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Speaker 1: Hi, This is NEWT Twenty twenty is going to be

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Speaker 1: one of the most extraordinary election years of our lifetime.

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Speaker 1: I want to invite you to join my Inner Circle

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Speaker 1: as we discuss each twist and turn in the presidential race.

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Speaker 1: my live events. Join my Inner Circle today at Newtcenter

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Speaker 1: Circle dot com slash podcast use the Code podcast at checkout.

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Speaker 1: Sign up today at Newtcenter Circle dot com slash podcast

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Speaker 1: and use the Code podcast. Hurry this Offtway Spires February fourteenth.

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Speaker 1: On this episode of NEWT World, we're losing more people

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Speaker 1: every year than we lost in ten years of fighting

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Speaker 1: in Vietnam. We lose more people from opioid misuse in

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Speaker 1: overdose than we do on the highways or from gun

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Speaker 1: violence or anything else. This is a huge, long term

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Speaker 1: impactful events nine to eleven happened, and in fact, I've

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Speaker 1: never known being a stassosition without this war. On this

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Speaker 1: episode of newt World, I have a new novel that

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Speaker 1: just came out called Collusion, which I co wrote with Pete.

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Speaker 1: Early in the novel, our main character is Brett Garrett,

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Speaker 1: a Navy seal who is injured in a helicopter crash.

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Speaker 1: Due to his injuries and pain, Brett becomes addicted to opioids.

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Speaker 1: On this episode, I thought we take a closer look

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Speaker 1: at opioid addiction and pain management in the military community.

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Speaker 1: I'm really pleased to welcome my guest, Pete Earley, my

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Speaker 1: good friend and co author of Collusion, Lieutenant General Eric Schumacher, MD,

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Speaker 1: pH D, US Army retired. Lieutenant General Eric Schumacher retired

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Speaker 1: in two and twelve from his role as the forty

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Speaker 1: second US Army Surgeon General and Commanding General of the

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Speaker 1: US Army Medical Command. This followed thirty two years of

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Speaker 1: active service in uniform and forty one years as a

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Speaker 1: commissioned Army officer. We also as our guest doctor Tripp

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Speaker 1: buck and Meyer, the third MD Colonel, US Army retired,

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Speaker 1: the director for the Uniform Services University's Defense and Veteran

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Speaker 1: Center for Integrative Pain Management. Pete, why don't you just

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Speaker 1: take a minute to explain both Brett Garrett's character but

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Speaker 1: also the injuries he suffered in the consequence of those injuries.

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Speaker 1: Brett Garrett is the hero of Clusion. He's a highly

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Speaker 1: trained Navy seal. When we first meet him, he's a

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Speaker 1: chief Petty officer who is working with the CIA to

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Speaker 1: rescue a hostage from Boko Haram. He ends up on

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Speaker 1: that mission making some crucial career changing decisions. He ends

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Speaker 1: up being shot down in a helicopter where he substains

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Speaker 1: substantial burns, and he becomes addicted to opioids. And this

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Speaker 1: is because the military has changed from just giving people

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Speaker 1: morphine to giving him fentanyl pops, which are much more powerful.

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Speaker 1: They go through your mouth quicker, they address the pain,

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Speaker 1: and like so many of our veterans who are in

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Speaker 1: combat situations who get injured, the threat of opioid addiction

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Speaker 1: looms over him during the novel, and so we have

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Speaker 1: a struggle not only with an exciting storyline, but also

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Speaker 1: with his personal struggle with what is an epidemic in

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Speaker 1: our country, opioid addiction. One of the things that the

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Speaker 1: speaker and I really wanted to do in this novel

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Speaker 1: is we wanted a character who is realistic and someone

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Speaker 1: who had flaws, And we also felt that we needed

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Speaker 1: to address the opioid crisis in a very personal way,

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Speaker 1: because it's just such an epidemic on an epidemic, and

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Speaker 1: it's not something we should ignore, and we wanted to

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Speaker 1: fight the stigma. I'm delighted to have a chance to

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Speaker 1: chat with General Eric Schumacher, who has had a remarkable career,

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Speaker 1: but his probably most important contribution was stepping in at

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Speaker 1: a time when we had to really profoundly rethink pain management.

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Speaker 1: The way we had been doing it had been led

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Speaker 1: to a dramatic increase in addiction. He's had a career

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Speaker 1: of serving the men and women in uniform in this country,

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Speaker 1: trying to help those who've been wounded, trying to make

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Speaker 1: sure that in general, their health is gave them the

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Speaker 1: optimum chance to lead a long life. Can you share

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Speaker 1: with people of your career in the military. I was

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Speaker 1: raised in the military. I'm one of a multi generational

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Speaker 1: family of Army soldiers. I came in as an RTC cadet.

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Speaker 1: By the time I was commissioned in nineteen seventy. The

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Speaker 1: Army didn't need lieutenants anymore, so I went to medical school.

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Speaker 1: And while in medical school, I got interested in research,

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Speaker 1: so I got a PhD in human genetics in the

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Speaker 1: first goal for I was the chief doctor in launch

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Speaker 1: school in Germany, and then I commanded a hospital and

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Speaker 1: I was brought down from Port Dietrich to command Walter

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Speaker 1: Read and then from there I was selected to be

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Speaker 1: the surgeon General and the commander of the Army's Medical Command.

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Speaker 1: Since then, I've retired and have come to the Uniform

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Speaker 1: Services University as a professor. It's been a real privilege

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Speaker 1: to work there and to continue the work that I think.

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Speaker 1: As a feature of this book, you both have written

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Speaker 1: about a wounded service member who, through no fault of

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Speaker 1: his own, acquired what we would call an opio use

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Speaker 1: disorder or an addiction to opioids, because this is unfortunately

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Speaker 1: the preferred treatment too often of chronic pain in America.

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Speaker 1: When you get up in the morning, what is it

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Speaker 1: you're thinking about trying to solve? Solving this problem of

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Speaker 1: what I think has become one of the most serious

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Speaker 1: health threats to the nation. I think a health threat,

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Speaker 1: the opioid epidemic, which is really an epidemic of epidemics.

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Speaker 1: Those of us who work in this area don't think

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Speaker 1: of this as an isolated epidemic similar to what we

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Speaker 1: went through in the seventies with cocaine or later with heroin.

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Speaker 1: What we have now is, unfortunately and between, are learning

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Speaker 1: more and more misbehavior on the part of the producers

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Speaker 1: the manufacturers of some of these drugs we've spawned. I

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Speaker 1: think a health epidemic that will rival, and I'm not

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Speaker 1: an economist, but it just seems intuitively that this will

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Speaker 1: eventually rival the nineteen nineteen flu econemic in terms of

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Speaker 1: its impact on the country. We are now losing through

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Speaker 1: accidental overdoses by prescription opioids and by its diversion or misuse,

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Speaker 1: or by drifting into other drugs like a fentanyl on

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Speaker 1: the street or heroin. We're losing more people every year

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Speaker 1: than we lost in ten years of fighting in Vietnam.

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Speaker 1: We lose more people from oi misuse in overdose than

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Speaker 1: we do on the highways or from gun violence or

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Speaker 1: anything else. This is a huge, long term, impactful event.

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Speaker 1: Heroin was apparently very readily available in Vietnam. But interestingly,

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Speaker 1: that was a kind of situational addiction, if you want

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Speaker 1: to call it, And once they got back into the States.

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Speaker 1: My understanding from people who studied this, like Lieutenant General

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Speaker 1: now retired Ron Blank, who was a former certain general

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Speaker 1: before my time, who studied that episode, that event that

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Speaker 1: period in Vietnam, there was really not a lot of

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Speaker 1: residual use. There was almost an effort to distract the

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Speaker 1: soldier from the nightmare of what Vietnam was for them.

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Speaker 1: These lacious experiences they had in the repeated short term

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Speaker 1: tours through it for a certain class of individuals, not everybody,

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Speaker 1: because not everybody who saw that experience was negatively impacted.

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Speaker 1: But once they came back, they didn't necessarily go on

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Speaker 1: a long term opioid use. And I don't know how

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Speaker 1: that was achieved. There were treatment centers in Vietnam at

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Speaker 1: the time, but that experience with drugs, which was of

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Speaker 1: course one of the features of the sixties and seventies,

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Speaker 1: then was dealt with you I think through discipline policies.

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Speaker 1: We had a succession of leaders through the seventies who

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Speaker 1: really made alcohol in drugs and misconduct focus of what

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Speaker 1: they did and about the same time we became a

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Speaker 1: volunteer army. In nineteen seventy three seventy four, the volunteer

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Speaker 1: Army became married. We're much more different in complexion. In

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Speaker 1: terms of the demographics of the military today, we're close

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Speaker 1: to sixty five or seventy percent of soldiers are married

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Speaker 1: now and have families, and I think it's just changed that,

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Speaker 1: coupled with leadership and a focus on keeping a drug

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Speaker 1: free and alcohol limited army, has changed it. I think

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Speaker 1: the use of opioids then changed, especially in the nineties

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Speaker 1: when I trained as an internal medicine doctor and as

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Speaker 1: a hematologist and took care of a lot of people

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Speaker 1: in pain, chronic and acute pain. At that time, there

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Speaker 1: was a real sensitivity about using opioid like drugs dem

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Speaker 1: all morphine. All of these drugs, whether they're synthetic or

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Speaker 1: they're natural, are derivatives of the opium poppy or related

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Speaker 1: to the opium poppy, and they all have a share

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Speaker 1: ability to both provide the soporific effects and the sedating

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Speaker 1: effects and pain relieving effects short term for acute pain,

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Speaker 1: but they also have this impact on the brain that

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Speaker 1: leads to a long term necessity to have that drug,

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Speaker 1: and if it's withdrawn after a period of time that

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Speaker 1: you become accustomed to it and then eventually dependent upon it,

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Speaker 1: then there are some really psychologically and physically devastating effects

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Speaker 1: of that withdrawal. You know, this probably emanates from a

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Speaker 1: time when our brains needed a receptor and a signal,

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Speaker 1: a material that would temporarily blunt stress and pain. You've

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Speaker 1: often seen an animal that may have been caught by

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Speaker 1: a hawk, for example, suddenly go into a freeze and

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Speaker 1: then relax, and that's probably from the release of these

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Speaker 1: endogenous opioids we talk about the runners high. These are

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Speaker 1: endogenous opi is that your brain makes in response to

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Speaker 1: stress and pain and relieves that. For a period of time,

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Speaker 1: the brain didn't put a receptor in there so that

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Speaker 1: someday we would find an opium poppy and extract heroin

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Speaker 1: and make heroin. There's an indigenous reason, but unfortunately there

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Speaker 1: is exists in nature now and now out of synthetic laboratories,

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Speaker 1: very very potent drugs which cross react with that receptor

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Speaker 1: and cause the same effects that the indigenous drug, if

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Speaker 1: you will, these endorphins do. When I was being trained

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Speaker 1: and up until the eighties and nineties, the attention really

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Speaker 1: was on limiting that, but the perception was we were

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Speaker 1: being overly cautious about using those drugs to relieve pain.

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Speaker 1: And the problem that began to be surfaced was that

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Speaker 1: we had too many people in pain who were not

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Speaker 1: being sufficiently treated for it, especially people with terminal illnesses

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Speaker 1: cancers in a light and so we went through a

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Speaker 1: period in which there was an effort made for us

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Speaker 1: to get more comfortable and more prolific in the use

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Speaker 1: of the opioids. In the late nineties as well, the

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Speaker 1: accrediting bodies for hospitals, the Joint Commission for Accreditation of

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Speaker 1: Healthcare Organizations now called the Joint Commission, made pain one

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Speaker 1: of the most important focuses that we should place on

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Speaker 1: caring for our patients, and it became one of the

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Speaker 1: signatory elements of a good hospital or a good health

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Speaker 1: system that you were always asking and always treating effectively pain.

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Speaker 1: If you've been to a doctor recently or any clinic,

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Speaker 1: you're asked by virtually everybody, from the parking lot attendant

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Speaker 1: to the nurse at the front desk to the dock

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Speaker 1: are you in pain? And that naturally led to the notion, well,

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Speaker 1: if you're in pain, let's do something about it. At

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Speaker 1: the same time, we were given the impression, through unfortunately

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Speaker 1: not really sound science, that if you were in pain,

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Speaker 1: say from postoperative surgical causer or traumatic injury, you're a

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Speaker 1: very unlikely to get addicted to these drugs. The people

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Speaker 1: who have quote sort of legitimate pain, if there is

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Speaker 1: such a thing, that you're not going to get in trouble.

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Speaker 1: So now we have a system that has a kind

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Speaker 1: of a knee jerk response to pain, especially acute pain.

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Speaker 1: You get a soldier or a seal or airman who's

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Speaker 1: badly injured. It has an absolutely essential role on the battlefield.

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Speaker 1: I mean it was one of my colleagues, doctor Trip

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Speaker 1: Buckemeyer says, when you get your leg blown off in combat,

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Speaker 1: you're not yelling for acupuncture, you're yelling for morphine, and

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Speaker 1: that has an enormously positive effect on it. Or fentinel

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Speaker 1: lollipops are Now we're using ketamine and some other things.

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Speaker 1: As that acute injury begins to heal and the tissue

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Speaker 1: begins to heal, pain then goes to a change, and

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Speaker 1: the pain experts call this chronification. That for the first

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Speaker 1: six weeks to several months, and it's different for different people.

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Speaker 1: That tissue heals, the nerves begin to return to normal,

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Speaker 1: but the pain that goes on to become chronic pain

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Speaker 1: is now a brain disorder. Pain is, after all, a

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Speaker 1: completely subjective event. There is no objectivity to pain. There

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Speaker 1: is no thermometer you can put in anybody. You've all

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Speaker 1: seen someone who's had a splinter under their fingernails seemed

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Speaker 1: to be in completely incapacitating pain, and yet we've had

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Speaker 1: soldiers that run through a hail of AK forty seven

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Speaker 1: rounds and are wounded, and yet are doing heroic things.

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Speaker 1: So what's different is the subjectivity and the context of that.

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Speaker 1: When that pain then becomes chronic pain, chronic low back pain,

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Speaker 1: chronic migraine pain, chronic joint pain, it's now not centered

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Speaker 1: in that tissue. It's centered in your brain, and it's

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Speaker 1: a dialogue between different parts of the brain that are

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Speaker 1: very different for different individuals. It probably as unique as

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Speaker 1: our fingerprints is. If you put people in imaging devices

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Speaker 1: and watch them while they're experiencing discomfort. It's different for

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Speaker 1: every human. But there seems to be several areas of

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Speaker 1: the brain that are deeply involved. One is emotion, the

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Speaker 1: other is memory. Think about this. A child who goes

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Speaker 1: to a doctor to get a vaccine rarely cries the

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Speaker 1: first time. They cry the second time when they see

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Speaker 1: that white code, because that's the memory and the emotion

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Speaker 1: talking to one another. This becomes part of the fingerprint

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Speaker 1: of our pain. We rarely in the military environment, but

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Speaker 1: probably in the world at large, see chronic pain as

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Speaker 1: an isolated thing. It's usually combined with post traumatic stress

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Speaker 1: or depression, or even traumatic brain injury, which through concussive

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Speaker 1: injury you rarely see. You are very unusual to see

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Speaker 1: chronic pain isolated without psychological or other physical problems. So

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Speaker 1: your character has had burns, he's lost friends and colleagues

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Speaker 1: in combat, so his memory of his injury and this

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Speaker 1: pain that's residual from that is embedded with memories and

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Speaker 1: a fight or flight response that occurred from combat. We

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Speaker 1: can't approach that with just a single drug. On top

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Speaker 1: of that, we now know pretty convincingly, and this is

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Speaker 1: I think universally accepted by people in the pain world

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Speaker 1: that although we in this country use chronic opioids frequently

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Speaker 1: for chronic pain, there is little or no evidence whatsoever

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Speaker 1: that chronic opioids have any role in the treatment of

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Speaker 1: chronic pain. In fact, there's a subgroup of people with

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Speaker 1: chronic pain who actually get worse when they get opioids.

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Speaker 1: It makes their pain worse. We have no long term

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Speaker 1: studies that show that chronic opioids even though, as I said,

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Speaker 1: you know, here's what seven percent of the global population

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Speaker 1: is using ninety percent plus of all the prescription opioids

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Speaker 1: in the world in this country. You don't see this

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Speaker 1: in Europe. You've got to Sweden, to Germany or places.

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Speaker 1: I'm told by friends they don't understand what we're going

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Speaker 1: through because they don't use this. If you've not read

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Speaker 1: Sam Kenonas's book Dreamland, I really strongly recommend it. It's

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Speaker 1: an astonishing book. It is because it really explains this

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Speaker 1: contemporaneous use of opioids for pain in young athletes in

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Speaker 1: the battlefield and other places. With now the insertion of

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Speaker 1: black tar heroine coming out of Mexico that Elchoppo and

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Speaker 1: other people benefited from in a very unique business model

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Speaker 1: that brought very cheap opioids to every community, rural and

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Speaker 1: urban in America. So now we have another kind of

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Speaker 1: epidemic of epidemics. This is devastating Appalachia. We're working with

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Speaker 1: the folks at West Virginia, which is really at the

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Speaker 1: epicenter of this, but southern Ohio, southern Indiana, Western Pennsylvania,

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Speaker 1: Western Maryland, Western Virginia, as well as West Virginia are

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Speaker 1: really now in the clutch of a really really profound

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Speaker 1: state and nation changing epidemic around these opioids. The thing

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Speaker 1: that's astonishing in Quinonas's work is both how human he

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Speaker 1: makes it. I mean, it is like a novel, and

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Speaker 1: how he intersects poverty and places that have no future

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Speaker 1: with changes in the nineties in the degree to which

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Speaker 1: we were willing to give people opioids, with the Mexican development,

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Speaker 1: and it's one of the great studies in entrepreneurship because

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Speaker 1: there's one town in Mexico that figures out that has

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Speaker 1: about three or four guys who figure out that you

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Speaker 1: can take the pizza delivery system and turn it into

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Speaker 1: a delivery program for heroin and you eliminate ninety eight

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Speaker 1: percent of the risk of ever getting picked up by

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Speaker 1: the cops. And so they gradually go from town to town,

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Speaker 1: establishing people in an apartment who have a phone, and

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Speaker 1: they basically go around to the right places and pass

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Speaker 1: out the phone number and say, when you need to

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Speaker 1: buy some call, we'll tell you which parking lot will

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Speaker 1: meet in. What Qunonas does is so astonishing is he

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Speaker 1: takes three or four patterns, shows you how they weave together.

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Speaker 1: And this is why I'm a historian. You could never

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Speaker 1: theoretically design this. This is an organic development that is

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Speaker 1: just astonishing and which led to it. And I think

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Speaker 1: you're one of the great surprises to me is I

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Speaker 1: got into this six or eight years ago, was that

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Speaker 1: you have a crisis of this scale that we can't

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Speaker 1: come to grips with. We're enduring it. We're gradually, piece

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Speaker 1: by piece starting to respond. But you would think if

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Speaker 1: we were losing this many Americans every year that to

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Speaker 1: be a dramatically higher crescendo. I'm glad to hear you

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Speaker 1: say that, because I think many of us working this

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Speaker 1: area are absolutely baffled as to why we have not

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Speaker 1: identified this. I mean, we went through a very prolonged

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Speaker 1: period we just could not get people galvanized run it.

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Speaker 1: We started the work in the DD about ten years

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Speaker 1: ago with this report that came out about a year

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Speaker 1: before the Institute of Medicine now the National Academy Medicine

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Speaker 1: did theirs. What we realized was number one, we become

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Speaker 1: overly reliant on interventional procedures, surgical and otherwise, or opioids.

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Speaker 1: I took a trip out to San Diego to talk

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Speaker 1: about this a couple months ago, and I sat next

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Speaker 1: to a woman just by chance struck up a conversation.

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Speaker 1: She was in her mid sixties, was going out to

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Speaker 1: visit her ninety five year old mother, and she said,

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Speaker 1: it's interesting the work you're doing, because the last time

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Speaker 1: I took this trip, my mother had had a hip replacement.

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Speaker 1: She was ninety two or ninety three at the time,

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Speaker 1: and they sent her home with a big bottle of oxyconton,

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Speaker 1: and like everybody her generation, she dutifully took her oxyconton

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Speaker 1: just exactly as they said to and then when that

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Speaker 1: ran out, she got up refill and eventually she began,

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Speaker 1: I'm an addict. And we realized that my mom is

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Speaker 1: now addicted to oxycont We went back to the rehab

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Speaker 1: center and said what do we do, and they said, well,

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Speaker 1: you can admit her to the a rehab center and

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Speaker 1: we will taper her off, but it's going to cost

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Speaker 1: you a lot of money. You can put her into

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Speaker 1: a street program that the City of San Diego runs

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Speaker 1: along with established addicts and pushers in the like, or

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Speaker 1: you can do it at home alone. And so they

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Speaker 1: did it cold turkey at home. She said it was

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Speaker 1: the worst four to six weeks of her life. She

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Speaker 1: had a ninety two or ninety three year old mother

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Speaker 1: going through cold turkey withdrawal from opioids. This is a

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Speaker 1: random stranger I meet on a plane. This is happening

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Speaker 1: in so many households, in so many communities. When we

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Speaker 1: come back, General Schoemaker, Pete and I will continue our

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Speaker 1: conversation on pain management and about how the military is

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Speaker 1: starting to approach pain treatment differently. What would you say

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Speaker 1: would be turning point if there's been one, in moving

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Speaker 1: us away from highly addictive approach towards a substantially less

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Speaker 1: addictive approach towards pain management. I think that's a great question,

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Speaker 1: mister speaker. I mean, for me, it would take place

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Speaker 1: around twenty ten, twenty eleven, and I think that the

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Speaker 1: publication of the Institute of Medicine Study Pain in America,

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Speaker 1: or now the National Academy Medicine and all of the

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Speaker 1: work that's followed that. About the same time we and

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Speaker 1: the DD began to work on this, we saw some

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Speaker 1: of the same things that the nation as a whole

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Speaker 1: was seeing. The work now that spread into the VA.

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Speaker 1: In fact, that VA had a lead on all of this,

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Speaker 1: the Veterans Administration. You're looking between the military health system

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Speaker 1: and the VA health system at about twenty million Americans.

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Speaker 1: That's a sizable slug of America. And I think we're

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Speaker 1: at a tipping point now back to this notion of

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Speaker 1: how can we keep ourselves healthy and strong, not wait

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Speaker 1: until we've fallen off the cliff of illness or disease

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Speaker 1: or mental health problems. We did a podcast with the

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Speaker 1: Congressman Patrick Kennedy and he talked about his father's generation,

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Speaker 1: and I think this was a big part of it. Initially,

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Speaker 1: the thought was it must be a weakness, it must

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Speaker 1: be a problem for people who are inadequate, and so

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Speaker 1: I think for over a decade the country couldn't come

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Speaker 1: to groups with the fact that it was the country.

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Speaker 1: And I think we as a medical community and I'm

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Speaker 1: a part of this, and probably gave as much opioids

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Speaker 1: in my developmental years, as anyone did thinking I was

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Speaker 1: doing good by these people. We suffered from a misunderstanding

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Speaker 1: about what it is. And that's been coupled with a

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Speaker 1: business model of medicine which reimburses a physician or a

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Speaker 1: clinic for fifteen minute visit in an opioid prescription. But

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Speaker 1: are you aware that we have eight or nine evidence

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Speaker 1: based approaches to chronic pain that are as effective or

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Speaker 1: more effective and not dangerous that we can't get reimbursed

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Speaker 1: for medical massage, yoga, acupuncture, mindfulness, meditation, music therapy, chiropractic therapy.

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Speaker 1: These all now have very good evidence for their use

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Speaker 1: there as effective as anything else out there right now.

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Speaker 1: And recent National Academy meeting that will result in a

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Speaker 1: publication reviewed all of the literature on pharmacologic and non

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Speaker 1: pharmacologic modalities and approaching chronic pain concluded that these modalities

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Speaker 1: that I just mentioned are as effective or more effective

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Speaker 1: than anything else we have out there. Everything is about

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Speaker 1: moderately effective, but very good yoga trials now have been conductive,

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Speaker 1: very good acupuncture trials have been conducted, and yet we

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Speaker 1: don't have a business model in American meta And it

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Speaker 1: allows me to say to a patient, hey, listen, I

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Speaker 1: want you to go and get medical massage, or I

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Speaker 1: want you to get accupuncture, even my wife who has

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Speaker 1: had acupuncture in yoga and everything else throughout these years,

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Speaker 1: or I who go to a medical massage therapist. I

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Speaker 1: can't build Tricare, my healthcare benefit program for that because

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Speaker 1: it's not covered outside the gate. I can do it

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Speaker 1: in our military hospitals when I was a certain general.

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Speaker 1: I can try to build a network internal to our

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Speaker 1: brook and mortar facilities to do that. Very tough to

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Speaker 1: do that, because the whole culture needs to change. I

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Speaker 1: think one of the things that will help us is

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Speaker 1: if we start looking at pain and injury differently than

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Speaker 1: we've rather than medicalize every pain that we have. Aren't

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Speaker 1: you in pain right now? I am. I've got this

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Speaker 1: knee that's bothering me, in my low back pain over here,

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Speaker 1: and I've got an elbow. I mean, nobody is free

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Speaker 1: of some degree of pain. And having talked to people

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Speaker 1: who are instrumental in National Football League and other sports,

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Speaker 1: will tell you there is no group of people other

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Speaker 1: than maybe soldiers warriors, who know that they have to

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Speaker 1: work with some level of pain and discomfort. I think

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Speaker 1: what you saw here with someone who, for legitimate reasons,

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Speaker 1: received an opioid after a battlefield event and probably during recovery,

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Speaker 1: but at some point didn't transition what we'd like to

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Speaker 1: see to non pharmacologic assistive modes that could be tailored

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Speaker 1: to his own needs. Listening to you is fascinating. Now.

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Speaker 1: I've been told and research seems to suggest that PTSD

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Speaker 1: is highly treatable, that it's often caused by being shot at,

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Speaker 1: by losing friends, by having a difficult time coming back

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Speaker 1: and relating to other people, emotional depression, etc. The studies

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Speaker 1: I've seen suggest that it is treatable purely through behavioral

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Speaker 1: cognitive therapy, not medication. Whereas what you're talking about with

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Speaker 1: chronic pain, everybody talks about medication. It sounds to me

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Speaker 1: like you're also suggesting that we need to help wean

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Speaker 1: people off of medication by providing good mental health services.

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Speaker 1: I think, first of all, let's be very clear, I'm

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Speaker 1: not an expert on PTSD, but we can't be around

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Speaker 1: military and veteran medicine that you aren't. My understanding is

432
00:27:30,400 --> 00:27:34,919
Speaker 1: probably the event in life which is most predictive of

433
00:27:34,960 --> 00:27:38,919
Speaker 1: developing PTSD is actually a rape. You know, over seventy

434
00:27:38,960 --> 00:27:41,840
Speaker 1: five percent of women and men probably who are raped

435
00:27:41,960 --> 00:27:45,640
Speaker 1: will eventually develop PTSD. Now we'll take on average sometimes

436
00:27:45,640 --> 00:27:48,960
Speaker 1: ten or fifteen years before they'll identify it and recognize this.

437
00:27:49,680 --> 00:27:52,840
Speaker 1: But there's a very very close relationship between violent crime

438
00:27:52,920 --> 00:27:57,760
Speaker 1: personal violent crime, especially a rape, and developing PTSD. Many

439
00:27:57,800 --> 00:28:01,320
Speaker 1: many people who survive Katrina or any of these tornadoes

440
00:28:01,359 --> 00:28:04,280
Speaker 1: that we're seeing right now. I even worry about border

441
00:28:04,320 --> 00:28:07,359
Speaker 1: patrolmen who were involved in separating families and things like

442
00:28:07,400 --> 00:28:09,520
Speaker 1: that in the border. I think we're going to see

443
00:28:10,200 --> 00:28:14,320
Speaker 1: problems with PTSD, policeman on the street, fireman on the street,

444
00:28:14,320 --> 00:28:19,480
Speaker 1: first responders. Anyone who's exposed to a life threatening, life

445
00:28:19,600 --> 00:28:23,800
Speaker 1: changing event like that is going to experience what you

446
00:28:23,880 --> 00:28:27,720
Speaker 1: and I all of us experience transiently but can become

447
00:28:28,400 --> 00:28:32,080
Speaker 1: established as a longer term disruptor of our life. Anyone

448
00:28:32,119 --> 00:28:35,560
Speaker 1: who's been involved in even a minor accident motivehicle accident,

449
00:28:35,600 --> 00:28:39,400
Speaker 1: experiences post traumatic stress. I mean, haven't you noticed after

450
00:28:39,560 --> 00:28:41,760
Speaker 1: you've had a funder vendor or something that for a

451
00:28:41,840 --> 00:28:44,680
Speaker 1: couple of weeks afterwards, you're always hitting the brake, even

452
00:28:44,720 --> 00:28:47,720
Speaker 1: if you're not driving the car. Or you're grabbing onto something.

453
00:28:48,200 --> 00:28:51,080
Speaker 1: That's the fight or flight reaction of post traumatic stress.

454
00:28:51,320 --> 00:28:55,440
Speaker 1: We all experience that. But when that becomes well established

455
00:28:55,440 --> 00:28:58,680
Speaker 1: and that fight or flight dialogue in our brains gets

456
00:28:58,760 --> 00:29:02,880
Speaker 1: locked in, we suffer from post traumatic stress disorder because

457
00:29:02,880 --> 00:29:06,840
Speaker 1: it becomes disrupt life. We have avoidance. We don't want

458
00:29:06,840 --> 00:29:09,560
Speaker 1: to be around where that is people who've been in combat,

459
00:29:09,720 --> 00:29:13,120
Speaker 1: or people who have been on ied alley or something.

460
00:29:13,200 --> 00:29:15,080
Speaker 1: They don't want to be in that environment. They don't

461
00:29:15,080 --> 00:29:18,880
Speaker 1: want to be enclosed. They have intrusive thoughts, maybe like

462
00:29:18,960 --> 00:29:23,440
Speaker 1: your character and sleep problems. They have irritability and ease

463
00:29:23,480 --> 00:29:26,600
Speaker 1: of anger. And we have soldiers and sailors and others

464
00:29:26,640 --> 00:29:30,120
Speaker 1: done since the beginning of time. To get sleep, they

465
00:29:30,200 --> 00:29:34,320
Speaker 1: drank alcohol. And in my generation, my dad's generation of

466
00:29:34,440 --> 00:29:37,680
Speaker 1: soldiers always had a couple of martinis every night. And

467
00:29:37,840 --> 00:29:39,560
Speaker 1: you know, I mean as a survivor of World War

468
00:29:39,560 --> 00:29:43,240
Speaker 1: Two and Korea and Vietnam, but especially Korea, I think

469
00:29:43,280 --> 00:29:46,000
Speaker 1: my dad and his generation came back with some terrible

470
00:29:46,200 --> 00:29:51,480
Speaker 1: experiences that they used alcohol as a solution for even therapeutically.

471
00:29:52,240 --> 00:29:55,280
Speaker 1: So yes, I totally agree with you. I think drugs

472
00:29:55,320 --> 00:29:58,360
Speaker 1: have their place in the treatment of PTSD and others

473
00:29:58,440 --> 00:30:01,120
Speaker 1: when it comes to short term help with sleep and

474
00:30:01,120 --> 00:30:04,200
Speaker 1: the light, but the long term there are some established

475
00:30:04,640 --> 00:30:09,760
Speaker 1: therapies now available to reset the nervous system, to expose

476
00:30:10,400 --> 00:30:14,760
Speaker 1: people cognitively to what they've experienced, and then to work

477
00:30:14,840 --> 00:30:17,720
Speaker 1: through what those symptoms really mean, how they can work

478
00:30:17,720 --> 00:30:21,720
Speaker 1: through them absolutely and remember, just like your character in

479
00:30:21,760 --> 00:30:24,920
Speaker 1: the book, these are often overlapping with other problems that

480
00:30:24,960 --> 00:30:27,800
Speaker 1: they're dealing with that are in this mental health kind

481
00:30:27,840 --> 00:30:32,960
Speaker 1: of mixture. And again, our business model, unfortunately in medicine,

482
00:30:33,000 --> 00:30:37,920
Speaker 1: is too often fragmented. What we really need is a transdisciplinary,

483
00:30:38,000 --> 00:30:42,680
Speaker 1: team based approach that uses many modalities. I might find

484
00:30:43,280 --> 00:30:50,160
Speaker 1: I'm very amenable to yoga and acupuncture and medical massages

485
00:30:50,200 --> 00:30:52,720
Speaker 1: wonderful for me, but other people may not find that

486
00:30:52,960 --> 00:30:56,880
Speaker 1: as effective because of their own unique experience it. We

487
00:30:56,960 --> 00:31:00,400
Speaker 1: know there are certain types of people who catastrophize about

488
00:31:00,400 --> 00:31:04,400
Speaker 1: their pain. One of the real benefits of mindfulness meditation,

489
00:31:04,480 --> 00:31:07,880
Speaker 1: which is based in the present let's move away from

490
00:31:07,920 --> 00:31:10,440
Speaker 1: thoughts of the future in the past to the present,

491
00:31:11,200 --> 00:31:14,240
Speaker 1: is to help us with this catastrophying. Hey, I'm always

492
00:31:14,240 --> 00:31:15,680
Speaker 1: going to be in pain. I'm never going to be

493
00:31:15,760 --> 00:31:18,040
Speaker 1: normal again. I'm never going to be able to play

494
00:31:18,720 --> 00:31:21,600
Speaker 1: with my kids on the front lawn. Suddenly my mind

495
00:31:21,680 --> 00:31:24,440
Speaker 1: is racing into this disastrous kind of place I'm going

496
00:31:24,480 --> 00:31:29,320
Speaker 1: to be. Those catastrophizing thoughts maybe need to be managed

497
00:31:29,320 --> 00:31:32,760
Speaker 1: with mindfulness meditation, which has been shown to be successful

498
00:31:33,200 --> 00:31:37,800
Speaker 1: in both helping PTSD as well as chronic pain. And

499
00:31:38,120 --> 00:31:41,560
Speaker 1: sometimes people who catastrophize like that are not as well

500
00:31:41,600 --> 00:31:45,120
Speaker 1: treated with acupuncture for whatever reason, we don't know why.

501
00:31:45,800 --> 00:31:47,880
Speaker 1: We need to start focusing on how do we keep

502
00:31:47,920 --> 00:31:50,840
Speaker 1: ourselves well, and a lot of the techniques I've just

503
00:31:50,880 --> 00:31:53,520
Speaker 1: talked about really ought to be applied in our well

504
00:31:53,640 --> 00:31:59,240
Speaker 1: state or partially unwell state to help restore us. You've

505
00:31:59,280 --> 00:32:01,840
Speaker 1: noticed in the past two or three years that life

506
00:32:01,840 --> 00:32:04,080
Speaker 1: expectancy the United States has dropped for the first time

507
00:32:04,080 --> 00:32:07,200
Speaker 1: in eighty years. Part of that's due to the opioid problem.

508
00:32:07,960 --> 00:32:10,360
Speaker 1: The CDC, the Centers for Disease Control and prevent a

509
00:32:10,400 --> 00:32:14,600
Speaker 1: Medicine down Atlanta tell us that a sizable chunk of

510
00:32:14,640 --> 00:32:19,120
Speaker 1: this has its origin and pain and how pain is managed,

511
00:32:19,520 --> 00:32:24,080
Speaker 1: and how people drift into using these drugs illegal and

512
00:32:24,160 --> 00:32:28,120
Speaker 1: legal as a consequence of that. So let's go back

513
00:32:28,160 --> 00:32:32,280
Speaker 1: to the source. Of this, which is a transdisciplinary approach

514
00:32:32,800 --> 00:32:35,800
Speaker 1: to the mental health problems that are comorbid with chronic pain,

515
00:32:36,360 --> 00:32:39,880
Speaker 1: to the problems of PTSD and TBI and other things.

516
00:32:40,400 --> 00:32:43,920
Speaker 1: Let's use a team approach that asks the question, how

517
00:32:43,960 --> 00:32:46,560
Speaker 1: can we relieve your pain most effectively that's going to

518
00:32:46,640 --> 00:32:49,320
Speaker 1: be best for you. And if some of that is

519
00:32:49,360 --> 00:32:53,040
Speaker 1: an existential crisis that you're going through that attends your pain,

520
00:32:53,480 --> 00:32:58,000
Speaker 1: then let's address that. At the same time, criminalizing opioids

521
00:32:58,040 --> 00:33:00,600
Speaker 1: alone is not going to be the solution to this. Unfortunately,

522
00:33:00,640 --> 00:33:04,280
Speaker 1: that's where we've drifted on this whole event, and we

523
00:33:04,400 --> 00:33:07,800
Speaker 1: have this residual that mister Gambris brought up earlier, which

524
00:33:07,880 --> 00:33:10,680
Speaker 1: is that we still have this dimension of this as

525
00:33:10,720 --> 00:33:14,480
Speaker 1: a moral failure. We don't want to give them subox zone.

526
00:33:14,560 --> 00:33:16,880
Speaker 1: Even those that are addicted, many of them say, I

527
00:33:16,880 --> 00:33:19,160
Speaker 1: don't Why am I using another drug to treat the

528
00:33:19,240 --> 00:33:20,960
Speaker 1: drug on mind? Well, because that drug is going to

529
00:33:21,040 --> 00:33:23,400
Speaker 1: keep you functional, and it's going to keep you out

530
00:33:23,400 --> 00:33:25,280
Speaker 1: of trouble. It's going to allow you to go back

531
00:33:25,320 --> 00:33:27,160
Speaker 1: and have a job, it's going to allow you to

532
00:33:27,200 --> 00:33:30,200
Speaker 1: stay together with your family. And I think to go

533
00:33:30,240 --> 00:33:32,440
Speaker 1: back to your question, what would a thirty six year

534
00:33:32,480 --> 00:33:35,840
Speaker 1: old veteran go through today. This is different. I'd like

535
00:33:35,880 --> 00:33:37,880
Speaker 1: to think because of the work that we're doing, that

536
00:33:37,960 --> 00:33:40,280
Speaker 1: we're trying to that we're starting to change the culture

537
00:33:40,320 --> 00:33:44,000
Speaker 1: that would ask that veteran from the get go. Okay,

538
00:33:44,040 --> 00:33:46,920
Speaker 1: let's look at all the dimensions of this. Wait a minute,

539
00:33:46,920 --> 00:33:50,280
Speaker 1: you're telling me that you lost friends when you got injured.

540
00:33:50,520 --> 00:33:53,360
Speaker 1: How is that playing into what's going on with your

541
00:33:53,400 --> 00:33:56,600
Speaker 1: pain and what might be going on with your wanting

542
00:33:57,040 --> 00:34:00,040
Speaker 1: to be sedated from that from that whole experience. And

543
00:34:00,840 --> 00:34:04,080
Speaker 1: you have a dimension too of being withdrawn from this

544
00:34:04,280 --> 00:34:06,600
Speaker 1: social environment that was simple social order. What can we

545
00:34:06,640 --> 00:34:11,280
Speaker 1: find that will provide you with that social construct again

546
00:34:11,360 --> 00:34:13,279
Speaker 1: that's going to be supportive of it, or at least

547
00:34:13,360 --> 00:34:16,200
Speaker 1: for you to acknowledge that. I think that's the idea

548
00:34:16,239 --> 00:34:19,759
Speaker 1: of a team based, transdisciplinary approach, and I'm pleased to

549
00:34:19,800 --> 00:34:22,439
Speaker 1: say the VA is taking a very very active role

550
00:34:22,440 --> 00:34:25,919
Speaker 1: on that their whole health approach that says, let's look

551
00:34:25,960 --> 00:34:29,839
Speaker 1: at mind, body, and spirit of every veteran. Let's make

552
00:34:30,080 --> 00:34:34,040
Speaker 1: life something for you that you can aspire to goals

553
00:34:34,480 --> 00:34:38,200
Speaker 1: irrespective of your state of health, of your age, of

554
00:34:38,280 --> 00:34:42,920
Speaker 1: your gender, of your experience in uniform. And by the way,

555
00:34:43,000 --> 00:34:45,400
Speaker 1: this is something I've always felt, why don't we leverage

556
00:34:45,440 --> 00:34:47,800
Speaker 1: the things the service taught to you that we're positive

557
00:34:47,960 --> 00:34:50,840
Speaker 1: that you can apply to your veteran status, all the

558
00:34:50,880 --> 00:34:53,680
Speaker 1: pride you took in serving the nation. How can we

559
00:34:53,719 --> 00:34:56,239
Speaker 1: apply those things to skills that you can use even

560
00:34:56,280 --> 00:34:59,600
Speaker 1: now as a veteran. When we come back, I'll be

561
00:34:59,680 --> 00:35:03,319
Speaker 1: joined by doctor Tripp buck and Meyer, the director for

562
00:35:03,400 --> 00:35:08,319
Speaker 1: the Uniform Services University's Defense and Veterans Center for Integrative

563
00:35:08,360 --> 00:35:28,919
Speaker 1: Pain Management. Doctor Chester trip buck and Meyer, the third

564
00:35:29,280 --> 00:35:31,880
Speaker 1: He's a medical doctor, colonel in the US Army, retired

565
00:35:32,280 --> 00:35:36,560
Speaker 1: director for the Uniform Service University's Defense and Veterans Center

566
00:35:36,880 --> 00:35:40,480
Speaker 1: for Integrative Pain Management, working with the Department of Military

567
00:35:40,520 --> 00:35:44,719
Speaker 1: Emergency Medicine, and a remarkable pioneer in the development of

568
00:35:44,800 --> 00:35:48,880
Speaker 1: better approaches and greater opportunities for people to deal with

569
00:35:48,920 --> 00:35:52,280
Speaker 1: pain in a way that does not cause long term damage.

570
00:35:52,960 --> 00:35:55,560
Speaker 1: What we really would like to hear from you, doctor, is,

571
00:35:56,360 --> 00:35:59,560
Speaker 1: in the modern system as it's been evolving, what would

572
00:35:59,600 --> 00:36:03,920
Speaker 1: happen and if you had somebody who's significantly burned in

573
00:36:03,960 --> 00:36:08,480
Speaker 1: a combat environment and you are metavacuum and then getting

574
00:36:08,480 --> 00:36:12,120
Speaker 1: them to burning the center, what would the experience be.

575
00:36:12,600 --> 00:36:17,360
Speaker 1: My focus has been trying to enhance pain management on

576
00:36:17,400 --> 00:36:20,160
Speaker 1: the battlefield, which in two thousand and three, when I

577
00:36:20,160 --> 00:36:22,920
Speaker 1: first deployed just a few months after we had launched

578
00:36:23,560 --> 00:36:28,000
Speaker 1: in Iraq, myself and many other colleagues were somewhat taken

579
00:36:28,000 --> 00:36:31,480
Speaker 1: aback and shocked that we were applying a nineteenth century

580
00:36:31,520 --> 00:36:35,600
Speaker 1: solution to pain management morphine in a twenty first century conflict,

581
00:36:36,320 --> 00:36:40,719
Speaker 1: and literally at the time, that was it, and it's

582
00:36:40,760 --> 00:36:44,719
Speaker 1: been essentially the only medication that has been used out

583
00:36:44,719 --> 00:36:47,400
Speaker 1: on the battlefield to great effect. I'm not if you

584
00:36:47,440 --> 00:36:50,440
Speaker 1: take away from this interview that I'm against opioids on

585
00:36:50,480 --> 00:36:53,399
Speaker 1: the battlefield. That would be a mistake I would take

586
00:36:53,560 --> 00:36:57,640
Speaker 1: to deploy as an anesthesiologist in this environment, which I've

587
00:36:57,680 --> 00:37:01,440
Speaker 1: done both to Iraq and Afghanistan and not have these tools.

588
00:37:02,120 --> 00:37:04,279
Speaker 1: I think the problem, just like it's been for the

589
00:37:04,280 --> 00:37:07,400
Speaker 1: rest of the country, is are thinking the medical profession

590
00:37:07,400 --> 00:37:11,560
Speaker 1: about pain sort of ended with the development of morphine.

591
00:37:12,040 --> 00:37:14,439
Speaker 1: It is certainly used a great effect in the Civil War,

592
00:37:15,160 --> 00:37:17,800
Speaker 1: and it's interesting that when you read that history, you'll

593
00:37:18,400 --> 00:37:22,160
Speaker 1: hear about soldiers disease. Soldiers after the Civil War with

594
00:37:22,280 --> 00:37:26,560
Speaker 1: horrific wounds, becoming dependent on opioid and becoming what they

595
00:37:26,640 --> 00:37:30,640
Speaker 1: called back then opioid eaters, and every conflict since that

596
00:37:30,920 --> 00:37:35,040
Speaker 1: same scenario has played out. What's different about this conflict

597
00:37:35,239 --> 00:37:38,160
Speaker 1: is the fact that many patients who never would have

598
00:37:38,200 --> 00:37:42,120
Speaker 1: survived in conflicts of the past are now routinely surviving

599
00:37:42,360 --> 00:37:47,799
Speaker 1: with one, two, three, four limb amputations. Less than ten

600
00:37:47,840 --> 00:37:51,920
Speaker 1: percent died of wounds rate has been achieved by your military,

601
00:37:52,000 --> 00:37:57,239
Speaker 1: and that's historic. Never before has a military achieved that

602
00:37:57,360 --> 00:38:01,040
Speaker 1: level of sophistication and in fact our ability to take

603
00:38:01,080 --> 00:38:05,600
Speaker 1: care of casualties. Literally, building an intensive care system on

604
00:38:05,640 --> 00:38:09,319
Speaker 1: the fly, where the new watchword has gone away from

605
00:38:09,400 --> 00:38:14,879
Speaker 1: stabilizing a patient for transport to providing just enough stabilization

606
00:38:14,920 --> 00:38:17,000
Speaker 1: to get them to the next node in the chain,

607
00:38:17,760 --> 00:38:21,080
Speaker 1: has really made all the difference in their survival. But

608
00:38:21,200 --> 00:38:24,239
Speaker 1: it really pointed out the fact that more people were surviving,

609
00:38:25,160 --> 00:38:29,200
Speaker 1: the number of healthcare providers in this chain that we're

610
00:38:29,239 --> 00:38:32,279
Speaker 1: interacting with a patient, the flaws that we had in

611
00:38:32,360 --> 00:38:35,799
Speaker 1: our ability to actually manage their pain, particularly if we're

612
00:38:35,840 --> 00:38:41,600
Speaker 1: only relying on opioids. This whole question of pain management

613
00:38:41,600 --> 00:38:44,600
Speaker 1: in the way it has evolved as we think about

614
00:38:44,640 --> 00:38:48,880
Speaker 1: it that there was a period there were apparently, particularly

615
00:38:48,880 --> 00:38:52,040
Speaker 1: the nineties, if somebody told you they were in pain,

616
00:38:52,680 --> 00:38:56,279
Speaker 1: there was a general consensus that you should deal with

617
00:38:56,280 --> 00:39:00,399
Speaker 1: it pretty aggressively, even at the risk of addiction. And

618
00:39:00,480 --> 00:39:04,960
Speaker 1: now we've seemed to have shifted gears pretty dramatically and

619
00:39:05,120 --> 00:39:08,880
Speaker 1: looking for alternative techniques for managing pain. And I know

620
00:39:09,000 --> 00:39:11,120
Speaker 1: that that is one of the areas where you have

621
00:39:11,200 --> 00:39:14,000
Speaker 1: really specialized and done a great deal of work and

622
00:39:14,160 --> 00:39:18,200
Speaker 1: looking at the nature of how the medical system has

623
00:39:18,239 --> 00:39:21,120
Speaker 1: shifted it's thinking about pain and how it's looked for

624
00:39:21,160 --> 00:39:24,799
Speaker 1: a series of alternative ways of dealing with things. We

625
00:39:24,800 --> 00:39:28,160
Speaker 1: were desperate for other options, and in fact, prior to

626
00:39:28,600 --> 00:39:31,200
Speaker 1: nine to eleven, I was finishing up my medical training

627
00:39:31,200 --> 00:39:34,680
Speaker 1: at Duke in a new area of medicine. It's one

628
00:39:34,719 --> 00:39:38,280
Speaker 1: of the newer specialties in anesthesia called acute pain medicine

629
00:39:38,280 --> 00:39:41,640
Speaker 1: and regional anesthesia. And so I was at an institution

630
00:39:41,680 --> 00:39:44,640
Speaker 1: at Duke, one of just a handful at the time

631
00:39:44,719 --> 00:39:48,200
Speaker 1: that we're placing what are called peripheral nerve catheters using

632
00:39:48,280 --> 00:39:52,520
Speaker 1: local anesthetics. Local anesthetics like novacame that you get at

633
00:39:52,520 --> 00:39:55,440
Speaker 1: the dentists have none of the downsides as far as

634
00:39:55,440 --> 00:40:03,200
Speaker 1: the sedation, restory, depression, dependence, no that are associated with opioids.

635
00:40:03,560 --> 00:40:06,680
Speaker 1: My boss at the time, Colonel Jack Chiles, and myself

636
00:40:07,120 --> 00:40:09,359
Speaker 1: we were trying to figure out ways that we could

637
00:40:09,360 --> 00:40:14,239
Speaker 1: more efficiently manage patients with fewer people have fewer call

638
00:40:14,320 --> 00:40:17,960
Speaker 1: In the First Golf War, we deployed these massive field

639
00:40:18,000 --> 00:40:21,560
Speaker 1: hospitals and after that conflict three hundred hours and three

640
00:40:21,640 --> 00:40:25,520
Speaker 1: hundred patients, the line officers were saying, look, you guys

641
00:40:25,560 --> 00:40:29,600
Speaker 1: cannot bring that much stuff. You have to become more efficient. Unfortunately,

642
00:40:29,640 --> 00:40:33,319
Speaker 1: technology what's going to make that happen. And so from

643
00:40:33,320 --> 00:40:36,839
Speaker 1: an anesthesia standpoint, we were trying to develop a way

644
00:40:37,480 --> 00:40:41,200
Speaker 1: of providing anesthesia for the common wounds that were happening,

645
00:40:41,320 --> 00:40:44,640
Speaker 1: and actually burns are not that common in this war.

646
00:40:44,680 --> 00:40:48,359
Speaker 1: Of course, it's been more limb injuries because of the IEDs.

647
00:40:49,200 --> 00:40:53,160
Speaker 1: These regional anesthesia techniques, particularly with a capital when you've

648
00:40:53,160 --> 00:40:56,319
Speaker 1: blown off a limb, I can turn that area of

649
00:40:56,360 --> 00:40:59,640
Speaker 1: your body off, providing not only a surgical level of

650
00:40:59,640 --> 00:41:02,400
Speaker 1: anisi sthetic where a surgeon can work on it without

651
00:41:02,440 --> 00:41:06,200
Speaker 1: the patient responding, but then between operations and during the

652
00:41:06,320 --> 00:41:09,480
Speaker 1: evacuation flights. I can provide a continuous infusion of this

653
00:41:09,560 --> 00:41:13,080
Speaker 1: local anesthetic that has none of the downsides of an opioid,

654
00:41:13,160 --> 00:41:16,000
Speaker 1: and so it allows far less utilization of an opioid

655
00:41:16,000 --> 00:41:20,080
Speaker 1: because oftentimes these patients have multiple injuries that required treatment.

656
00:41:20,640 --> 00:41:23,520
Speaker 1: But for these main injuries, it was a real advancement.

657
00:41:23,960 --> 00:41:27,080
Speaker 1: We actually took this technology early in two thousand and

658
00:41:27,160 --> 00:41:29,840
Speaker 1: three tour Iraq. In fact, that was the first time

659
00:41:30,080 --> 00:41:33,560
Speaker 1: I was deployed to demonstrate that we could actually do this.

660
00:41:33,640 --> 00:41:35,960
Speaker 1: And I want to just make sure you understand the

661
00:41:36,000 --> 00:41:39,879
Speaker 1: stage in two thousand and three, when I just graduated

662
00:41:39,880 --> 00:41:43,120
Speaker 1: a few years ago from Duke nine to eleven, happened.

663
00:41:43,160 --> 00:41:45,760
Speaker 1: And in fact, I've never known being a staff physician.

664
00:41:46,280 --> 00:41:50,000
Speaker 1: Without this war, there were probably only five institutions at

665
00:41:50,040 --> 00:41:53,040
Speaker 1: best in the United States that we're doing this. I

666
00:41:53,080 --> 00:41:56,280
Speaker 1: actually was able to bring this very efficiently, this cutting

667
00:41:56,360 --> 00:42:00,080
Speaker 1: edge technology out to what I considered one of the

668
00:42:00,120 --> 00:42:02,720
Speaker 1: most usteer environments you can do medicine in an Iraq,

669
00:42:03,719 --> 00:42:08,239
Speaker 1: and it was wildly successful. The first patient, Brian Wilhelm,

670
00:42:08,239 --> 00:42:11,160
Speaker 1: this is hippo compliant. He allows us to discuss it.

671
00:42:11,239 --> 00:42:15,160
Speaker 1: He had lost his right leg to a rocket propelled

672
00:42:15,160 --> 00:42:18,880
Speaker 1: grenade is chronicled in a book called Out of the Crucible.

673
00:42:19,800 --> 00:42:24,000
Speaker 1: But with that first case, it allowed us to understand

674
00:42:24,080 --> 00:42:27,160
Speaker 1: better that we needed to have a multimodal approach to

675
00:42:27,200 --> 00:42:30,879
Speaker 1: pay management on the battlefield. We needed providers that were

676
00:42:30,920 --> 00:42:34,400
Speaker 1: focused on that issue, and we needed other tools in

677
00:42:34,440 --> 00:42:38,520
Speaker 1: the toolbox. And from that initial experience, I'm very pleased

678
00:42:38,560 --> 00:42:41,719
Speaker 1: to say that the care that we're providing for pain

679
00:42:41,800 --> 00:42:46,560
Speaker 1: on the battlefield today is vastly different from that nineteenth

680
00:42:46,600 --> 00:42:49,600
Speaker 1: century approach we were applying when I arrived in two

681
00:42:49,600 --> 00:42:54,480
Speaker 1: thousand and three. When you talk about anesthesiology the way

682
00:42:54,480 --> 00:42:58,680
Speaker 1: you're doing it, regional anesthesia actually means applied to a

683
00:42:58,800 --> 00:43:02,600
Speaker 1: region of the body, is correct. That's correct. When I

684
00:43:02,719 --> 00:43:05,239
Speaker 1: arrived in two thousand and three in Iraq, whether you

685
00:43:05,320 --> 00:43:08,880
Speaker 1: had a hand garnaid injury or a hangnail, everybody was

686
00:43:08,880 --> 00:43:14,000
Speaker 1: getting evolved lanesthetic and that's crushing on resources. We remember,

687
00:43:14,040 --> 00:43:18,000
Speaker 1: we drive those anesthesia machines to provide that general anesthetic

688
00:43:18,000 --> 00:43:22,640
Speaker 1: with fifty five psi of oxygen, while some trooper has

689
00:43:22,719 --> 00:43:26,480
Speaker 1: to slept that oxygen to these areas. In my case,

690
00:43:26,560 --> 00:43:30,759
Speaker 1: I was in Blide, Iraq. One of the things that

691
00:43:30,800 --> 00:43:34,320
Speaker 1: we were looking at is. If we could provide regional

692
00:43:34,320 --> 00:43:37,280
Speaker 1: anesthesia for a number of the cases we were dealing

693
00:43:37,280 --> 00:43:41,480
Speaker 1: with again limb injuries and avoid evolved lan aesthetic, we

694
00:43:41,480 --> 00:43:43,920
Speaker 1: would have a better product, if you will, from a

695
00:43:43,960 --> 00:43:48,520
Speaker 1: recovery standpoint, that could move through the system with fewer resources.

696
00:43:49,000 --> 00:43:52,600
Speaker 1: I even have a photograph of a burned patient. In

697
00:43:52,640 --> 00:43:54,560
Speaker 1: this case, it was a kid who burned his hand,

698
00:43:54,600 --> 00:43:59,319
Speaker 1: a third degree burn. We burn our sewage out there.

699
00:43:59,480 --> 00:44:02,680
Speaker 1: It's actually quite pretty. It might when also as we

700
00:44:02,760 --> 00:44:06,960
Speaker 1: call them, turd fires are with off. But the poor

701
00:44:07,040 --> 00:44:11,239
Speaker 1: kid burned himself and I did a continuous purple nerve

702
00:44:11,280 --> 00:44:14,279
Speaker 1: block on him and he's actually watching the surgeon to

703
00:44:14,480 --> 00:44:17,080
Speaker 1: breathe his hand, and I have a photograph of that.

704
00:44:17,080 --> 00:44:20,720
Speaker 1: That's how powerful this can be. But more importantly, after

705
00:44:20,760 --> 00:44:25,560
Speaker 1: the operation, you have an alert, pain free, not nauseated

706
00:44:25,960 --> 00:44:29,719
Speaker 1: patient that can be a proponent of their own evacuation.

707
00:44:29,800 --> 00:44:33,080
Speaker 1: And what I mean by that is they're able to

708
00:44:33,080 --> 00:44:37,960
Speaker 1: participate in their evacuation as opposed to a general anesthetic patient.

709
00:44:37,960 --> 00:44:40,880
Speaker 1: It might be severely injured, and you can imagine the

710
00:44:40,920 --> 00:44:45,080
Speaker 1: resources it takes is far greater than dealing with somebody

711
00:44:45,080 --> 00:44:49,040
Speaker 1: that's breathing on their own talking and pain free. And

712
00:44:49,239 --> 00:44:51,759
Speaker 1: of course there's some patients that are so wounded that

713
00:44:51,800 --> 00:44:56,160
Speaker 1: they absolutely need a general anesthetic and they need intensive support.

714
00:44:56,760 --> 00:44:58,840
Speaker 1: And what I felt that I was doing was freeing

715
00:44:58,960 --> 00:45:03,000
Speaker 1: up resources to focus on those people that desperately needed

716
00:45:03,000 --> 00:45:07,160
Speaker 1: that attention, while some of these lighter injured people we

717
00:45:07,200 --> 00:45:10,480
Speaker 1: could take care of just as efficiently but with not

718
00:45:10,640 --> 00:45:14,080
Speaker 1: as much attention because of these techniques. Since we're telling

719
00:45:14,160 --> 00:45:17,160
Speaker 1: war stories, I actually deployed with a British to Afghanistan

720
00:45:17,200 --> 00:45:20,160
Speaker 1: in two thousand and nine to establish the first acute

721
00:45:20,200 --> 00:45:23,160
Speaker 1: pain service because the British were willing to do this.

722
00:45:23,239 --> 00:45:25,279
Speaker 1: So we went out there and I came across a

723
00:45:25,400 --> 00:45:28,520
Speaker 1: guide Disney, a British lieutenant who had lost his foot

724
00:45:29,480 --> 00:45:32,280
Speaker 1: and he was in a considerable pain. Had be given

725
00:45:32,360 --> 00:45:35,480
Speaker 1: a lot of morphine. And after we'd done our primary

726
00:45:35,520 --> 00:45:38,160
Speaker 1: and secondary surveys and we were ready to get some

727
00:45:38,239 --> 00:45:41,239
Speaker 1: imaging studies and take them to the o R, I

728
00:45:41,280 --> 00:45:43,520
Speaker 1: looked at him and I said, when you wake up,

729
00:45:43,520 --> 00:45:46,920
Speaker 1: you'll be pain free. Now, I want you to digest that,

730
00:45:47,160 --> 00:45:50,520
Speaker 1: because any anesthesiologists is able to say that to a

731
00:45:50,600 --> 00:45:53,359
Speaker 1: patient just a few years ago would have to have

732
00:45:53,480 --> 00:45:58,200
Speaker 1: big braskahonies. But I had this technology where I was

733
00:45:58,239 --> 00:46:01,400
Speaker 1: going to block his leg. I knew that when he

734
00:46:01,480 --> 00:46:04,640
Speaker 1: woke up from that operation that I would be able

735
00:46:04,680 --> 00:46:08,600
Speaker 1: to deliver on that promise. We did TIVA on him

736
00:46:08,640 --> 00:46:11,040
Speaker 1: total I the anesthesia. We didn't expose him to the

737
00:46:11,120 --> 00:46:14,600
Speaker 1: voltile anesthetics. Now, I was very busy and bad day

738
00:46:14,680 --> 00:46:16,400
Speaker 1: that day. We had a lot of casually, so I

739
00:46:16,400 --> 00:46:20,759
Speaker 1: didn't get to see him immediately after the operation. But

740
00:46:20,920 --> 00:46:24,120
Speaker 1: when I had finished up, I walked back there. I

741
00:46:24,160 --> 00:46:26,000
Speaker 1: didn't get to talk to him again because he was

742
00:46:26,040 --> 00:46:28,840
Speaker 1: on the phone to his mother and he said words

743
00:46:28,840 --> 00:46:31,400
Speaker 1: along the lines of Mum, I had to give him

744
00:46:31,440 --> 00:46:33,680
Speaker 1: a foot, but I'm okay, and I'm going to see

745
00:46:33,680 --> 00:46:36,600
Speaker 1: you in a few weeks. And that was a poignant

746
00:46:36,640 --> 00:46:38,880
Speaker 1: moment for me, and one of the reasons I chose

747
00:46:38,960 --> 00:46:41,440
Speaker 1: him for this Out of the Crucible book because it

748
00:46:41,560 --> 00:46:44,080
Speaker 1: condenses what I've been trying to do. Here was a

749
00:46:44,080 --> 00:46:47,640
Speaker 1: soldier who had just had his foot blown off, and

750
00:46:47,680 --> 00:46:51,279
Speaker 1: he's talking to his mother about the future. That's good

751
00:46:51,320 --> 00:46:56,719
Speaker 1: pain management. That's what this country needs when you free

752
00:46:56,760 --> 00:47:00,360
Speaker 1: a patient from the pain in a safe way. We

753
00:47:00,440 --> 00:47:05,280
Speaker 1: still used opioids on him, but very limited amounts because

754
00:47:05,280 --> 00:47:11,040
Speaker 1: we were doing this multimodal approach, particularly leveraging this regional anesthesia,

755
00:47:11,120 --> 00:47:14,200
Speaker 1: and we were able to provide a product at the

756
00:47:14,280 --> 00:47:17,960
Speaker 1: end of this that was ready for transport, pain free,

757
00:47:18,360 --> 00:47:22,080
Speaker 1: was not a burden on the nursing resources, and was

758
00:47:22,120 --> 00:47:25,920
Speaker 1: actually thinking about his future. Much of this PTSD and

759
00:47:26,880 --> 00:47:32,160
Speaker 1: depression and suicide, I'm of the opinion occurs because we

760
00:47:32,239 --> 00:47:36,000
Speaker 1: allow too many soldiers not to have that experience. They

761
00:47:36,080 --> 00:47:38,960
Speaker 1: wallow in their pain. We know that pain is a

762
00:47:39,040 --> 00:47:44,520
Speaker 1: significant contributor to PTSD, and it just snowballs and builds

763
00:47:44,600 --> 00:47:48,360
Speaker 1: and so months years later you end up with that

764
00:47:48,640 --> 00:47:51,360
Speaker 1: veteran taking their life. And as you know, that's a

765
00:47:51,400 --> 00:47:55,560
Speaker 1: real problem right now, many veterans every day committing suicide.

766
00:47:56,040 --> 00:47:59,080
Speaker 1: The only good thing that comes from wars advances in medicine,

767
00:47:59,080 --> 00:48:01,759
Speaker 1: and that has certainly in the case for the last

768
00:48:01,960 --> 00:48:04,680
Speaker 1: nineteen years of conflict. It's one of the reasons I'm

769
00:48:04,680 --> 00:48:07,560
Speaker 1: a graduate of the Uniform Services University why I think

770
00:48:07,600 --> 00:48:12,040
Speaker 1: that institution is so vital to our military, because that's

771
00:48:12,040 --> 00:48:15,720
Speaker 1: the repository of this knowledge so that we're not starting

772
00:48:15,719 --> 00:48:18,440
Speaker 1: over again in the next conflict. Let me ask you

773
00:48:19,040 --> 00:48:23,920
Speaker 1: the remarkable work you've done on pain and the progress

774
00:48:23,960 --> 00:48:26,719
Speaker 1: you've made. You were part of the Pain Management Task

775
00:48:26,760 --> 00:48:29,920
Speaker 1: Force with General Schoemaker, and we had a chance to

776
00:48:29,960 --> 00:48:34,040
Speaker 1: talk with General Schoemaker from his perspective, But what were

777
00:48:34,080 --> 00:48:37,600
Speaker 1: the real changes in thinking and the real recommendations that

778
00:48:37,760 --> 00:48:40,839
Speaker 1: you think began to move us towards a much more

779
00:48:40,840 --> 00:48:46,359
Speaker 1: effective method of dealing with pain without having follow on complications. Well,

780
00:48:46,360 --> 00:48:48,840
Speaker 1: the Pain Task Force was a top to bottom look

781
00:48:49,280 --> 00:48:53,160
Speaker 1: to General Schoemaker's credit, had the good and bad and

782
00:48:53,360 --> 00:48:56,319
Speaker 1: ugly that was going on in military pain medicine. The

783
00:48:56,360 --> 00:48:59,400
Speaker 1: good news was that as far as a standard was concerned,

784
00:48:59,440 --> 00:49:02,239
Speaker 1: we were meeting a standard for pain management that would

785
00:49:02,239 --> 00:49:06,399
Speaker 1: be recognized in any system. But that's not necessarily a

786
00:49:06,480 --> 00:49:09,440
Speaker 1: good thing because that bar was so low. What we

787
00:49:09,560 --> 00:49:13,960
Speaker 1: really determined, and you know, mostly because of the service

788
00:49:14,000 --> 00:49:17,160
Speaker 1: members expressing to us that while they were begging us

789
00:49:17,239 --> 00:49:20,560
Speaker 1: for pain management and begging for these opioids because they

790
00:49:20,560 --> 00:49:24,600
Speaker 1: are so effective at reducing pain intensity, if they would

791
00:49:24,600 --> 00:49:29,160
Speaker 1: have known what that meant to their eventual recovery and rehabilitation,

792
00:49:29,360 --> 00:49:31,719
Speaker 1: they would have begged us to come up with some

793
00:49:31,800 --> 00:49:36,000
Speaker 1: other ideas. Now we've had a long conversation about regional anesthesia,

794
00:49:36,080 --> 00:49:41,120
Speaker 1: but that's just one piece of the whole pie of

795
00:49:41,160 --> 00:49:46,400
Speaker 1: managing pain. Pain Unfortunately, unlike other chronic disease processes like

796
00:49:46,520 --> 00:49:51,360
Speaker 1: heart disease or diabetes, liver disease doesn't have a lab test.

797
00:49:51,840 --> 00:49:55,400
Speaker 1: We don't have something that we can objectively measure. We

798
00:49:55,480 --> 00:49:59,520
Speaker 1: have to rely on the patient. Part of the problem

799
00:49:59,600 --> 00:50:03,120
Speaker 1: is this the disease of the central and purple nervous system,

800
00:50:03,960 --> 00:50:06,200
Speaker 1: part of the body that we probably have the least

801
00:50:06,280 --> 00:50:09,759
Speaker 1: understanding of how it functions and how it works, with

802
00:50:09,920 --> 00:50:13,799
Speaker 1: new concepts developing every day. But we do know that

803
00:50:13,880 --> 00:50:18,240
Speaker 1: pain is a biopsychosocial experience. What do I mean by that, Well,

804
00:50:18,680 --> 00:50:22,640
Speaker 1: it certainly has a biological basis. You probably struct your

805
00:50:22,800 --> 00:50:26,120
Speaker 1: thumb with a hammer like we all have, and everybody

806
00:50:26,200 --> 00:50:30,239
Speaker 1: understands that pain. But when we're talking about somebody who's

807
00:50:30,280 --> 00:50:35,400
Speaker 1: had a true trauma, the impact of their psychological state,

808
00:50:36,160 --> 00:50:43,520
Speaker 1: their social interactions is just as important as that biological stimulus,

809
00:50:43,560 --> 00:50:46,000
Speaker 1: which is so vital for our survival as we move

810
00:50:46,080 --> 00:50:50,399
Speaker 1: through our environment. Pain helps us protect ourselves, but these

811
00:50:50,480 --> 00:50:54,120
Speaker 1: other issues are no less as important. And so we

812
00:50:54,200 --> 00:50:58,560
Speaker 1: have two patients, both with their legs blown off. One

813
00:50:58,600 --> 00:51:03,560
Speaker 1: of those patients, as an active family support system, has

814
00:51:03,640 --> 00:51:07,200
Speaker 1: good pain control, has a future that they're thinking about.

815
00:51:08,080 --> 00:51:11,239
Speaker 1: That patient is going to do far better than the

816
00:51:11,280 --> 00:51:15,800
Speaker 1: exact same patient from a clinical standpoint that has no

817
00:51:15,960 --> 00:51:20,440
Speaker 1: social support, is wallowing in their pain, maybe had poor

818
00:51:20,440 --> 00:51:25,320
Speaker 1: pain management early on and through their course, and doesn't

819
00:51:25,360 --> 00:51:29,600
Speaker 1: have a real sense of future. And so we don't

820
00:51:29,640 --> 00:51:32,640
Speaker 1: measure that. Right, You've been asked about your pain, probably

821
00:51:32,680 --> 00:51:34,959
Speaker 1: from a doctor, what's your pain on that scale zero

822
00:51:35,040 --> 00:51:37,319
Speaker 1: to ten, And we've all been exposed to that. But

823
00:51:37,440 --> 00:51:41,360
Speaker 1: all that's measuring is pain intensity. It doesn't give the

824
00:51:41,480 --> 00:51:45,759
Speaker 1: clinician any idea on what might be going on in

825
00:51:45,760 --> 00:51:50,240
Speaker 1: your life in terms of your activities, your sleep, your stress,

826
00:51:50,680 --> 00:51:54,399
Speaker 1: your mood, what level of depression you might have, how

827
00:51:54,480 --> 00:51:58,279
Speaker 1: much you might catastrophize about your pain. I can tell

828
00:51:58,320 --> 00:52:02,560
Speaker 1: you personally. I've just witness soldiers who don't fixate on

829
00:52:02,600 --> 00:52:07,560
Speaker 1: their injury and aren't catastrophizing about their future just do

830
00:52:07,680 --> 00:52:11,719
Speaker 1: better than those patients that essentially get sucked into their

831
00:52:11,719 --> 00:52:17,640
Speaker 1: injury and the woe's me syndrome. And so we've been

832
00:52:17,640 --> 00:52:20,319
Speaker 1: working very hard. One of the most important things that

833
00:52:20,360 --> 00:52:22,120
Speaker 1: came out of the Pain Pass for us. Was that

834
00:52:22,719 --> 00:52:26,839
Speaker 1: understanding that this is a biopsycho social phenomenon and that

835
00:52:26,880 --> 00:52:30,360
Speaker 1: we needed to measure better. I'm of the opinion that

836
00:52:30,440 --> 00:52:33,359
Speaker 1: that zero to ten scale, while it was a very

837
00:52:33,360 --> 00:52:38,000
Speaker 1: important step forward and understanding pain, is partly responsible for

838
00:52:38,120 --> 00:52:41,680
Speaker 1: the rut we're in right now with opioids, because the

839
00:52:41,719 --> 00:52:45,200
Speaker 1: best thing to get your pain intensity down is an opioid.

840
00:52:45,560 --> 00:52:48,000
Speaker 1: I can get anybody's paying down to zero. I don't

841
00:52:48,040 --> 00:52:50,480
Speaker 1: care who you are. You might be on the floor

842
00:52:50,480 --> 00:52:53,360
Speaker 1: blowing spit bubbles, but that's not what you asked me

843
00:52:53,400 --> 00:52:55,600
Speaker 1: to do. You asked me to get your pain to zero,

844
00:52:55,640 --> 00:52:58,600
Speaker 1: and that's what we were doing early in these conflicts.

845
00:52:59,040 --> 00:53:01,920
Speaker 1: We've now figured that's probably not the right way to

846
00:53:01,920 --> 00:53:06,040
Speaker 1: approach this and probably not the patient's self interest. Certainly,

847
00:53:06,080 --> 00:53:09,359
Speaker 1: we want to reduce your pain, but more importantly, we

848
00:53:09,400 --> 00:53:14,360
Speaker 1: want to bring therapies to bear that improve your physical

849
00:53:14,480 --> 00:53:18,279
Speaker 1: and emotional function. That's a new way of thinking. That's

850
00:53:18,280 --> 00:53:22,080
Speaker 1: a cultural shift, and when we start talking about that,

851
00:53:22,760 --> 00:53:27,160
Speaker 1: opioids you find aren't as effective. But other things like

852
00:53:27,280 --> 00:53:35,880
Speaker 1: regional anesthesia, other drugs, other techniques such as acupuncture, massage, yoga,

853
00:53:36,480 --> 00:53:41,520
Speaker 1: behavioral health modification, those things are now able to compete

854
00:53:42,239 --> 00:53:45,040
Speaker 1: with these opioids in a way that they've never been

855
00:53:45,080 --> 00:53:48,080
Speaker 1: able to before. When all we were asking was that

856
00:53:48,200 --> 00:53:52,240
Speaker 1: zero to tend scale. If you were advising our central

857
00:53:52,360 --> 00:53:55,560
Speaker 1: character and who and what he should do, you know,

858
00:53:55,640 --> 00:53:59,400
Speaker 1: Brett gard now as a opioid addiction. He's trying to

859
00:53:59,440 --> 00:54:02,080
Speaker 1: break fully from it, and you obviously have a lot

860
00:54:02,120 --> 00:54:06,400
Speaker 1: of veterans who have similar situations. What are the patterns

861
00:54:06,480 --> 00:54:10,000
Speaker 1: you recommend? I mean, how does one deal with this

862
00:54:10,080 --> 00:54:14,320
Speaker 1: kind of pain? Well, the first part is just helping

863
00:54:14,400 --> 00:54:18,360
Speaker 1: him understand what we were just discussing that pain is

864
00:54:18,360 --> 00:54:20,879
Speaker 1: a part of life. You know, life is pain. You've

865
00:54:20,920 --> 00:54:24,680
Speaker 1: heard that before. Well, that's true. Pain is a vital

866
00:54:24,920 --> 00:54:28,040
Speaker 1: part of your survival. You can't move through your environment

867
00:54:28,239 --> 00:54:32,480
Speaker 1: without the help of that sensation. When it becomes overwhelming

868
00:54:32,640 --> 00:54:35,480
Speaker 1: like it is in this case, you have to discuss

869
00:54:35,600 --> 00:54:40,040
Speaker 1: management in terms of maximizing this function and help him

870
00:54:40,120 --> 00:54:44,160
Speaker 1: understand that this burn and this chronic pain might be

871
00:54:44,200 --> 00:54:47,239
Speaker 1: a lifelong issue that will have to manage, but it

872
00:54:47,280 --> 00:54:51,520
Speaker 1: doesn't have to become a life destroying issue. And so

873
00:54:51,680 --> 00:54:56,200
Speaker 1: management first is recognizing that when you're only using one tool,

874
00:54:56,880 --> 00:55:00,040
Speaker 1: these opioids, and now this individuals. Certainly by asking the

875
00:55:00,120 --> 00:55:04,719
Speaker 1: question is insight into the damage that this particular approach

876
00:55:05,040 --> 00:55:10,000
Speaker 1: is causing him. Hopefully it will allow a discussion about

877
00:55:10,080 --> 00:55:12,800
Speaker 1: other options. And the tool that we're using in the

878
00:55:12,880 --> 00:55:15,640
Speaker 1: VA and the DoD to assist this in this discussion

879
00:55:15,760 --> 00:55:18,800
Speaker 1: is called the stepcare model of pain. The first step

880
00:55:19,040 --> 00:55:23,080
Speaker 1: this model isn't involving healthcare providers at all. It's what

881
00:55:23,120 --> 00:55:26,960
Speaker 1: can the patient do to improve their situation in terms

882
00:55:26,960 --> 00:55:31,920
Speaker 1: of power, my relationships, my diet, am I drinking a

883
00:55:31,960 --> 00:55:36,239
Speaker 1: lot of alcohol, my smoking? Am I not exercising? Am

884
00:55:36,239 --> 00:55:39,879
Speaker 1: I actually creating conditions where the other things that might

885
00:55:39,920 --> 00:55:43,120
Speaker 1: be tried can be effected. The next step on that

886
00:55:43,360 --> 00:55:46,480
Speaker 1: is integrative health modality some that we've just mentioned that

887
00:55:46,600 --> 00:55:50,560
Speaker 1: have a very low side effect profile but in many

888
00:55:50,600 --> 00:55:54,920
Speaker 1: cases have tremendous benefit. I actually am a license acupuncturist

889
00:55:55,000 --> 00:55:58,239
Speaker 1: in Maryland and I have a side practice. I work

890
00:55:58,320 --> 00:56:01,960
Speaker 1: for my wife who's at Odds Therapist as her acupuncturists

891
00:56:02,640 --> 00:56:07,359
Speaker 1: dealing with a lot of muscus scalpel and behavioral anxiety

892
00:56:07,480 --> 00:56:11,759
Speaker 1: issues with just acupuncture, and so I know that that

893
00:56:12,600 --> 00:56:16,359
Speaker 1: can be extremely effective, but not in a vacuum. The

894
00:56:16,480 --> 00:56:20,920
Speaker 1: idea is not using any one modality. The idea is

895
00:56:21,000 --> 00:56:24,360
Speaker 1: having a lot of providers that are bringing different things

896
00:56:24,520 --> 00:56:27,399
Speaker 1: with the patient at the center, and then using all

897
00:56:27,440 --> 00:56:31,799
Speaker 1: of these modalities to minimize the need to use any

898
00:56:31,880 --> 00:56:36,200
Speaker 1: one like opioids, knowing that these things all work synergistically.

899
00:56:36,800 --> 00:56:39,160
Speaker 1: And so, for example, my wife and I have discovered

900
00:56:39,200 --> 00:56:43,719
Speaker 1: that massage an acupuncture, particularly for back pain, the most

901
00:56:43,760 --> 00:56:48,680
Speaker 1: common pain that plagues Americans, is exquisitely effective because she's

902
00:56:48,719 --> 00:56:53,240
Speaker 1: providing me information from her massage that helps me guide

903
00:56:53,280 --> 00:56:57,600
Speaker 1: my acupuncture needles. We know that from a drug standpoint,

904
00:56:58,200 --> 00:57:01,560
Speaker 1: I'm not against opioids, but when you combine opioids with

905
00:57:01,640 --> 00:57:04,480
Speaker 1: other drugs. One of the biggest things that have come

906
00:57:04,520 --> 00:57:06,680
Speaker 1: out of this war, and one of our biggest frustrations

907
00:57:06,760 --> 00:57:10,640
Speaker 1: right now is the usefulness of ketamine as an analgesic.

908
00:57:11,280 --> 00:57:14,919
Speaker 1: But we're still having challenges getting the FDA to recognize

909
00:57:15,480 --> 00:57:20,400
Speaker 1: that ketamine is an analgesic. And so today, right now

910
00:57:20,440 --> 00:57:24,280
Speaker 1: there are soldiers at Walter Reid on ketamine infusions, which

911
00:57:24,320 --> 00:57:27,720
Speaker 1: is an off label use. And this soldier that you're

912
00:57:27,760 --> 00:57:31,160
Speaker 1: talking about today, most likely from these burns, would have

913
00:57:31,160 --> 00:57:34,480
Speaker 1: been exposed to ketamine, particularly as a special force is

914
00:57:34,480 --> 00:57:39,880
Speaker 1: true ketamine. It's not replaced morphine on the battlefield, which

915
00:57:39,880 --> 00:57:43,280
Speaker 1: it should not. But instead of just in the past,

916
00:57:43,360 --> 00:57:45,960
Speaker 1: if you got morphine and you had more pain, you

917
00:57:46,080 --> 00:57:51,400
Speaker 1: just got morphine. Now we usually do morphine and if

918
00:57:51,400 --> 00:57:55,360
Speaker 1: you still have severe pain and we're talking real trauma here,

919
00:57:55,680 --> 00:57:59,040
Speaker 1: ketamine is now the next choice that in and of

920
00:57:59,080 --> 00:58:03,120
Speaker 1: itself is a huge change from battlefields of the past

921
00:58:03,160 --> 00:58:06,880
Speaker 1: and even right now. And so we're understanding that it's

922
00:58:06,880 --> 00:58:10,920
Speaker 1: not that opioids are bad, the way we as clinicians

923
00:58:10,920 --> 00:58:14,240
Speaker 1: have been using them is bad, and that to manage

924
00:58:14,280 --> 00:58:18,040
Speaker 1: pain you have to open your scope and look at

925
00:58:18,120 --> 00:58:22,600
Speaker 1: a lot of different modalities and this stepcare model sort

926
00:58:22,640 --> 00:58:25,040
Speaker 1: of helps us. So you step from what can the

927
00:58:25,080 --> 00:58:29,959
Speaker 1: patient do, what sorts of low impact, integrative, how things

928
00:58:29,960 --> 00:58:34,080
Speaker 1: can we do? And then medications and then possibly opioids

929
00:58:34,400 --> 00:58:38,320
Speaker 1: or other interventional procedures which can be very effective in

930
00:58:38,400 --> 00:58:42,160
Speaker 1: selective cases. And so it's bringing all of that to bear.

931
00:58:42,280 --> 00:58:44,520
Speaker 1: And that's what the Pain Task Force was trying to say.

932
00:58:44,880 --> 00:58:48,560
Speaker 1: With your development and your focus on integrated health, which

933
00:58:48,600 --> 00:58:53,080
Speaker 1: you bring an enormous background in pain management too, as

934
00:58:53,160 --> 00:58:56,440
Speaker 1: vy understand it correctly, right now, trycare still would not

935
00:58:56,600 --> 00:59:02,320
Speaker 1: take thankupuncture, yoga, massage an integrated health function and pay

936
00:59:02,360 --> 00:59:05,440
Speaker 1: for it, although they would pay for the drugs designed

937
00:59:05,440 --> 00:59:09,800
Speaker 1: to achieve the same goal. Is that accurate? That is accurate?

938
00:59:09,840 --> 00:59:12,800
Speaker 1: And just by you saying it doesn't that make absolutely

939
00:59:12,800 --> 00:59:16,120
Speaker 1: no sense. Now, what they'll tell you is we don't

940
00:59:16,160 --> 00:59:18,880
Speaker 1: have the data. And so one of the most important

941
00:59:18,880 --> 00:59:21,680
Speaker 1: things that came out of paying task Force was a

942
00:59:21,680 --> 00:59:26,480
Speaker 1: program we call pastor Paining Assessment Screening Tool and Outcomes Registry.

943
00:59:27,120 --> 00:59:30,280
Speaker 1: What this does is it leverages a hundred and ten

944
00:59:30,360 --> 00:59:36,160
Speaker 1: million dollars taxpayer efforts from NIH called Promise instruments. And

945
00:59:36,240 --> 00:59:39,360
Speaker 1: what the folks at NIH did if they recognize the

946
00:59:39,560 --> 00:59:44,120
Speaker 1: morass that we have in research and that everybody tends

947
00:59:44,160 --> 00:59:48,680
Speaker 1: to use their favorite scale, their favorite way of evaluating something,

948
00:59:48,760 --> 00:59:52,160
Speaker 1: and so it makes the literature and paying very difficult

949
00:59:52,160 --> 00:59:55,160
Speaker 1: to assess. What the smart people at NIH did is

950
00:59:55,200 --> 00:59:58,440
Speaker 1: they took all the questions. Let's say, as an example,

951
00:59:58,480 --> 01:00:02,720
Speaker 1: physical function. A physical function battery of questions is to

952
01:00:02,480 --> 01:00:06,080
Speaker 1: try to determine where you are on a measuring stick

953
01:00:06,160 --> 01:00:10,640
Speaker 1: from somebody who's bedridden to lanswer Armstrong on steroids. Now,

954
01:00:10,960 --> 01:00:13,880
Speaker 1: if I was a computer and I knew nothing about

955
01:00:13,960 --> 01:00:17,840
Speaker 1: your health and your physical function, I would probably ask

956
01:00:17,880 --> 01:00:20,520
Speaker 1: a question in the middle of the road. What these

957
01:00:20,520 --> 01:00:23,600
Speaker 1: promise instruments do with this? What I'm describing right now

958
01:00:23,720 --> 01:00:27,360
Speaker 1: is computer adaptive testing. Instead of having to ask you,

959
01:00:27,440 --> 01:00:30,600
Speaker 1: let's say, the hundred questions that are in that physical

960
01:00:30,640 --> 01:00:34,280
Speaker 1: function bank, I can expose you to those hundred questions,

961
01:00:34,280 --> 01:00:37,600
Speaker 1: but the computer ask the question and then based on

962
01:00:37,680 --> 01:00:42,240
Speaker 1: your answer, ask the next most informative question that figures

963
01:00:42,280 --> 01:00:46,320
Speaker 1: out where you are on that measuring scale. And so

964
01:00:46,440 --> 01:00:48,400
Speaker 1: while I can expose you, and this is going to

965
01:00:48,560 --> 01:00:51,040
Speaker 1: blow your mind a little bit, I can expose you

966
01:00:51,080 --> 01:00:53,640
Speaker 1: to all one hundred questions, but I only need to

967
01:00:53,680 --> 01:00:57,120
Speaker 1: ask four to six questions, and the answer that I

968
01:00:57,240 --> 01:01:01,040
Speaker 1: get is actually superior the answer if I'd ask you

969
01:01:01,080 --> 01:01:04,440
Speaker 1: all one hundred questions. And so what we're doing with

970
01:01:04,480 --> 01:01:06,760
Speaker 1: this pastor right now is we have a bank of

971
01:01:06,800 --> 01:01:11,919
Speaker 1: eight different domains speaking to the biopsychosocial nature of pain,

972
01:01:12,080 --> 01:01:15,720
Speaker 1: where the patient's giving us information on their depression, their

973
01:01:15,800 --> 01:01:20,160
Speaker 1: social function, their physical function, their mood, their stress. It

974
01:01:20,320 --> 01:01:22,600
Speaker 1: asks some other things that we're very interested in, like

975
01:01:22,880 --> 01:01:26,680
Speaker 1: the PTSD screener, like their use of alcohol, and it

976
01:01:26,760 --> 01:01:31,320
Speaker 1: gives a very detailed summary with graphs on a two

977
01:01:31,320 --> 01:01:35,240
Speaker 1: page report that sort of gives a fingerprint, if you will,

978
01:01:35,280 --> 01:01:38,760
Speaker 1: of the patient's physical and emotional state as it relates

979
01:01:38,800 --> 01:01:43,400
Speaker 1: to their pain that a clinician can then assess how

980
01:01:43,440 --> 01:01:47,000
Speaker 1: their approach to their pain is actually impacting on this

981
01:01:47,080 --> 01:01:50,600
Speaker 1: particular patient. I'm of the opinion that this approach is

982
01:01:50,640 --> 01:01:54,640
Speaker 1: going to give us the data that we need for acupuncture,

983
01:01:55,160 --> 01:02:01,960
Speaker 1: for massage, for yoga, for behavioral interventions, also stimulating civilian medicine.

984
01:02:02,000 --> 01:02:04,800
Speaker 1: We have a partnership with West Virginia and they are

985
01:02:04,840 --> 01:02:09,000
Speaker 1: now using Pastor and the Defensive Veteran's Pain Rating Scale

986
01:02:09,360 --> 01:02:12,120
Speaker 1: for help with as opiated crisis. So these products that

987
01:02:12,120 --> 01:02:15,640
Speaker 1: we're using in our soldiers are actually now impacting on

988
01:02:16,400 --> 01:02:19,440
Speaker 1: civilian medicine in a very positive way. Let me just

989
01:02:19,440 --> 01:02:22,040
Speaker 1: say there's a summary forsation what I'm really struck with

990
01:02:22,960 --> 01:02:25,400
Speaker 1: as you walk me through your own evolution and your

991
01:02:25,440 --> 01:02:29,280
Speaker 1: own thinking and the exciting projects organ you're really very

992
01:02:29,280 --> 01:02:33,200
Speaker 1: optimistic that the next ten to fifteen years will be

993
01:02:33,240 --> 01:02:36,680
Speaker 1: in a dramatically different world of managing pain. When I

994
01:02:36,760 --> 01:02:40,520
Speaker 1: graduated from USUS in nineteen ninety two, the medicine that

995
01:02:40,600 --> 01:02:44,560
Speaker 1: I was practicing then is unrecognizable to the medicine that

996
01:02:44,600 --> 01:02:48,160
Speaker 1: I'm practicing today, and we're doing things right now. One

997
01:02:48,200 --> 01:02:51,960
Speaker 1: of the exciting things were combining that patient reported outcomes

998
01:02:52,040 --> 01:02:56,560
Speaker 1: data with biological samples blood and saliva. We're going to

999
01:02:56,640 --> 01:02:59,840
Speaker 1: start the promise of genetics and medicine, which is taking

1000
01:03:00,560 --> 01:03:03,320
Speaker 1: we're at the portal right now to a new epoch

1001
01:03:04,080 --> 01:03:07,320
Speaker 1: in healthcare. But we're actually going to be using your

1002
01:03:07,400 --> 01:03:11,320
Speaker 1: genetics eliminating many of the diseases of the past. Thank

1003
01:03:11,360 --> 01:03:20,840
Speaker 1: you very very much for a remarkable conversation. I want

1004
01:03:20,840 --> 01:03:24,040
Speaker 1: to thank my guest General x Scremaker and doctor Tripp

1005
01:03:24,040 --> 01:03:26,680
Speaker 1: buck and Meyer. You can see an excerpt from my

1006
01:03:26,760 --> 01:03:30,600
Speaker 1: new novel Collusion and explore the history of opioid addiction,

1007
01:03:31,000 --> 01:03:35,000
Speaker 1: pain management, and treatment on our show page at newtsworld

1008
01:03:35,040 --> 01:03:39,600
Speaker 1: dot com. Newtsworld is produced by Westwood One. The executive

1009
01:03:39,640 --> 01:03:44,480
Speaker 1: producer is Debbie Myers. Our producer is Carnesy Sloan. Our

1010
01:03:44,600 --> 01:03:49,840
Speaker 1: editor is Robert Borowski. Our researcher is Rachel Peterson. The

1011
01:03:50,000 --> 01:03:53,920
Speaker 1: artwork for the show was created by Steve Penley. The

1012
01:03:54,080 --> 01:03:58,200
Speaker 1: music was composed by Joey Salvia. Special thanks to the

1013
01:03:58,200 --> 01:04:02,360
Speaker 1: team of Gingrich three sixty and Westwood Ones Tim Sabian

1014
01:04:02,720 --> 01:04:06,560
Speaker 1: and Robert Mathers. Please email me with your comments at

1015
01:04:06,640 --> 01:04:11,120
Speaker 1: Newt at newtsworld dot com. If you've been enjoying Newtsworld,

1016
01:04:11,480 --> 01:04:14,800
Speaker 1: I hope you'll go to Apple Podcasts and both rate

1017
01:04:14,920 --> 01:04:18,400
Speaker 1: us with five stars and give us a review so

1018
01:04:18,520 --> 01:04:21,760
Speaker 1: others can learn what it's all about. And the next

1019
01:04:21,760 --> 01:04:26,120
Speaker 1: episode of Newtsworld, I'm joined by veteran journalists daughter, mother

1020
01:04:26,200 --> 01:04:30,480
Speaker 1: and grandmother Cookie Roberts. For Mother's Day, will be celebrating

1021
01:04:30,520 --> 01:04:34,320
Speaker 1: moms everywhere with a discussion about our country's founding mothers

1022
01:04:34,720 --> 01:04:39,000
Speaker 1: and Cookie's book Founding Mothers, the women who raised our nation.

1023
01:04:39,440 --> 01:04:42,440
Speaker 1: Just getting through the day in the eighteenth century was hard.

1024
01:04:43,000 --> 01:04:46,120
Speaker 1: These women, they sometimes lose two children in a week.

1025
01:04:46,160 --> 01:04:49,680
Speaker 1: It was horrible. But they would still sit up at

1026
01:04:49,760 --> 01:04:53,480
Speaker 1: night and write letters about what seemed important to them

1027
01:04:53,520 --> 01:04:56,720
Speaker 1: about the new nation that they wanted to see form.

1028
01:04:57,320 --> 01:05:09,880
Speaker 1: I'm Newt Kingridge. This is Newtsworld, the Westwood one podcast network.

1029
01:05:10,160 --> 01:05:11,120
Speaker 1: Everyone's listening