Pain and Fear

Nick:
Hello, and welcome to the Ascend Health show. I’m your host, Nick Angelis. I’m a Nurse Anesthetist and one of the Owners of Ascend Health Center. And today we have a very special guest. Actually they couldn’t make it, so it’s just me. So this won’t be a very long show because I can’t stand to listen to myself for about 25 minutes. But I think I’ll start with a disclaimer. Now we have a separate video that has a disclaimer. It mentions a lot about just like you don’t use your toaster in your bathtub, anything you see on the internet or on television, you shouldn’t immediately incorporate into your own health and wellness, but it’s probably time for a refresher. So I’m a nurse anesthetist. I’m highly trained in pain. I have a background in mental health, also in holistic health, but at the same time I can’t speak individually to your probably complex situation. Our clinic, Ascend Health Center, almost exclusively deals with complex health problems, so probably can’t solve anything just talking to a TV screen right now.

At the same time, I’m still hoping that you get some information. Usually I have a guest on the show, simply because I want to learn things and so you, the audience, learn along with me. I feel I’m an expert in some fields and not at all on others. So that’s why for most of these shows, I appear inquisitive is because I am. I have no idea about the knowledge of the other person, and that’s the whole purpose of the show. And that’s also purposeful because I don’t want this to look like an infomercial where we’re talking about mango juicers or things of that nature.

So now that we’ve got that settled, I think today and obviously I’m inventing this a little bit as we go along since my original guests couldn’t show, but I really think I want to talk about fear and pain. Those are related but many of the maladies and the illnesses that we suffer in life are based on fear. Now I’m not saying this from an alternative medicine perspective of mind over matter, everything is in your head. I think that’s insulting. I don’t tell patients, “No, this is in your head. This isn’t real pain.” And the reason is that pain itself has gone through a metamorphosis over the years. So I’m about to turn 39 years old in a few days, and when I was in nursing school in the early 2000s, we were told pain is the sixth vital sign, meaning that whatever the patient says their pain is, that’s how you should believe them. You should trust them. You should medicate them appropriately and we’re told stories about all these mean nurses who wouldn’t give their patients pain medicine. And now 15 years later we’re realizing, no, it’s pretty foolish to let the patients decide on their own what pain medicines they should receive. It’s not wise for them to say, “Well, I’m here in the ER. What’s that medicine that begins with a D, is it Dilaudid, Dilauded.” No. If you go to the ER now, you won’t get much other than a pat on the back and maybe some Toradol. That’s why one of the things we do at Ascend Health Center is for our established patients, operate almost like an urgent care or an ER.

And at some point today, I may speak a little bit more about what our clinic does. Usually it’s in passing because I don’t want to take time away from our guests to talk about myself and our clinic. But it’s important to note that there is a balance between give the patient whatever pain medicine they need and hope you feel better buddy, thanks for coming in. Unfortunately, right now in healthcare, most of the balance is hope you’re going to do fine but we’re not really going to give you anything for your pain. So patients of course get desperate, and that’s where the fear comes in. The fear that you — that there’s no solution, that you won’t get better that this pain is a constant companion to you. So we can address that fear as long as you realize that there are solutions.

Let me start with describing pain a little bit more clearly. So, you — let’s say you bang your finger against something. Pain travels — the nerve sensation travels to your spinal cord. It’s in process slightly, goes up to your brain. Your brain sends another message down to your spinal cord to that nerve telling you, okay, here’s how you should react. So it’s not just a simple reflex. There’s different parts of your spinal cord that look at different sensations and interpret it. That’s why in chiropractic care for example, they have TENS units, where the buzzing distracts your nerve. In dermatology, for a long time they said you cannot have itching and pain at the same time. Patients with psoriasis for example said, “No, that’s not true. This itches and it hurts.” And they later found out, no, you can have multiple sensations in the same area. So a lot of the current research in pain isn’t how can we deaden this nerve, but rather how can we distract this nerve so that pain isn’t the only thing that’s felt?

Most of the pain patients that I treat, they have conditions where the pain is almost constant or where nerves have lost the sensitivity to different sensations and almost everything is interpreted as pain. A slightly gross analogy for this is in healthcare when we put a Foley catheter and the patient says I have to pee and the nurse will say, “No. You have a catheter. You can pee, won’t get on the bed, it will go in this tube, you’re fine.” The reason is because your bladder doesn’t have these abilities to say actually, I don’t have to pee. It’s simply that there’s something in the way. It simply knows how to tell your brain one thing. Guess what? I have to pee. There’s something going on and the only way I can interpret this is I have the need for urination. So sometimes our nerves undergo the same process. And unfortunately and this is why our clinic does mental health and pain, what you’ve experienced in life often alters this process, so that sounds ludicrous. I was bullied as a child, and now stuff hurts. And it may be a bit more complicated than that, but does it really need to be. Does it need to be more complicated than my brain doesn’t know how to process this experience or I have some PTSD from something I went through, or I really just I’m having a fundamental issue with my belief system where I really want to believe in this but it’s not logical, but rather than confronting this belief, my body will find some way to explain that there’s some dissonance here. Things aren’t adding up.

And sometimes that’s what pain is. In your brain, they’re just a situation where what’s happening, the way you want to interpret it, and often it’s that reality is just too hard to really face. And that’s where the mental health component comes in. We require patients who receive ketamine infusions, for example, to also have therapy, which does — in patients — you mean, like physical therapy. No, we mean talk therapy where you talk to someone about what’s going on in your life. Obviously in the case of ketamine, that’s because it’s a mind-altering drug. It’s mind expanding. It allows you to process difficult things from the past. And that’s not wise to just go into without some integration work, where you can understand, okay, here’s what I felt, here’s what it means, here’s how I can move forward and shed this identity as a pain patient. So that’s all very important, but in general, one way to deal with pain is to talk to others about it, to really look at your thoughts and think about the mental health aspect of it. Because like I said earlier, pain and fear are related.

Now, another problem is that we often get desperate for solutions, so we’ll look at whatever is hyped up. Again, the issue is, I’m going to have this problem, I have no idea how to solve it, there must be some miracle cure. First of all, there isn’t. I don’t have any miracle cures. I don’t have any treatments at Ascend Health Center. Dr. Molina doesn’t have treatments, Mark, our nurse practitioner, our therapist, there’s nothing we can do for you that’s completely free of discomfort. There’s no easy fixes. It’s not a magic pill. And you can see that and this is community V but I don’t mind saying things that would probably get me in trouble on a wider venue. If you’ve ever seen a Tylenol or Advil commercial, if you actually took those drugs away that they recommended on the commercials. For Tylenol, you destroy your liver. For Advil, you destroy your kidneys, like no — there’s no drug that is completely innocent, that you can take day after day whenever you have the slightest problem that allows you to live that full life without at least some minor consequences.

Now the theme is correct. If you see the commercials where someone is trying to exercise and then they winced and they realized I should have taken that 800 milligrams of ibuprofen. So the theme is we want function. It doesn’t count as pain relief if, like I mentioned the old days back in 2004 as I was graduating from Youngstown State, Go Penguins, where okay, I’m on my couch. I’m not doing anything but these opioids sure took away the pain. That’s not a win; that’s a loss, because all you’re doing is putting indentations on your couch. So the hype, it started around that same time with statins, where you couldn’t go anywhere without hearing how bad cholesterol was for you. And there’s plenty of legitimate reasons for that but one of the simpler reasons is that Lipitor made Pfizer billions of dollars. So there’s articles everywhere about how good it is to be on Crestor or Lipitor or another cholesterol fighting drug. Then when I worked at Cleveland Clinic in the cardiothoracic ICU, there was a thankfully brief amount of time when we started giving even more insulin to patients, because there are these studies that came out that said, you know, if you keep the blood sugar really low, it’s so much better for the patients, and then thankfully, fairly quickly, doctors realized, no, these companies want to sell more insulin. This is a bad idea because it increases the risk that you’ll give your patients too much insulin and they’ll have a stroke or die.

And then more recently, I’d say within the last three years, marijuana is getting so much good press, CBD as an anti-inflammatory which I do believe in, THC for all of the problems it can solve and even when I started my clinic in 2019, I was like, this is great. Ketamine and marijuana, they work on some of the same receptors. I can use certain strains of marijuana with the ketamine and these patients are going to do even better. But then I slowly realized obviously it’s not the devil’s lettuce anymore. But it’s true that it’s not living up to the hype. There are so many side effects. In many ways, marijuana is like alcohol, where you feel good when it’s in your system but then unlike ketamine, as soon as it’s gone, you’re back to where you were. And how can a substance that only works as long as in your system be a sustainable solution for something as complex as complex regional pain syndrome or recurring complex PTSD or some of these other issues.

And so I’ve realized that there’s a lot of money behind the medical marijuana market right now. And so it makes sense that we’re not talking about the increased rate of psychosis, the increased rates of people playing video games in their basement with Mountain Dew and Cheetos. Maybe that’s a little hard to clinically elucidate from the data, but that’s a real thing. And so it’s the same with what I provide at our clinic of ketamine. Right now, ketamine and psychedelics, meaning psilocybin, LSD, Ecstasy in its more generic less harmful form, there is a lot of promises especially in mental health, but — well, for sure, it’s overhyped, because there’s a ton of venture capitalist money coming to the space. So we have to realize that no matter how afraid we are, I’m going to have to deal with this pain for the rest of my life, I would have to deal with this anxiety or depression for rest of my life. We can’t just go to whatever’s hot, whatever the hype is. There needs to be a standardized approach. For example, my clinic is not at all a first-line treatment for pain. We’re not pain management. We’re not going to give you any opioids. We have topical treatments, IV, intramuscular. There’s a lot that we can do, but it’s not pain management, and I should not be the first step if you’re having some pain.

Later today, Dr. Bob is going to be one of my guests. He’s a chiropractor. He’s a great first step, a lot easier than having an intravenous solution of medications inserted into you. So when we have fear, it’s challenging. Where do we start? I think something like a chiropractor or your primary care physician is a good step. And we have to remember that we — there is a methodical process to dealing with any complex issue. Sometimes there’s a very quick trauma, and I don’t mean traumas as a mental health trauma like I’ve been referring to, I mean, maybe a car accident that changed everything. Maybe it was Epstein-Barr virus or a Covid or something that fundamentally changed the way your nervous system works and now you’re fatigued, so that fear is present.

The first thing you need to find out is what may help. So many patients of mine, I’m actually not looking for a sustainable comeback every month solution. I’m looking to prove I can help you and then maybe I don’t need to help you. So this is a strange concept. But think of it as you start a diet. As soon as you start a diet, you’re like, “Ooh, I’ve got those doughnuts. Some chocolate cake in the fridge. Pretty sure there’s bacon there too.” Before you started the diet, you just said got chocolate, got bacon, it’s no big deal. But as soon as you’re in that scarcity mindset of I can’t eat those things anymore, all you can do is think about that. And pain is the same way as a sphere. It’s called — and I can’t pronounce this right. I’m going to try it. Catastrophizing your fear, catastrophizing your pain, meaning that instead of this is bad, you’re like, “This is bad. This is going to get worse. It’ll never get better. I won’t be able to do any of the things I used to enjoy.” And then you pull out your wallet, you spend all your money on every treatment you can Google as quickly as you can, and usually you’re not any better for it.

So we need to look at that root cause of the fear. But at the same time, we have to realize, okay, what can help. So the ketamine infusions, for example, help with almost every sort of neuropathic pain. Often these are the types of pain where you look at an x ray and you don’t quite see it. And so again, it’s a lofty goal of let’s get rid of this pain forever. And sometimes that happens, and that’s usually what happens at my clinic. But other times, it’s all I need to do is give a patient an infusion or two and they realize this is working, and then they can start on all the self-help things that we usually ignore. If you’re in bone crushing pain, who’s going to do yoga, or eat better or sleep better or look at their diet, or do whatever they need to do to live an anti-inflammatory lifestyle. But once you find something that works and you’re more willing to. Now even opioids can work like that. Most doctors limit their — what they’ll prescribe for about a seven-day course of let’s say Vicodin or Percocet, but that can’t take away the pain. And then you realize, well, they’re not going to refill this prescription. It’s time to take some responsibility and do the little things that will help with pain. And that’s true and so this isn’t something where I’m trying to bash the different types of medicines. But I probably should take this moment to explain how opioids work since obviously with the opioid crisis, like I mentioned, when I was first in nursing school before anesthesia school, we were told, “Well, if patients take these medications right, they won’t get addicted.” That’s not true. They still often get addicted, but there’s still a place in anesthesia, I use opioids all the time that no Dilaudid, morphine, whatever the case. Obviously, it’s a bit of a limited, it’s during the surgery, and it’s not easy for patients to acquire those substances without me, but at the same time, there is a place for non-steroidal anti-inflammatory drugs. I mentioned Tylenol and there’s Motrin, aspirin, things of that nature. But we have to realize, well, when is this useful and when do I have to try something else? So that’s the challenge.

I mentioned marijuana, psychedelics, statins, opioids, diabetes medications, more specific insulin, that all these at some point have been hyped at, you need even more and the cure is to have even more of this. What I’m saying is if we address the fear, if we talk to our close friends about it, if you look at talk therapy, if we really look at the worst case scenario, if we look at reason, can I reasonably say that this would be unending or is there some solution? What can I try and how can I try different things to help with this pain without bankrupting myself? And that’s so hard. Part of that is who can I trust? What healthcare provider can I trust will tell me if they can help me? How can I get diagnostic work? For example, I love functional medicine, but it doesn’t involve a lot of tests. How can I get diagnostic work that I can afford, and that will give me some clues on how I myself can do this? Because that’s what it really is. How can you empower yourself to do things outside of your doctor or your chiropractor, or your physical therapist or your massage therapist, or like I said, your talk therapist?

So where fear comes into play, we have to realize the emotional and spiritual implications. How was I raised? Was I able to trust my parents? Was I was able to trust those who told me things? Was I was able to trust authority? And as we drill down on that we get a better sense. Again, pain is through your nervous system. Your brain is part of the nervous system. So pain is a very subjective situation.

When I’ve done nerve blocks, I had one case where a woman was beat up by her boyfriend, I gave a nerve block to block the entire arm as we were going to do wrist surgery. And she started crying like this hurts. I said, no. What you’re feeling is numbness from the bupivacaine that I inserted into your nerves. And it took a while for her to understand like this is the absence of pain, not pain itself. So we have to realize there is a psychological component about pain. So we don’t deny it and say. this doesn’t hurt at all and then sprain our ankle even worse, but we just acknowledge that it’s okay to say some of this is in my head and still receive treatment that I am perceiving pain. It’s not for anyone else to tell me what is or isn’t pain. At the same time, I realized that opioids working on the mu receptor in my brain in such a way that my brain no longer feels like making the substances endogenously, internally that can help me with pain. You know, if we stub our toe, our body releases chemicals that make it feel bad after a little while. Once you’re on medicines for a little while, our body doesn’t do that anymore because it says you know what, at four o’clock, I’m going to get some OxyContin and I’ll take care of it. And that’s the challenge is that physically speaking, our bodies are lazy. If we provide it with something from an outside source, it’s probably not going to make it anymore. So that’s why we have to engage our minds and our bodies when we’re talking about fear and pain.

I’ve already talked longer than I wanted to, and I am boring myself a little bit. So just to finish, I’ll speak just for a minute or two of what I actually do offer at Ascend Health Center. So a Medical Director is a psychiatrist, especially for migraines, fibromyalgia, those conditions that blur the line between pain and depression and anxiety and more than mental health concerns. It does take a holistic, integrative full view of what’s going on. That’s why our psychiatry team use every patient before we decide, okay, maybe ketamine is the answer for you or maybe it’s TMS, that’s Transcranial Magnetic Stimulation, and that is a drugless way to treat depression. We also use it for anxiety, insomnia, OCD, and so it doesn’t directly affect pain, but we’ve seen patients get better just because we’ve taken away that fear part or that trauma part, because if you think about it, pharmaceuticals are a fairly blunt way to treat conditions. Meaning take this every day, it’s going to change your body’s chemistry and you’re going to need this as long as you have this problem. And that’s perfectly fine. We do a lot of that work with mental health, but maybe there are better ways. So that’s where therapy comes in. We have our own therapists or we encourage patients to continue on with their own therapist. Even with our psychiatry team, what we have is highly specialized. We have a lot of patients with EDS, Lyme disease, complex issues that many professionals don’t know how to treat. And we can only do so because we work in hand with pain management, with primary care physicians. It’s not competitive, it’s collaborative.

So that’s a synopsis of what we do. And again, when you’re having pain, remember, it’s not wise to rush off and have pain procedures and go to every doctor that you can and start spending every cent you have on I need to get better now. It’s better to find some people you can trust, be methodical about it, and go from there. And one way that you can see if you can trust someone is, are they going beyond their expertise? For example, I’m a nurse anesthetist. Again, we’re not a pain management specialty per se. It’s just that pain is one of many things that we treat at Ascend Health Center. Thus whoever you’re talking to about your issue, say I can do everything for you or at some point, are they saying, look, if it turns out to be this condition, here’s another place that you need to go to. Because sometimes arrogance is a thing in medicine and we often feel, well, I can treat whatever problem you have. That’s not true. Well, let me put it this way. It may be true, but am I the best choice always for each condition? And the answer is often no. So we balance that. Let’s not send a patient to 10 different specialists where every specialist will look at only one part of the equation. At the same time, let’s not go overarching and say, we can treat everything that you have. Come to Ascend Health Center no matter what the issue is, you’ll be a okay. It doesn’t work that way.

So again, this is the Ascend Health show. I’m Nick Angelis, and I’m so happy that you could join us today for this episode.