DREAM CAMPAIGN SUPPORTS 11 RESEARCH FUNDING PRIORITIES
Duke Dream Campaign Podcast
Pain Management and the Quality of Life After Surgery
Andy Shaw, MD
Hello I’m Elizabeth Perez and welcome to the Duke Dream Campaign Podcast.
We are here with anesthesiologist and researcher, Dr. Andy Shaw who is best known for his revolutionary work with iPEGASUS, a study that collaborates data from institutions around the world. Dr. Shaw’s research interests center around the genetics of perioperative medicine, particularly the role of genetic variation in the response to cardiothoracic surgery, and in postoperative acute renal failure. Three of his research endeavors, including iPEGASUS are part of the 11 funding priorities of the Duke DREAM Campaign. Today we will be discussing his study, Pain Management and the Quality of Life After Surgery. Dr. Shaw, thank you for taking the time to talk with us today.
Tell me how this study will work.
This study is concerned with the way pain is managed and the effects that that has on an individual’s quality of life after their surgery. We have collected a large amount of pain and quality of life data over the last 3 or 4 years predominately from patients having lung surgery, because we know that they experience a lot of pain over a short term. We also know that a large percentage of them will go on to experience chronic pain and have their life adversely affected after that. The first part of this project is to try to understand if the data we have already collected can tell us about the sort of things that are likely to predict who will experience a lot of pain and who will have a poorer quality of life after surgery. The second part of the study is to collect data in a prospective fashion, as we move forward, and to try and measure the type of pain perception an individual person has before their surgery. We will then try to correlate that to what happens to them while they are asleep in the perioperative period, and to relate that to their experience postoperatively.
Dr. Shaw, 58% of patients who have chronic pain also experience depression. What measures will you use to manage the quality of life for patients?
We have a series of survey type instruments that have been extremely well validated. These instruments look at different axes of quality of life not just in surgical patients but in all sorts of patients. We are studying cancer patients mainly because the quality of life literature is best developed in the cancer population. We also have different surveys that look into various aspects such as the physical, psychological and social wellbeing of patients and using questions that have been shown in the past to be reliable in describing and predicting how someone is feeling.
It is estimated that 9% of the US adult population suffers from moderate to severe non-cancer related chronic pain. With so many different pain medications available, why can’t people find relief from their pain?
We do not know who to give the right type of pain medication to. We try one, and if that does not work then we try another one. The simple fact of the matter is that we just cannot predict who will respond to what treatment and so what happens is those people that were lucky and get the right medicine the first time say that they respond well. The person who it might take us 4 or 5 times, we say that they have a difficult pain to treat. We sometimes blame the patient for complaining rather than our inability to find the right medication for them. There are so many people walking around with chronic pain and we just do not know enough about the basic physiology of why some people perceive some stimuli as painful while others do not.
How do you prevent dependency when narcotics are used to treat chronic pain and what are the chances of a patient becoming addicted to his/her narcotic pain medications?
There are a number of different factors that affect a patients’ chance or risk of becoming addicted. Not the least of these is whether or not they have previously been addicted to other substances or behavior patterns. We cut to the very core of an individual’s response to drug therapy, not just any sort of adverse stimulus. I would not like to give any individual a number or percent chance of becoming addicted to a pain medication because it is so variable. However we do know that people who experience significant amounts of chronic pain, tend to become addicted less than people who take those same drugs in the absence of a pain state. The quick answer is that people will become addicted if they take the drugs in the absence of pain.
Have you ever heard of retraining the nervous system to reestablish more nerval connections through the use of exercise and psychological treatment to help diminish chronic pain as an alternative to narcotics?
There are ways to reduce both the type and severity of the noxious stimulus. For example, using nerve blocks and regional anesthetic type procedures, and there are also techniques to try and reduce the discomfort that someone perceives that same stimulus. We can also try to reduce the discomfort and the unpleasantness someone feels. The regional anesthetics and the nerve block techniques aim to do the former and the more behavioral treatments, the talking treatments and the psychological approach, tends to try and make people more comfortable with the same stimulus.
Do patients considering surgery have to choose between living long and living better?
Take for example someone coming in for a lung resection. We know that the only way to cure lung cancer is to find it early and to remove it. To remove a tumor almost always requires an operation with a sizeable incision. We also know that about 50% of these patients are going to suffer some kind of chronic pain. That means 1 in 2 lung cancer patients trade that for a lifetime of chronic pain and potential discomfort. But you know if the alternative is to be dead, there is no real alternative. This is one of the big reasons that I got into the problem in the first place. It happened to my grandfather, and I thought that in 2004 it is not okay for us to just say “well the alternative is to be dead.” Currently there’s nothing we can do about it and we do not think this is acceptable which is why we are studying this problem.
And it’s probably why, according to the gallop pole, less than half, 42% of people who visit their doctor for pain believe that their doctor completely understands how their pain makes them feel. How do you think research can help doctors better understand their patients who suffer from pain?
Doctors like to treat patients with conditions for whom they have a fix. Nobody likes to have someone come to their office and sit there for a half an hour, complaining about a problem that we cannot do anything about. One of the goals of our research is to try and describe why individual people feel pain and have adverse quality of life when others do not. I think by educating our fellow caregivers, in many ways it frees them from the constraint that they think they have to be able to fix everything. We believe that by exploring the physiology and genetics behind pain perception, we can describe the biological processes that are going on and then find new therapies to address them.
How do you hope that this study will help to change the lives of patients whose quality of life decreases as a result of surgery?
I think if we can find the reasons why quality of life declines and if we can find the reasons why some people feel terrible pain and why others do not, then we can start to design treatments and therapies. We can then test those treatments and therapies in studies that are designed to test one against another. We can improve the quality of those people who come for their lung resection and other types of surgery by conducting, what we would call the “Gold Standard Test”, which is a randomized clinical trial in which we compare one treatment against another. This is how we find out if what we are doing is actually making a difference as opposed to just convincing ourselves that it is.
Thank you for listening to the Duke Dream Campaign podcast. Special thanks Tom Freeland and to our producer, Cindy Cho. For more information about this research project or how you help this featured research project come through fruition, please visit us at http://dreamcampaign.duhs.duke.edu or call (919) 681-2849.
To learn more about our 11 funding priorities please click on the images above.
If you are interested in becoming a donor to the Duke Dream Campaign, please contact Elizabeth Perez at 919-681-2849.