Your Brain Health Episode 13

Introduction: This is Your Brain Health with noted Neuroscientist, Dr. Kristen Willeumier. Your Brain Health explores strategies to maximize your cognitive functions through life. Here’s Dr. Kristen Willeumier.

Dr. Kristen Willeumier: I’m Dr. Kristen Willeumier. At present chronic pain affects 1.5 billion people worldwide with 23 to 26% of the population experiencing lower back pain. In the United States over 50 million people are experiencing chronic pain, which is defined as having daily pain for over six months. STEM cell based therapies are making advances and providing a novel approach to treating common chronic pain syndromes such as degenerative joint diseases and neuropathy. Here to talk to us more about chronic pain and therapies to treat. It is my dear friend, Dr. Christopher Zarembinski. Dr. Zarembinski is an attending physician at the Pain Center at Cedar Sinai Medical Center specializing in Anesthesiology. He’s practiced at Cedar Sinai Medical Center for the past 28 years, practicing exclusively in Pain Management and is one of the original founders of the Pain Center.

 

The Pain Centers become a model program for the hospital with respect to comprehensive management. The multidisciplinary approach translates into individually designed treatment programs that best suits the patient’s needs. He’s also worked with the television show, Dancing with the Stars as their medical consultant for the past 17 seasons. Dr. Zarembinski previously served as the assistant clinical professor of anesthesiology at UCLA Pain Management Center and the USC Department of Anesthesiology. He received his medical degree from the University of Arizona School of Medicine and he’s completed his internship at St. Joseph’s Hospital in Phoenix and his anesthesiology residency at Washington University in St. Louis. He also completed a fellowship in pain management at UCLAs anesthesiology department. His areas of interest include STEM cell research, joint and spine treatment and charity. So welcome my dear friend, Dr. Zarembinski. It’s such a pleasure to have you with us today.

Dr. Zarembinski: Yay. I just want to say a big thanks to Kristen. You’re the smartest woman I know.

Host: Oh, bless your heart, doctor Z. You’re so cool and honestly, I can’t think of a better person to dive into this topic in greater depth then you, I’ve called you many times with people that have been in my own personal life, struggling with pain issues. So that’s why I wanted to talk to you today so you can share with our audience some of the great things you’ve shared with me. And as you know, you know, pain comes in many forms from back pain, fibromyalgia, complex pain syndromes, irritable bowel syndrome, headaches, migraines, just to name a few. So tell the audience what type of pain syndromes do you specialize in treating?

Dr. Zarembinski: Sure. So, we pretty much see the gamut from head to toe, whether it be acute versus chronic. With the acute setting, we’re looking mostly at postoperative pain problems postsurgical for example. But we also deal with those patients who have had a difficult metastatic tumor related pain. On the chronic side, the large areas include just garden variety, low back issues from degenerative disc disease migraine headache issues, neck, chronic neck issues. Most of those problems are degenerative in nature. And that kind of summarizes those broad areas,

Host: I love that. You know what, I’m going to actually dive into a question that I have. I get a lot of calls from parents who have children that play collision based sports and have persistent migraines. And what kind of recommendations do you have for migraine treatments?

Dr. Zarembinski: Yes, so note that the migraine issue, there’s a lot of great drugs which are coming on the market, as we see with the management of many of these pain problems, the drugs are good but the side effects can be lousy. And so what I think is an important trend is how do you minimize side effects moving forward. And that is, and that becomes really important when you have a discussion with your headache specialist to have an idea of what the future looks like. Clearly there is a genetic predisposition. Clearly female tend to have more migraine headaches than males. And also the neck complaints can also be a strong triggering factor for the onset of some migraine problems. So I think that to know that there are future options is an important piece of this.

Host: And in these types of cases are good ones to come into the Cedars Pain Center to get treated. Because truly I feel like I get these calls all the time and people just don’t know how to manage them or they try to live their life with daily headaches. And that’s not optimal for long-term functioning.

Dr. Zarembinski: Exactly. I think that’s absolutely you’re right. So we look for a comprehensive approach where we’re able to address the psychosocial issues. How do you manage the side effect issues? How does one prevent the preventative piece is just as important as the actual treatment of those symptoms? And so preemptive analgesia, in other words, how do you prevent the onset of symptoms becomes an important part of this.

Host: And you had mentioned that certain people are predisposed to chronic pain or you were just saying females tend to be more prone to and the genetic predispositions. Can you talk a little bit more about that? Cause I think that’s fascinating.

Dr. Zarembinski: Yeah, it’s really interesting. There’s, we talked about plasticity, neuro plasticity where if one has the chronic bombardment of their spinal cord with painful stimuli, that can set up a feedback loop which can actually cause a persistent problem. Note that there are two kinds of pain fibers, the large and the small or the large being the a Delta, which is a myelinated or an insulated form where the fiber transmissions very fast and the very small fibers, which are the C fibers, which is not myelinated, which is a very slow progression. And if this constant bombardment from these small fibers creates this feedback loop whereby this really important a peptide called substance P is transported back to the periphery where the problem first initiated and lowers the threshold for more pain stimulation to bombard the spinal cord further. So we have this evil feedback loop that can be a problem in the chronic pain issue. There is an important, or I will say it an interesting piece is called epigenetics, whereby the genetic formation or the genetic code is not changed. However, how that gene is expressed maybe change is similar to if you have blonde hair versus dark hair, the DNA, that hair is the same. But how the DNA is expressed may be related to the genetic component of pain.

Host: That makes perfect sense to someone like me. So are there medications that help to reduce substance P so you don’t have this lowering of the threshold for pain? Is that?

Dr. Zarembinski: Yeah, exactly. So I think that the, what we spoke about before, and this is important for some of the patients who we see in the operative arena, is the whole concept of preemptive analgesia. If you can prevent that feedback loop from even occurring, that’s to your benefit. So for example, if you have a patient who’s going to be having an amputation and they’re at risk for having Phantom limb pain, which is pain stemming from the limb, that is not there, that could be a chronic issue. Well that potential problem can be minimized by blocking the nerves which go to that leg before they even have their surgery. So the preemptive analgesia is interesting. So the preemptive analgesia, it helps prevent that problem from occurring significantly. Now once that problem is occurring, then it becomes a more difficult problem to address. And there’s a bunch of different ways to do that. Local anesthetic blocks, different kinds of medications like Gabapentin, may also have some benefit, but it tends to become a more of a difficult a problem once that comes into play.

Host: Well, and I want to delve into a little bit more about ways you treat acute and chronic pain and you, and I’ve had dialogues because I have somebody very close to me in my life who had an accident five years ago and has had persistent chronic pain. So what are ways to treat acute pain versus chronic? And I know that’s a very broad question, but just a few.

Dr. Zarembinski: Sure. So we’ll, talk about a couple of ways. The acute pain model is really looking at the getting the patient through the surgical experience. We’ll use that as an example. And so you kind of tailor your treatment based upon the location of surgery, the level of trauma that is induced by that surgeon. Not all surgeries are created equally and different kinds of surgeries will have different kinds of challenges associated with them. For example, a thoracic surgery. The importance for that patient to have to take a deep breath and avoid a postoperative pneumonia is really important. So that is a very different kind of approach than someone who has, say an ankle surgery. So we tend to tailor the approach based upon how long the expected time will be for healing and what is the location of those symptoms. Also note that looking at comorbidities becomes really important also. Does that patient have a history of tobacco usage? Are they diabetic? Because those factors also play a role with the kinds of medication that you use.

 

So that becomes a kind of a limited time treatment plan, where we’re treating that patient during the time period that they’re in the hospital with conversion of intravenous or epidural opioids or local anesthetics or whatever, using it to an oral form so they can be discharged. And that’s going to be the goal. Note that the pressure from many insurance companies is that you want to get these patients mobilized and get them out of hospital. So there is an incentive from all parties that you want to have these patients under control pain-wise so that they can have a seamless transition to the outpatient arena. That compares with the chronic pain area where patients may have had problems with pain months, perhaps years after the surgery has ended. So now we have the potential for that evil feedback loop that we’ve mentioned before. And also with chronic pain, the emotional piece of it or the behavioral piece of it may become more of an issue. So with chronic pain, we see patients who are more likely to be, have insomnia, having anxiety. So being able to address that piece of it becomes more important the longer those symptoms tend to persist. That may also play enrolled with this plasticity issue, whereby there may be a rewiring of some of those neural circuitry that really plays a role with augmenting or worsening of those behavioral components as symptoms progress.

Host: You’ve said a wealth of information in that short period of time. And I was going to get to that piece. You know, what kind of changes do we see in the brain when people experience pain syndrome? So you know, I’ve done reading on this and I’ve seen that there are actual volume metric changes that happen in the brain. So the loss of neural tissue as a result of having pain. But what’s even more fascinating is when people get treated that there’s a regeneration of that tissue. So perhaps the changes in the brain are allowing the chronic pain to persist. And do you have any ways to help treat pain issues by addressing the brain?

Dr. Zarembinski: Well, I think what you’ve mentioned originally is really important that there is this potential for normalization once the symptoms improve. And also note that even though there may be those volume metric change, many of those areas maybe in that behavioral part of the brain, like the prefrontal cortex for example, that may be a protective mechanism. We talked about that this may be something where with the constant bombardment of the stimuli, maybe the brain needs to shrink a little bit. So it doesn’t have as much exposure to that chronic persistent stimuli.

Host: I love you.

Dr. Zarembinski: It’s something that’s making the problem worse, so there may be a protected area, so in terms of the kinds of things that we, that we employ we’re always trying to look at two things. One is the, one is the benefit, but also what is the risk profile? What are the side effects? As we said before, there’s a lot of medications which work very well, but the side effects become horrific in certain kinds of categories that’s really exemplified by the opioid crisis and how there’s over a hundred people dying per day based upon opioid overdose. So there are a lot of drugs, but how do you minimize a side effect? Part of that becomes really important.

Host: Well, I’m happy that you just brought this up about the opioid crisis this weekend. I actually had a dear friend who just passed away of an opioid overdose and he was a medical doctor and he happened to be riding one of the bird scooters, which we have all over the Los Angeles area. And he had gotten hit by a car, and the result of that were several fractures in his cervical spine. So for the past two months, he’s been on opioids to address the pain. And we got the call on Friday night that he passed. And here we have somebody who’s in the medical profession who understands how to use these medications and how potent they are. So, you know, part of the reason why I feel so blessed to know you and I really wanted to have you on the podcast was to let people know that treating chronic pain, acute or chronic pain it’s important. You need to have a support system. You need to, you don’t want to take this lightly, and I feel that people need to have resources available because a lot of people are doing, you know, these topical CBD oils or smoking taking the medical marijuana and trying to address it on their own. And I feel that having somebody to consult with in the medical profession such as going to the Pain Center is really important.

Dr. Zarembinski: Yeah, I would agree with that. The whole marijuana or the Canibadial CBD industry is being supported by this opioid addiction issue and that there may be other ways to address some of these pain problems without some of these side effects. The unfortunate item as of today is that there really is a lack of data with respect to THC and CBD as it relates to pain. In fact, if anyone looks at the pub med review there really are very, very few studies in humans. So there is an opportunity to gather data to see what is real and what is not and where are the areas of prime importance.

Host: This has been fascinating. I know our time is coming to a close. So first of all I need to have you back on because I wanted to delve into PRP therapy and STEM cell therapy, but I think that will be for our next conversation. So Dr. Zarembinski, my dear friend, where can people find you?

Dr. Zarembinski: They can find me at Cedar Sinai at the Pain Center. (310) 423-9600 that’s a phone. My website’s DRZPRP.com. Again, DRZPRP.com and DrZarembinski.com, both those come directly to me and I’m always happy to help.

Host: Oh, you are such a gem. I’m so blessed to know you. Thank you so much for taking the time to come on and teach us a little bit more about pain and what happens in the brain and ways to treat pain. And I would be delighted to have you come back on my show so we can talk PRP and STEM cell therapy. So what do you think?

Dr. Zarembinski: I think it’d be a big pleasure.

Host: Wonderful. All right. Have a great day, my friend. I’ll talk to you soon.

Dr. Zarembinski: Thank you.

Host: Bye bye.

Conclusion: You’ve been listening to Your Brain Health with Dr. Kristen Willeumier. For more information or to contact Dr. Willeumier, visit Dr. Willeumier.com. That’s D, R, W, I, L, L, E, U, M, I, E, R.com.