Accepting and adapting to change is a function of growth and development, which is a critical factor in the complex and fast-growing pursuit of personalized medicine.
As a clinical pharmacologist, Robert L. Barkin, MBA, PharmD, FCP, OFRSM, has been involved in pain management for decades. Barkin is currently a professor in the Departments of Anesthesiology, Pharmacology and Family Medicine at Rush Medical College, Rush University in Chicago. At 82, he has concluded there are three important areas of personalized medicine: patient-specific, patient-focused, and patient-centered care.
“We live in a world of generic drugs but no generic patients,” said Barkin. “Each patient has unique needs that must addressed in that personalized care.”
Learning about the patient in a continuum of care requires communication.
“The specialization within anesthesiology provides the patient an enormous benefit, a sense of security and satisfaction knowing their life is preserved while in surgery, which increases the patient’s confidence and, ultimately, the patient-specific outcome.”
Jelena Janjic, PhD, an Associate Professor at Duquesne University in Pittsburgh, who specializes in the development of nanotechnology-based therapeutic interventions for chronic pain, knows about pain as a researcher and a patient.
As the founder and co-director of the Duquesne University’s Chronic Pain Research Consortium (CRPC), established in 2011, Janjic began looking for pain researchers when her own personal pain heightened in 2010.
For Janjic’s pain experiences, however, there was not one plan that was personalized enough to adjust to the changes that ensued.
“My pain was personal, but the pills were not what I consider to be personalized medicine,” Janjic said. “The totality of the patient must be addressed, not just the procedure. Those who live with pain experience pain differently. As the patient changes over time, so does the pain.”
By 2021, Janjic and her research partners – James Pollock, CRPC, Duquesne University; Andrew Shepherd, MD Anderson Cancer Center; and Vijaya Kumar Gorantla, MD, Wake Forest Institute for Regenerative Medicine – published a book on the topic, which is discussed in a TEDxCMU talk (asamonitor.pub/3UNYOk0).
“We studied the biological differences and known immunological differences in preclinical research models in both males and females, which was very rewarding,” said Janjic, who applied advanced technology to create the first inflammatory pain nanomedicine that directly targets the pain source.
Rebalancing care and communications
Personalized medicine is also knowing when to rebalance the patient’s treatment based on the changes in pain level as well as the changes within the patient.
“Immune-nervous system interactions are one of the reasons why we experience pain differently as individuals,” said Janjic.
Knowing there is a strong inflammatory component in pain, Janjic said the current research design of nanotechnology can be adapted anywhere there is inflammation.
“One area is regenerative medicine,” she said. “Although the treatment is designed for initial injuries and acute pain, we hope to promote a rebalancing of the nervous and immune system interaction.”
Adapting the communication style in the physician-patient relationship also requires a fine balance, notably the full disclosure of health history, said Barkin, who acknowledged that some subjects of discussion are challenging, such as the disclosure of drug or alcohol dependence.
Clinicians, he said, must be taught how to ask those questions. This requires listening to the patient versus hearing them and quantifying the “yes” and the “no” relative to specific questions.
Spending time with the patient to build the relationship sets the stage for more personal questions, said Barkin. He noted that even if the clinician is in a hurry, the patient likely is not.
Pain is a sign something is wrong, while chronic pain is a disease itself, said Janjic.
“A patient experiences chronic pain because the acute pain has not been addressed,” she said. “To manage pain in personalized medicine, we know there are variables around pain and the patient. In anesthesia, patients experience variable responses.”
Janjic indicated that various pain levels depend on how each individual heals and that pain management should also be a healing management.
“Bringing the immune and nervous systems into balance so we won’t need pain medication ultimately supports the healing process,” she said.
According to Barkin, the healing process is multifactorial. “The healing process has different ratings and amplitudes based upon the end point,” he said. “Regardless, the patient needs to be assured that we process that together.”
Honoring the patient’s pain experiences is important. Janjic and Barkin both agree: all pain must be honored. One can possess many degrees, but if you are unable to effectively communicate and observe nonverbal communication directly with the patient, the therapeutic outcome is less likely to be positive.
“The specialization within anesthesiology provides the patient an enormous benefit, a sense of security and satisfaction knowing their life is preserved while in surgery, which increases the patient’s confidence and, ultimately, the patient-specific outcome,” said Barkin.
Perception in the periphery
Using nanotechnology, Janjic targets the immune system, from injury to infection, at the intersection of the nervous system to study how immune cells respond to treatment and interact with the nervous system, and how the immune system responds to injury or infection that primes the nervous system.
“A peripheral injury can trigger neuroinflammation,” she said. “While more research is needed to understand the interaction, it’s about balance and intercepting at the cellular level.”
We need to look at the route of delivery and the context of pain as a biological problem, not just a nervous system problem, said Janjic.
“In the peripheral nervous system, it’s critical not to study pain in isolation, but consider the individual differences such as gender, age, and ethnicity,” she concluded.