Listen to Prof. Hegarty chatting with Gareth O'Callaghan on Cork's 96FM Opinion Line where he discusses treatment options for those with chronic pain and some management options to help control the situation.
Gareth O'Callaghan who recently suffered a road traffic accident and ended up with prolong treatment, discussed the impact on his life over the last number of months.
Professor Hegarty, explained the long term impact required to help individuals with chronic pain and why we need to draw awareness to the options.
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GOC: Dr Dominic Hegarty runs Pain Relief Ireland. He's on the line with me now. Good morning to you, Dominic.
DH: Good morning. Good morning.
GOC: You by the way, I have to recommend your website. It's an excellent website I have to say and very insightful, particularly from the point of view of pain and medication and obviously medication is probably the one stop shop for many people because I think people tend to say I don't really have the time to carry out the physical exercises, the Pilates, the, you know, the physio that's required to actually alleviate this pain.
It's much easier just to get a prescription from a doctor and go to the pharmacy isn’t that the case?
DH: So thank you very much for bringing this kind of topic to the airwaves.
It's very important that people realize that there are pros and cons to medication and I suppose just as a caveat, people who are on these products, I wouldn't suddenly suggest they stopped them because stopping them in a hurry can equally cause problems.
So if people are having difficulties they need to manage as well. So yes, just as a caveat for people who were on these products, because as you said there's a lot of people on them.
“from a pain consultants perspective, and what my target is, is to try and eliminate and at least minimize these levels of products for people - to give them back the quality of life without depending on pharmacology.”
But I suppose from a pain consultants perspective, and what my target is, is to try and eliminate and at least minimize these levels of products for people to give them back the quality of life without depending on pharmacology. It must be said there are great tools there is a there is a role for them. But the role has to be modulated has to be looked after it has to be taken care of. And that's a small square.
The whole crux of the question is, where do we draw the line? and when do interventions such as pain procedures, perhaps pilates, more advanced techniques, whether they fit into others? There's a huge role for this and very often that's lack of knowledge, Gareth, from people that just don't know there is another option.
They believe that popping the pills every morning and every night is the only solution to the problem. And the reverse that happens people get enough of it and they just say they give up on the tablets. And of course they're still left with the pain. So there's a no win situation for these individuals.
But I would be in the general of physicians Pain Physicians, we will be offering things like interventions, injections, localised target injections to these areas. And this area has developed phenomenally over the last number of years, the last decade or so.
And with greater insights with a greater understanding the quality or we can provide from interventions are outstanding. And so we like to think there's a great option here for people.
GOC: When you will, a lot of experience and over a long, long number of years in this whole area. And it's invaluable experience because unfortunately there are not many people with the insight that you have as a result of your experience. When someone comes to you and says the pain medication is having no effect whatsoever but I can't give it up because I'm addicted to it. And I'm terrified. I tried to give it up but the withdrawal symptoms are horrific. What approach do you take there?
“…that’s where I would focus on…targeting that source of pain, try and minimize that. …we reduce those medications by 30%/50% and then get them back into activity.”
DH: And that's a very standard way people would come and present to us.
So let's just take the area of back pain, back pain has been a theme I suppose.
So we'd be looking for why, why is the pain being generated? What is, What are the causes for it? Is it a mechanical element? So people in fact may have a facet joint, they may have a lumbar disc that's actually irritated that's inflamed. And then it's constantly driving the pain pattern on a day to day basis. So they might start well in the morning. And as the day goes on, they get stiffer, begin to get soreness. They end up with radiating pain across the front of their hips down their legs. So that actually is the driver. So that's where I would focus on then, is targeting that source of pain. try and minimize that. And then as part of that then one of the outcomes would be can we reduce those, those medications by 30% 50% and then get them back into activity. And it is very feasible to do that because obviously people have to buy in, they come with the good intentions to help themselves. That's who you need to work with.
But that is all very wasteful because you're actually beginning to get on top of the week source of the problem. You're not covering the problem over but just taking a tablet to make you feel better get you over an acute flare up.
But when it's been really driven by something a lot more, a lot more significant and we may investigate, we do MRI scanning for example. And various X rays to try and organize it. And then you find people fit into certain pathways. So there's like a pyramidal effect of where you start. You might step forward to the next procedure from there, and that helps people a lot.
“If I start this set of injections, I'm going to be stuck with injections?
Actually, the answer is no. You tend to get much better and people tend to progress quicker.”
Now, the first thing people always ask me then is well am I on a similar slippery slope. If I start this set of injections, I'm going to be stuck with injections.
Actually, the answer is no. You tend to get much better and people tend to progress quicker. It allows them to get back into pilates, maybe even something as simple as walking down to the shop and walking the dog, which is a huge problem for the moment that rebuilds up the muscle structure.
“…this just erodes their confidence they're not able to go to work and not able to get out and do social things. And they… become so isolated …life doesn't really be any more fun.”
So they're really beginning to work with them with their own issues and we build within that framework to get it right. So there are, there is another complete scope outside it and probably people who come to my clinic, we would look at 70% or 80% of them requiring some form of procedure because they need it because there is another option in generally speaking, it's not drugs, not drug related. It's not an opioid and so be it. Well it does make a big difference for these people to get a bit of confidence in it. Because I'm sure the other thing that's been across your program is the way people feel that this just erodes their confidence they're not able to go to work and not able to get out and do social things. And it just wants to kind of become so isolated. That life doesn't really be any more fun. You know?
GOC: The way you put it, it makes perfect sense. One thing I've done over the last few months I've kind of I took a crash course and educated myself in my spine. And this is something I was never aware of before that. When I knew that the spine literally controls the entire body but I wasn't aware that there are four different areas to the spine and each area has a responsibility for different parts of you. Like when you think of the unit the cervical the thorax, the lumbar the sacral they are like different continents and they they're drawn together connected but they're like different continents.
DH: completely you couldn’t say it nicer to describe it that way. I think that's exactly it. And that's part of the challenge. For example when, when I would examine someone's sick which of those portions are the key player which is the one that's driving this, because essentially, you probably know yourself. It feels like your whole back is is really really in trouble. It's all over the place. It's just don’t know where it's coming from - is it my shoulders? is it my lower back? but by focusing on a primary area I will work on that aspect to it so and then from there, the other areas become much more manageable.
“sometimes you actually find that that shoulder pain you thought was a problem actually can be resolved by dealing with the lower back”
And sometimes you actually find that that shoulder pain you thought was a problem actually can be resolved by dealing with the lower back end aspect to it itself. And so it's a really controlled really clinically driven evidence based for this aspect to it.
And thankfully, you know, pain medicine, although people don't talk about it, it's been around for an awful long time. I mean, the last 10/20 years of just what we can do, interventionally, imagery, has brought in massively forward and there’s people now who we really would push the interventional aspect from patients perspective because they can see the benefit and it ranges right across interventions, as I said injections, right up to technology, we have really advanced technology that can deal with all these aspects and, and help people move forward with their lives again. So yes, the key is you've got to try to localize where the driving source is. Start with that and move on from there.
GOC: Were you surprised at the statistics I read out yesterday, Dominic?
In relation to the number of Irish people who have got back pain issues.
86% of Irish people at some point in their lives, will experience bad to severe back pain issues. Were you surprised by that?
“it's a very, it's a big, big issue, because you must think about it about 60% of admissions, or at least discussions with GP, revolve around pain.”
DH: No, that's that will be the norm expectation, the evidence the literature has been stating that for an awful long time. There was a study going back almost to 2010 and maybe 2000 before that from Europe. So in Ireland as part of that when we're a big player in it. And it's a very, it's a big, big issue, because you must think about it, about 60% of admissions, or at least discussions with GP, revolve around pain. And back is one of the key aspects when it comes to that. When I see people in my clinic and we do our work, because I’m based in the Mater Private, so we see a lot of people coming through the services here.
It's low back pain is 60/70% of the time, and it's really problematic and we're always trying to get the right mix for people right. So no doesn't surprise me at all and other areas, get forgotten about – the sinus area, headaches for example, chronic pelvic pain, Coccygodynia – which is tail end pain because someone has slipped on the ice or fallen off the chair at home?
These things just add up so quickly Gareth it's it's, it's amazing. And you know, one in five people suffering globally/in Europe with chronic pain mixes the massive disease it makes it a huge issue way beyond diabetes, beyond every kind of cardiology level of stuff, but unfortunately, it doesn't just have that kind of glamour that doesn't have that kind of a sexy appeal for people to push it on to meet the needs that are needed globally at this stage.
And Ireland is no different than the UK and in Europe. And perhaps in Europe, they take the ratio a bit better - more physicians or consultants involvement, so we're always trying to bring the profile up.
“it’s a spectrum disease and it needs multi management - it needs a spectrum of management and there are thankfully a range of options but, unfortunately, people are just not aware of what they are”
You need the people who are skilled to do clinical and healthcare work. And we also rely on physiotherapist. We often rely on other areas to try and help people out an awful lot as well. So it's not just you know, paying consultants driving this it's a whole the whole family if you like it's a multi team approach because it's this is the disease of pain, it’s a spectrum disease and it needs multi management. It needs a spectrum of management and there are thankfully our range of options but unfortunately, people are just not aware of what they are and as you started this conversation is, is it a prescription that's fine because it can be done there and then in a GPs office or wherever it gets the ball rolling, but, you know, three months down the road you are defined as having chronic pain. It's only three months 12 weeks, so if someone came in today with pain by The Jazz Weekend and they could technically be a chronic pain patient it comes on that quickly.
So people do need to pay attention to try and react with reasonably quickly and act on it. You know, it's important that they discuss these with, with people who know what they're what are driving them to the right level of GPs.
Now we're more alert than ever, thankfully, of the dangers with these products and optiods are not on their own, there are other problems with other agents as well and we have to be alert to that.
But the idea here really is to get the multimodal balanced approach the item that works for an individual because that one size fits all model really doesn't exist.
And you pick up on the bits that people get the benefit from so for you it could be a number of facet injection, on another individual it might be something as advanced as neuromodulation spinal cord stimulation, and the spectrum is there.
So that's, that's what we're trying to do. But awareness is the key element.
So to complement you and the team there in 96fm to put this kind of conversation out there for people, because people just don't probably realize that they can do an awful lot by helping themselves and get knowledgeable about the area and perhaps more people should study their spine like you did Gareth!
GOC: …this I suppose as a result of that car crash that I was in almost four months ago.
DH: And I compliment you, sorry. Not that many… people struggle to get back to work so quickly after such a level of accident, you know, and that's, that's, that's a huge achievement and it just so fair play to you and but for there's so many people who do their very best with this and who deal with the pain on a day to day.
It's amazing, really, and I compliment everyone, they're just doing their best to do it. So we have to give credit to these people as well.
GOC: When absolutely and as you know, as you said it's a multi team approach. And I think as you know from the staff where you are there in the Mater Private and where I was in CUH Infirmary Doctor Declan Reedy, that spine surgeon and that - extraordinary people with an amazing insight but I think it's only when you see the insight and the experience that they have Dominic that you say to yourself, I really need to learn more about my body.
And that was where I discovered the whole issue of what was causing the shocking nerve pains down my left leg into my foot.
And it's interesting because Barry a listener says if you could just ask Dominic –
I had a bad car accident two years ago, but I'm now left with burning sensations in my feet and in my ankles and I was diagnosed recently with peripheral neuropathy. Can you ask him? Can I expect to have this for the rest of my life or will it pass?
DH: The true answer is, at about two years out, that’s probably very well established in the neural fibers at this stage. So it's likely it will stay put. Of course, we know historically, many years before either of us were around, pain does settle down over time, whether it's the peripheral aspect of its central zone or whether it's the central bit, the actual bit in the brain, the Pain Centre begins to accept that as norm and says this is my normal and I accept that. So that's probably what will happen in some respects. But at that stage. Oh, you know, neuropathies I will be inquiring what has been done. Is there some options to do that and to manage that locally? Is there some aspects that can be treated? So it's not something you'd say, oh, that's the end of the call. We do have options or it's topical agents for example, to deal with peripheral neuropathy. We for example, would have methods of assessing that neuropathy. See how far those fibers are in the mainstream of whether they're outside a certain parameter and how well they could or might respond to the Receptus. The is a technique called, quantitative sensory testing, which really just sees how well those nerves would function in an office setting. What would happen how does it respond to hot and cold and then comparing that to a database that I have from the German model and it's globally there. We can see when an individual sets and immediately that's hugely informative to a person because you do not say, Well, I'm sticking my finger in the sky here and I think the wind is blowing left or right. And you can say no, I can see that 50% of your fibers are miss-functioning, but that means just 50% of them doing okay, maybe we can work on retaining those and possibly making the other group a little bit better.
So that's the kind of way you know, we should be thinking of this type of disease is looking for the solutions by going forward. So I know that kind of is slightly off the question just demonstrates, it demonstrates how a conversation would go in my, in my clinic when a person comes in. That's exactly what I want to tease out. Where are we? And then we can work out where the endpoint can be from there and work out. In an individual what works for them.
So then what's the best option? etc. So these kind of different things need to be discussed.
GOC: I've got one final question because I know you're up to your eyes there in the clinic.
In relation to over the counter pain medication and I suppose our over reliance on it because it's just so generally easy to go in and pay for and pick up and take.
Are we still in that corner of the ring? Is that the first option? Or are we becoming more aware of the importance to look into the options that you've been talking about?
DH: That’s a very hard one to answer straight off Gareth. Because of, because of the ease of walking in and getting something and it's a quick fix, and you get sorted, you know, I can understand why you do that. I understand why that happens. I think what I will be saying to people, if that becomes the norm and that's your accepted, then they do need to look beyond it.
“if it becomes the norm and that's part of your day to day routine having to take tablets? I think they then do need to look at what's going on.”
Its grand if it's dealing with the issue and it's dealing with the pain and there’s a spectrum of pain disease. So if that was managing it for people, that's fine. What if it becomes the norm and that's part of your day to day routine having to take tablets? I think they then do need to look at what's going on.
Have a discussion with someone GP wise for example, might be a very good starting point. And just see is there are other ways of dealing with it. And you know, even if you look at the dosages of some of these products that are available over the counter, and you highlighted this at the start, they’re sometimes in excess, because obviously the pharma business, they want it to be effective. They want their client who buys our product. They think it's wonderful. It's a great job. So they're tending to err on the side of we give plenty, whereas an individual might need that much they might need only half of it. So that's the kind of manipulation that you need to look at, see what the numbers are going out.
So it is easy to get to it - thankfully the pharmacists have been very helpful in helping control this. And anyone who's gone looking for these products nearly has to fill out the whole form now to get it and that's the right thing to do. Because it's not been it's not trying to be negative towards people. They're actually trying to help you. And if you have to go through that each time and it's once a week or once a month you're doing it you know you probably do need to be speaking to someone and try and find a better solution. Because long term as that documentary and many other ones who've gone on over the years, it's not really the long term solution just pouring stuff into your body, as the body is clever. It does realize if I'm getting something I like it will look for more - it will crave for it. And that's what you have to be observant of, and provide other ways of dealing with pain.
“thankfully, we understand pain medicine and pain pathways far better now than we ever did. And I [am] very confident that we can help a lot of people and …make such a different difference in a person's quality of life.”
And as I said, thankfully, we understand pain medicine and pain pathways far better now than we ever did. And I very confident that we can help a lot of people and maybe not 100% would have been there 50 60% improvement for individuals that can make such a different difference on a person's quality of life. And that's what it comes down to pain as a part of the picture, quality of life, sleeping quality ability to go to the wedding, the party with the friends and at least socialize and be around people who they take care of and your family because that's the other side that fall out from this and I'm sure you might have even seen this yourself Gareth, so many people fall under stress once the individual in their life is in pain. Everybody else is also struggling.
The knock on effect of chronic pain is just right across for community.
GOC: That is so true. It just changes the whole dynamic of the family. It certainly does.
Dominic, thank you so much for talking to us this morning. Thanks for taking the time out of your busy day. And we'll chat to you again soon.
DH: Thank you very much. Have a great day.
You too and thank you. Thank you.
That's Dr. Dominic Hegarty. Check out his website by the way. It's a very enlightening, very insightful website. There's huge amounts of information on what we've just been talking about. That's www.painreliefireland.ie