Pain management’s painfully fine line [PODCAST]

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“I find that managing chronic pain can be a bit of a dance between myself and the patient. Sometimes a little bit of a compromise. I always tell my patients that pain is subjective but many things can contribute to pain — certainly stress, lack of sleep, any emotional issues can make pain worse. Your pain is different than my pain. I don’t like to use the word “tolerance” when it comes to opioids, but certainly, some people are able to tolerate pain more than others. But it does go back to the emotional component related to pain. One of my attendings in fellowship — known to be a bit of a hard ass — used to tell our patients, you can’t die from pain. Your blood pressure that’s 210/110? That can kill you. The 100 percent blockage of your artery in your heart? That can most certainly kill you. Your smoking four packs a day? That may kill you. Your pain is a by-product of your experience. Snowing yourself with opioids only tricks your body into believing there’s nothing more serious going on. And it’s a temporary solution for a more permanent problem.”

Michelle Dang is an anesthesiologist and hosts the podcast, WISH Well.

She shares her story and discusses her KevinMD article, “The painfully fine line of pain management.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Michelle Dang. She’s an integrative pain management physician, and she’s a podcaster at the Wish Well Podcast. She wrote the KevinMD article a few years ago, “The painfully fine line of pain management.” Michelle, welcome to the show.

Michelle Dang: Thank you so much for having me, Kevin. How are you?

Kevin Pho: I’m doing well, thank you. We’ll get into the article in a bit, but first off, tell me your story and your journey to where you are today.

Michelle Dang: Awesome. So, Kevin, as you mentioned, I am an integrative pain management physician. I kind of developed that term, integrative pain management, myself, actually. My background is I am an anesthesiologist and pain management physician. I did my fellowship training in Texas. I was born and raised in Texas, and after I was in practice for a couple of years, I struggled with trying to find other ways to help my patients. And so from there, I discovered the field of integrative medicine. I did complete a two-year fellowship with Dr. Andrew Weil out of the University of Arizona, so that was an integrative medicine fellowship.

So I combined integrative medicine alongside my interventional pain management training, and I started, maybe a few years ago, talking more about integrative medicine and how we can incorporate it into interventional pain management. And so I started my personal website, and for me, I do a lot of just speaking about it. I post about it. I write about it. So I’m hoping to do a little bit more in the field of integrative pain management.

Kevin Pho: So how exactly does integrative pain management differ from, say, standard pain management?

Michelle Dang: So integrative medicine in general is a combination of traditional as well as alternative techniques to help manage overall well-being. So it could be things like nutrition changes, nutrition and diet changes, as well as movement therapy, which is sort of why I fell in love with the field of integrative medicine, because I’m a big believer in movement therapy. I am a yoga instructor and a Lagree fitness instructor, so I know that’s helped me personally with chronic pain, or dealing with chronic pain or pain issues that come up. And so that’s how integrative medicine can be utilized in daily life and to make lifestyle changes.

Kevin Pho: And how has the pandemic affected you and your practice over the last few months?

Michelle Dang: Oh, gosh, thank you for asking. I live in Houston, so right now things are a little bit crazy. I had to shift my practice, the first two months when the pandemic started, to telemedicine. I stopped all of my elective procedures. With pain management, I do a lot of injections, and those are all considered elective, so we stopped that for the first two months. As restrictions eased up, I started back seeing patients again and starting procedures again, but now, with the second surge that’s happening, we’re starting to slow down a little bit. So it’s been pretty stressful.

And personally, it has been really difficult for me just to maintain my personal health and wellness and fitness. Since I’m pretty active, I go to a lot of studios to work out, so I’ve stopped doing that the last couple of months, and that’s been really challenging for me.

Kevin Pho: Sure. So let’s move on to your KevinMD article. You wrote that a few years ago, but I still think a lot of the things that you wrote about are still relevant today. So can you summarize this article and why you decided to write it?

Michelle Dang: So I wrote that probably about four years ago, and I was in a private practice at that time. It was a solo practice. I wrote the article about two different patients I had seen. One was a patient with cancer who ended up passing away, and she did not want any pain medications at all. In fact, her daughter and I had to convince her to take pain medications to help with her pain. And then the dichotomy of that was, I saw another patient who had knee pain, and I talked to her about integrative medicine techniques to help with it, and all that she wanted at that time was pain medication.

During that time, I was pretty burnt out, I think, in the field of chronic pain management. Although I had already completed my integrative medicine fellowship, I still struggled with incorporating that into my practice. My goal in writing that article was just to bring to the audience an awareness of the challenges that we face, not only me as a specialist in pain management, but general practitioners also deal with patients with chronic pain, and it can be very challenging.

I know that, with that particular article, it was hard for me reading all the comments, because some of the comments I did take a little bit personally. I feel like I’m a very compassionate and empathetic physician, and sometimes I forget that that is who I am. When you have patients who are frustrated with dealing with chronic pain, and they don’t know how to deal with it, and they may on some level project to you as a physician, it’s hard for me to remember that. And so my goal is just to let people be aware that this is a challenge. The opioid epidemic is continuing to be a challenge, and there are other ways to manage it. And it doesn’t make me a bad physician, or other people bad physicians, if they’re not able to really help that particular patient who may be really wanting one specific thing for their pain.

Kevin Pho: I think you summarized that nicely. I’m an internal medicine primary care doctor, and chronic pain is one of the most difficult issues that we face, almost on a daily basis. Now, if you’re thinking about opioids for chronic pain, what are some of the factors that go into your decision-making process?

Michelle Dang: For me personally, I honestly don’t prescribe opioids that much. I usually will tell them that there is a place for it. Typically, I will be all for prescribing opioids if a patient has cancer pain. I mean, that is one of the conditions in which I really don’t have a problem with prescribing narcotics. However, if they are dealing with a specific condition and they would like narcotics, I tell them, “Why don’t we try other things? And if you need medications for breakthrough pain, then by all means, we can talk about that.”

But until I know that they’re putting in some effort. And that’s kind of the thing that I talk to all my patients about when it comes to chronic pain: “For you to get better, you’re going to have to put in some effort, whether it is to do some physical therapy or chiropractic care or walking.” I mean, you just have to show me, because it kind of goes both ways. Medications are not the end-all be-all, and I think that’s something that requires a lot of educating for the patient.

Kevin Pho: And when you talk to patients about that in general, what has the reaction been?

Michelle Dang: So it really depends on the person, right? I mean, it depends on how much they’re willing to accept the part that they play in whatever condition it is. And so if they’re morbidly obese, if they have a BMI of 45, obviously there’s a lot that goes into that, and pain is one part of it. And so it just depends on where they are mentally. Some patients are willing to make that next step, and some patients are not.

And it’s something that I’ve learned. I’ve been in practice for eight, nine years, and I can’t help them all. And so if they’re willing to meet me somewhere halfway, then we can have that conversation. And it’s not to say that I’m not against prescribing opioids at all. I’m willing to. I want them to be willing to have that discussion with me on how we can help them.

Kevin Pho: Now, you wrote your KevinMD article three to four years ago. Has anything changed in those intervening years?

Michelle Dang: Yes. I was in a solo practice at that time. I left that practice a couple of years ago, so now I’m in an orthopedic practice. So it’s a very different practice. I’ve been in pretty much all the practice models there can be. My current practice is an orthopedic practice, and so I get a lot of referrals specifically for injections, so interventions. And so from that standpoint, it has helped just my overall mental well-being, in the sense that patients come to me for specific issues, for specific interventions, and I’m able to talk to them more about integrative medicine techniques that they can utilize. And so I have maybe 5 percent of my patients on medications. The rest just get the injections, and then they either get better or they don’t, and they have surgery, and they have physical therapy. So it’s a different model. So I think, overall, I’m in a better place.

Kevin Pho: Sure. And one of the things that we face in primary care is really a lack of pain management specialists, and that’s especially true in my area. So what kind of tips can you share with your primary care colleagues when it comes to managing chronic pain?

Michelle Dang: Great question, and that’s something that I still struggle with. I’m trying to talk to more primary care physicians out there, because what I find is, and I’m just generalizing, many primary care physicians will refer to neurosurgery or orthopedic spine, and I don’t know if they forget that we’re available and we’re not just about medications. What I find is, many times I’ll get referrals from general practitioners for medication management, and then the same patient would be referred to my spine surgeon partner for back pain, when they could just send them to me. So I feel, overall, that we are a little bit underutilized in the appropriate way.

So I think if a patient has back pain, the first thing that many, many general practitioners can ask is, “Are you interested in surgery?” Because if you’re not, then you can see an interventional pain specialist, and they can work you up and get imaging and physical therapy, and there’s a lot that we can do outside of just medications, and outside of even just injections. But what I find is, a lot of times, patients get referred to a spine surgeon, and that patient comes to me after already having to wait months to see my spine surgeon partner. And then, at the end of the day, the patient doesn’t want surgery and then has to wait to see me. And so then that’s months down the road before the patient can get any type of interventions or any type of therapy.

And so it’s a frustrating system, I think, for some of my patients as well, because I feel like they’ve gone to literally every single specialist, and sometimes have even been sent to rheumatology before they even get sent to a pain specialist. So I think if a patient does have some issues with some type of pain, we are well equipped as pain specialists to work the patients up. And if the patient needs surgery, we’ll know what to look for, and we will send the patients to the appropriate specialist at that point.

Kevin Pho: OK, thank you so much for sharing that. I’m always looking for tips when it comes to managing chronic pain, because it is such a challenging issue. Now, can you share something that you know now that you wish you knew five to six years ago?

Michelle Dang: I think right now there are so many specialties out there that were not really readily available, or people didn’t really know about them before. With integrative medicine, I basically had to do a search to find the fellowship. There’s functional medicine, and there’s lifestyle medicine, there’s culinary medicine, and there are all these different types of specialties that I personally was not aware of even five or six years ago, and the only way I really found out about them was googling. So I think nowadays there really is a shift. People do want to get better without having to be on 10 different medications.

I mean, my dad has a lot of medical problems. He’s on probably 30 different medications, and I think, 20 years ago, all he really had to do at that time was really make significant lifestyle and diet changes. And so I think that is something that I’m constantly learning about now: all the things that you can do, more in a preventive way, to help people overall with their health and wellness and well-being.

Kevin Pho: We’re talking to Michelle Dang. She’s an anesthesiologist and an integrative pain management specialist. She’s also a podcaster at the Wish Well Podcast. Can you tell my audience a little bit about your podcast?

Michelle Dang: Sure. So this is something a little bit outside of just my interventional pain management background. With my background in integrative medicine, I started this Wish Well Podcast, which is the Women’s Integrative Summit on Health and Wellness. Initially, it was started to bring to the audience different speakers related to women’s health and wellness, and the whole idea was we were putting together a conference. It was supposed to be our inaugural conference in Houston, Texas, in May, and of course, the pandemic happened, and so that had to be postponed, and we have no idea at this time when we’ll feel comfortable with putting it on.

So in the meantime, I started this podcast just to feature women and their health and wellness journeys. I called it the Wish Well just because it was cute, and the whole idea was to wish women health and wellness. And so I started featuring women who come on sharing their personal health and wellness journeys. A lot of the women who come on are physicians, but I do have people in my circle who are yoga instructors and who are in the fitness community, and so I just feature their stories. I started doing that right before the pandemic, probably a few weeks before this all started, so it was in March, and I really enjoyed it.

And Kevin, you and I talked about the joy of putting together a podcast. It’s a steep learning curve. It’s been a lot of fun. I put on weekly episodes, but I’ve also started recording segments where I discuss a little bit about little stories, my personal stories. I think in one podcast episode, I recorded a solo episode on different cooking gadgets that I love to use. I love cooking, and so it all kind of is related to integrative medicine. And so, yeah, it’s the Wish Well Podcast, and my Instagram page is wishwell.health, and it is available on all the platforms.

Kevin Pho: And my final question: What’s your take-home message for the KevinMD audience?

Michelle Dang: Yeah, so I thought about this, and my take-home message is actually to get moving. I like that phrase, because moving is more than just a physical type of thing. It also is a mental thing, too. Looking back on the article that I wrote for you for the KevinMD blog, I was feeling a little bit stuck and a little burnt out, and I wasn’t able to move beyond that at that point. And so I think changing my mindset helped me to get moving out of that stuck and burnt-out feeling.

And also, get moving means physically moving, too, and I think it’s important during this pandemic. My husband and I actually just talked about this earlier, how much stress we feel just not being able to move in the way that we’re used to moving, like going running when it’s like 100 degrees in Houston. He’s used to going to the gym, and I’m used to going to work out at the studio. So just finding alternatives in order for us to get moving and get our juices flowing, our blood flowing, I think that’s really important.

Kevin Pho: And how can people reach you?

Michelle Dang: So my personal website is michelledangmd.com, and I am pretty active on social media. On Facebook, it’s also Michelle DMD, and on Instagram, I post a lot, and it’s Michelle DMD. So that’s kind of my name everywhere.

Kevin Pho: Thank you so much for your time, and thank you for joining me on the show.

Michelle Dang: Thank you so much, Kevin.

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