well-known being fibromyalgia, with CRPS being common in my clinic. The medications traditionally prescribed for this often don’t work very well, or produce unpleasant side effects. These medications include antidepressant class pain medications or anticonvulsants. I have become of a very big fan of using low-dose naltrexone to treat patients with these syndromes, and have seen some dramatic cases of success. It’s important to highlight this because many of these patients seemed otherwise intractable and irretrievable. As a second line agent, I frequently reach for a drug called memantine (aka Namenda) which blocks certain receptors in the spinal cord and brain that modulate the excitability of the nervous system. The results are not often as dramatic as with low-dose naltrexone, but nonetheless frequent enough to justify a trial. Ketamine is another way of getting at treatment of these receptors. The batting average, again, is not very high, but I have seen sustained recoveries in patients treated with a series of IV ketamine infusions.

Ketamine

IV ketamine for depression deserves special mention because the world seems to have gone ketamine-crazy this year. There are months-long shortages from supply companies. I have found it very useful for patients with treatment refractory depression, and have many patients now in successful maintenance being treated once every month or two. Patients are often apprehensive before beginning treatment. They’ve heard of the infamous k-hole, and don’t want to go there. Who would? Using a gentle titration, I can get patients into the therapeutic zone for the medication while still keeping them lightly alert and comfortable. It usually takes about a week of infusions to see the positive effects start to build.

PTSD and Stellate Ganglion Blockade

One of the most interesting and exciting changes to my practice since I opened Portland Pain Solutions two years ago, has been expanding my scope to include the treatment of post-traumatic stress disorder. There is often a linkage between PTSD and central sensitization type pain problems. You often see the PTSD event occur in temporal proximity to onset of the pain syndrome. For example, someone might be in a car wreck, and shortly thereafter you begin to see emergence of central hypersensitivity. This may be reflected in musculoskeletal pain, but could manifest as other unusual sensitivities. Sometimes patients will report burning or prickling sensations randomly scattered around the body. They may have unusual taste, or smell perceptions. I have also seen unusual gastrointestinal and urinary sensitivities to.

It often makes sense to treat as one problem both the symptoms of centralized hypersensitivity, and the underlying PTSD. I look at this as more of a “wiring problem“ then one of abnormal brain chemistry. These are abstractions, of course, but they are a simple way of understanding my strategy. My goal in treatment is to change the way that brain circuitry is aligned so that pre-existing maladaptive circuits are quieted, and replaced by something different- and hopefully better.

Patients with PTSD can go years without making progress using the standard array of therapies. What’s needed is a catalyst to get the brain wiring shifted in the right direction. For some patients clonidine helps (a blood pressure drug), others have found success with psychedelics, like MDMA or psilocybin. Being a pain specialist, the tools I reach for are stellate ganglion blockade, and sometimes IV ketamine.

What’s a Stellate Block?

Stellate ganglion blockade is described in detail elsewhere on my website, but in short, this is a simple nerve block performed at the base of the neck, generally on the right side, which can lead to rapid and dramatic changes in the way that the body reacts to stress. There are two things that my patients often tell me at their two week follow up visit after a stellate ganglion block. The first is that the weight of anxiety has lifted off of their chest. The second is that their emotional reactivity to stress has quieted. Stressful events will still occur, but they don’t elicit the usual fight or flight response. This leads to a productive, positive feedback loop of less reactivity, less anticipatory anxiety, and greater comfort in one’s on skin. Similar to the effects that I have seen with low-dose naltrexone in patients with hypersensitivity disorders, the results I have seen with stellate blockade are often dramatic. Even in cases that one would never imagine such gains could be possible.

Meditation

I usually assign homework to my stellate patients in the form of meditation. My own personal brand! Numerous studies have been done demonstrating the effectiveness of meditation. I am interested in its potential to build on the catalytic effects of medical treatment as a form of physical therapy for the brain. If we want maladaptive brain circuitry to simply be quiet, we need to train it to stay that way. I suspect that the core benefit to meditation lies in building a quiet brain. Not just in terms of the mind, but in terms of sensory experiences too. A quiet nervous system has lower blood pressure, fewer sensory anomalies, fewer muscle twitches, less anxiety, depression, and PTSD. I suspect it helps OCD and ADHD as well.

The instructions I give to patients are quite simple. The key ingredient, and you can’t get around this, but it is time and intensity. If you want to physically change the structure of the brain, you need to approach it, the same way that you approach exercise for the body. You wouldn’t expect to become a marathoner doing a five minute jog once a day. I take sustained effort to build the body that is needed to handle a marathon. Likewise, if you want to build a truly quiet mind, it takes time and energy.

Getting Started with Meditation

Here is what I recommend: Find a quiet place to sit where there are things to observe. This can be anywhere, but I recommend a natural setting, away from technology and transportation noise. Sit at attention with feet flat on the ground. This experience is not intended to be relaxing. Set a timer for 30 minutes and turn it away from you. Pick an object of interest in your environment, and direct your gaze towards it. Focus on every last detail of the object. For example, if it is a squirrel, observe every bristle of fur, every undulation of its movement, the full richness of its color. In doing so silence all reactive thought. Silence your inner monologue. Quiet your emotions, and reject any instinct to recognize patterns or trigger thoughts. The goal is to use your focus to completely quiet every aspect of your brain except for the part that is observing the object. If you’re finding difficulty maintaining focus, use the power of a long exhale to bring it back. Spent two or three minutes on each object before moving onto the next. At first it may be difficult to do this for more than five or ten minutes. Just like aerobic exercise, meditation can feel exhausting when you’re new to it. Build up to a full 30 minutes. For the truly motivated individual, I recommend morning and afternoon sessions for the first two weeks, and then a single daily session for the remaining six. Once eight weeks have been completed, much of the work of shifting the brain circuitry has been done. At this point, you will likely be able to maintain the benefits with just a few minutes of focused meditation where you can work it into your day.

The benefits of meditation are vast. In my personal experience, the results have been normalized blood pressure, much better sleep onset and duration, minimal anxiety, and ability to maintain a calm, objective mind when confronted by stress.

Happy Second Birthday Portland Pain Solutions!

It’s been an exciting first two years at Portland Pain Solutions. We’ve gone from only a few patients per day to seeing 10 to 15 daily. I typically reserve the early mornings for treating my stellate and ketamine patients. I spend the rest of the day seeing pain cases. The best part about this career has always been seeing my patients do well, and the challenge of getting them there is a rewarding way to spending one’s days. This is what gets me up in the morning, despite all the hassles of running a practice, and dealing with the administrative aspects of care. If you’ve made it this far, thanks so much for reading, you can always email me with comments or questions.

Get (a very small part of you) Born Again!

The next topic I want to address is regenerative medicine. We have a brand-new, state-of-the-art setup for concentrating platelet rich plasma, as well as alpha-2-macroglobulin. My guess is that you have no idea what these things are. Let’s change that. Stay tuned!