Dr. Staats: Well, it wasn’t really part of the master plan, I went to Hopkins because of their great critical care pro-gram and sort of found pain management along the way. At that time, pain management was just forming and I thought, ‘There are really some cool opportunities here!’ I had great mentors like Dr. Mark Rogers who was chairman of the anesthesia department and Dr. Srinivasa Raja, a world-renowned physician researcher, among so many along the way that got me interested in the field.
Dr. Gudin: Peter, you’re known for your expertise in treating all kinds of chronic pain. I’ve seen you talk about intrathecal drug delivery systems, spinal cord stimulators, and more recently, peripheral nerve stimulation. Give our readers some insights as to how pain care has changed over the past 20 years.
Dr. Staats: I really do think the field has changed dramatically. When I entered pain medicine in the early 1990s, pain physicians were simply expected to go fill a prescription written by the surgeon for injections, such as three epidural steroid injections. But a few people were really trying to make pain management a career of science, like Dr. Raja, who made a science out of understanding RSD or what we later termed chronic regional pain syndrome (CRPS). He was instrumental in transforming our field from just being a service to its own discipline, really understanding a diagnosis, and developing treatment algorithms.
Over time, pain physicians became real experts in the diagnosis and management of complex pain problems. We figured out their unique pathophysiology and came up with rational therapeutic algorithms on how to treat them. We have developed a field of advanced minimally invasive surgical skills. We’re providing all kinds of site-specific treatments to try to solve chronic pain problems. In addition, our success has been based on two things: establishing an accurate diagnosis and incorporating evidence-based medicine into all of our algorithms.
Dr. Gudin: I’m thrilled to hear you talk about that. I always tell my fellows and new associates that it’s really about getting back to basics. We’ve become in the pain world, almost like mini neurologists who are trying to nail down a diagnosis to help us formulate a treatment plan. And I find that some of the students these days are lacking. They can’t wait to get out and do those epidurals and radiofrequencies. But how do you think we’re going to get the next generation of doctors to focus back on the patient? Could we become again a patient-
Dr. Staats: Such a great comment, Jeff. I think that the key thing for residents and fellows to know is that each and every time you have a patient in front of you, you should give them 110% of your attention. Establish a diagnosis as best you can and come up with the most rational therapeutic algorithm.
But you need to think very carefully about this and provide the most patient-centric care. What is best for the insurer, what is reimbursed, or best for society, should not be a primary concern.
When I was chairman at Hopkins, I used to tell my fellows on the first day and the last day of their training: ‘Do the right thing and the money will follow.’ You’ll make a fine living if you try to take good care of patients. Don’t provide care in order to make money. You may not be as rich as some other people, but you’re going to have a long, fruitful, and gratifying career if you do the right thing.
Dr. Gudin: I love that philosophy. Those of us that really care for patients know it’s hard to do that hand-holding, have that interaction, but it goes miles and miles toward patient benefit.
Dr. Fudin: This conversation gets me thinking back to the 1990s when pain centers were using intravenous and continuous subcutaneous buprenorphine – things have changed so much – look at what buprenorphine does now, for example. But let’s also take a step forward… Dr. Staats, are there any technologies or approaches that you’re particularly excited about?
Dr. Staats: My career has been mostly in neuromodulation, but my interest has been in the magic of electricity and how it modifies pain signals. More recently I have been interested broadly in how neuromodulation affects disease. I co-founded a company back in 2005 based on neuromodulation of the vagus nerve. We initially were trying to solve anaphylaxis because my son had peanut allergies. We made great strides with this and we showed that we could block airway reactivity. We uncovered that headaches were going away. The focus of the company changed and this is now a commercial product for cluster and migraine headaches. Over time, however, we learned about the incredible power of the vagus nerve and how this may be an explanation of both alternative medicine and the concept of mind over matter. Today people are doing research on everything from post-traumatic stress disorder and traumatic brain injury, to rheumatoid arthritis and gastrointestinal disease… I’m fascinated by that.
Dr. Fudin: The vagus nerve innervates so many different organ systems and has parasympathetic activity and, of course, drugs affect that nerve. Could you explain how you stimulate specific parts of the vagus nerve because it would be, in my mind, very comprehensive if you stimulate it as a whole.
Dr. Staats: You’re absolutely right. We do stimulate all of the fibers when we’re capturing vagus nerve stimulation non-invasively in the neck; the good news is that the device has been developed to avoid stimulating C fibers, which may cause bronchoconstriction.
But as you point out, vagus nerve stimulation affects both afferent and efferent fibers. There are innervations in the spleen, that go to the brain, and to the gastrointestinal tract, as well as the pulmonary tree, but most of the effects of vagus nerve stimulation are positive. So broadly speaking, having specificity is not necessary. For example, it is not bad if we get a side effect of improving anxiety while treating a headache. The truth is, we are not selective at this point and there is a tremendous amount we’re still figuring out.
Editor’s Note: In July 2020, FDA authorized the emergency use of vagus nerve stimulation for the treatment of COVID respiratory related illness.
Dr. Gudin: I want to get back to the younger residents and fellows who are considering pain management as a career. You’ve already given us some insight into how the patient has to be the center of your attention. Is there any other advice you can give those pursuing a career in pain management in terms of preparing themselves?
Dr. Staats: First, this is going to be an exciting ride. The field is expanding. Our understanding of neuromodulation is exploding. Our use of ultrasound to identify targets has made our therapeutic options much more readily available. We’ve developed new techniques that just were not around when I started. Everything from basivertebral nerve ablation for degenerative changes in the spine to having a spinal cord stimulator that interacts with the spinal cord, and actually measuring feedback with a control loop is now possible. Residents can develop their own areas of expertise as they advance. I would suggest to all young doctors, to invest in yourself and really become an expert in what you are interested in – don’t just listen to what the professors before you have told you. This is going to be lifelong learning and you need to continue to be part of the development of our field.
Dr. Fudin: I agree completely. Clinical pharmacy is also becoming a more popular field with more pharmacists going into pain management. I started a residency program six years ago and at the time there were 11 pain residencies in the country, and now I think there are close to 30. Part of that has to do with clinicians like you who worked together with PharmDs so we can concentrate more on the pharmacology of therapeutics while you concentrate on the procedures. The potential for collaboration is really incredible and moving fast.
Dr. Staats: Indeed… I was just reflecting on the early days of calcium channel blocker infusion into the spinal cord. What is emblematic of our collaboration is how we were infusing a snail venom from the Philippines via an implantable pump, which had to be done by an interventionalist into the spinal cord to modulate pain. And that drug later became Prialt. This is a great example of how our partnerships can advance the field.