Controlling Cancer Pain Health Radio Network January 10, 2008 Salahadin Abdi, M.D., Ph.D. Introduction

Transcription

1 Controlling Cancer Pain Health Radio Network January 10, 2008 Salahadin Abdi, M.D., Ph.D. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction Thank you for joining us once again on Patient Power on HealthRadio Network. Andrew Schorr, broadcasting live from Seattle, Washington. Yes, gray skies again in January, but it's not cold here. Hopefully it's okay where you are. We're going to meet someone from Texas shortly and someone from Miami. They bask in the sunshine in Miami, but they also practice some great medicine there at the University of Miami, and we're going to hear from a leading expert in chronic pain, and today we're going talk about something that we haven't talked about before, and we really have needed to for a long time, and that is cancer pain. When you talk about cancer pain, you're talking about often where cancer or some effect of the treatment has affected the bones, and that could be very painful, and so along the way we're going to be taking your questions. Very limited commercial interruptions today as we really dig into this topic deeply. Bruce's Story I want you to meet someone who's been dealing with all this, and that's Bruce Towers. Bruce joins us from just the little town, just a little over 2000 people, in Tool, Texas, 80 miles southeast of Dallas. Bruce used to be in the insurance business, and he was diagnosed with prostate cancer back in 1996, a very serious diagnosis. He benefited from being in a clinical trial for a drug we've talked about before on Patient Power, Provenge, which hopefully, hopefully will be approved for people with more advanced prostate cancer. It s a cancer vaccine, and take a look at for replays of those programs. At any rate, that helped him a lot with the prostate cancer, but he still has had a lot of pain related to the spread of the prostate cancer to his bones, and also he had had radiation, and that affected his bladder and kidneys. 1

2 Bruce, I know you are an active soccer coach, and you want to be an active guy. You're retired now, but you have to take morphine now for the pain. Tell us what medicine you take, and what has the pain been like that you've been trying to get past? The largest problem we've had with the pain situation is that it's very difficult for many doctors to realize that you're in pain 24/7, and there are several levels of pain. I take morphine in a pill tablet; that's for longer lasting relief; and then I have breakthrough pain, and those are pains when you do something, be it walking, be it standing, something strenuous that causes a real severe point pain, and I take a liquid morphine for that pain. Now, you've been through a lot of other medicines. What are some of the other ones you've taken along the way? Darvocet, Vicodin, hydrocodone. If you name it in a tablet form, I've probably taken it with very minimal results. Have you worn any patches as well? Have you worn any of those time-release patches as well? I have. I did not seem to get the benefit out of it that I hear others have, so it didn't seem to, and maybe because my pain is not designated to just one area, but it's in several areas. You know, I'm currently fighting infection in both kidneys and infection in the bladder, and I had a lesion on the left hip, and lymph node problems in the pelvic area, so it's pretty well wide spread from a pain relief standpoint. What you want to do is feel good enough so that you can do your soccer coaching and just enjoy every day. Yes, I mean, what I've done, you know, I have an innate fear I'm going to get hooked on the pain medication, and so what I've done is I've kind of self-managed the situation. We had talked about a comp, but those days that I'm not doing anything active, and I'm pretty much inactive at home, I probably won't use any morphine at all. Now, on a day when I get very active; I recently went and talked about Provenge at the FDA, and I had to take medication because of the standing and the walking that we did. That's where I 2

3 need the relief, and I've tried to mentally handle the pain situation when it's not a necessity. First of all, I want to thank you for speaking out for newer medicines that maybe can help men with advanced prostate cancer, so good for you in making the trek up to Washington D.C. and coping with the pain as best you could. Really, your whole situation brings up a lot of issues, and that is you mentioned about people's fear of addiction, maybe even doctor's fear of patients being addicted, and on the other side is, what is your right as somebody who's in chronic pain to get medicines that help you go on with life? See that was the most difficult part I had was getting a doctor to understand my pain who wasn't afraid I was going to get on an opiate or something and become addicted. It's literally taken me months and months to get to the point where somebody will listen to me and somebody will work with me with my pain. Right and say it's not some kind of scam to get medicine for a drug addiction or to become a drug addict. It's for you to go on with your life. Yes. If you knew me that would be the furthest thing from anything I would want to do. The Importance Of Evaluation and Treatment of Chronic Pain Right, Coach Bruce. I'm sure. Let's meet a highly recognized expert in this, and that's Dr. Salahadin Abdi, and he is Professor of Clinical Anesthesiology. He's Chief of the Division of Pain Medicine in the Department of Anesthesiology at the University of Miami Leonard M. Miller School of Medicine. Dr. Abdi, thank you for joining us. So when you hear Bruce's story, this is not unique is it? Somebody with a cancer where it's spread; it's affected their bones, and he's had the effects of radiation as well, and the guy just wants to get through every day without being in serious breakthrough pain. It's a reasonable request, isn't it? Absolutely. First of all Andrew, thank you very much for inviting me so that I share any knowledge that I have in this area with you and everybody else who is listening to our radio show. 3

4 Now, it's heartbreaking whenever you hear this type of history because Bruce has got a legitimate, what sounds like legitimate pain, and we also need to keep in mind that pain management is really a fundamental human right, especially cancer pain, which we all know can be very, very painful, needs to have appropriate diagnosis, appropriate evaluation, and appropriate treatment accordingly. Bruce also mentioned the fact that not only in lay people but also physicians, some physicians at least, are very afraid to prescribe important and beneficial narcotic medication for this type of pain. Now fortunately a lot of physicians do evaluate their patients appropriately and do make the right diagnosis and feel comfortable prescribing various different types of medication, which includes especially in Bruce's case certain narcotics. Bruce mentioned that he's taking a morphine type of pill as well as morphine liquid. The morphine type of pill that he is taking is probably the so-called a longer-acting opioid or morphine-like medication, which really covers the pain, the so-called background pain, 24 hours a day. However, patients like Bruce who have got metastasis to their bone do have the so-called incidental pain whenever they move or whenever they do any type of activity, which could be very, very painful, and this needs to be covered with medication which really kicks in quickly because the incidental pain hits you very quickly, and you don't want to have a longer-acting medication that stays in your system for a long period of time for coverage of the incidental pain. That is the reason why Bruce is getting the liquid type of morphine, which kicks in quickly and leaves his system relatively quickly; however, he's also getting as I said to cover his background pain, which is always there no matter what he does or he doesn't do, and that is generally covered with a longeracting narcotic. Most importantly we also have to really keep in mind and also discuss about it, this pain, especially cancer pain, doesn't affect only the patients, in this case Bruce, it affects the whole family. So it's very, very important, and I always emphasize that, you have to incorporate the family members whenever you treat the patients. I always ask my patients to bring their family members with them to educate the family members as well as the patients about their pain so that they have a better understanding. Interestingly, there was a nice study a few years back where they surveyed about 1000 people, and a lot of those people who were surveyed said that, at least 40% of them, they felt uncomfortable discussing their pain issue with somebody else including their family members because they think, the patient thinks, that the family members and other relatives do not believe that they have their pain. So it's very, very important to incorporate other people. 4

5 Let's ask Bruce for a second. Bruce, so, everybody knows you've been through a lot of treatment. Have people you know, and you're in a small town, are they sympathetic? Do they acknowledge that you're really suffering and that you're just trying to put one foot in front of the other and do your coaching and other things you love? You know, what I find out is no. They don't have an understanding. Number one, I'm so active, okay? And number two, I don't have the appearance of someone; I have good color, you know, I don't have a sallow complexion, so I don't look sick. Ergo, if I complain about pain, people don't understand, and the doctor's exactly right. I mean, until recently my family did not understand that basically I'm in pain 24/7, and I think now we've realized that I can become a different personality at a family function if I take some pain medication to ease everything that's going on because pain not only affects the body; I believe it affects your mind. I believe it affects how you act, your personality. Sure. Absolutely. I have one other question, Bruce. One other question for you; one of the obstacles to pain management for people who are suffering has sometimes been their family. So let's take the situation whether it's somebody our age, you and I are about the same age, or somebody older, and maybe there's an adult child who is really advocating against pain meds because there's the fear that mom or dad or grandma or grandpa would become addicted, and so, 'Oh no, we can't use that,' and when you talk about medicine like morphine, it sounds pretty heavy duty, 'Oh my goodness.' So was that a concern at all in your family, Bruce, that well if daddy takes morphine that he's going to be a drug addict? Was there anybody saying anything like that? My son is an ex-chief of police, so yes. I mean, there was a real concern on his part just because of what he's seen of drug addicts and that type of thing, and that was kind of his specialty was in methamphetamines and that type of thing. So, yes, he had a real concern about that. Dr. Abdi, you're a renowned expert. Put this in perspective for us and for our family members and listeners about this whole, is this a red herring, this whole concern for people suffering so much? 5

6 The main thing is really understanding the patient and his situation, and the most important aspect of that is the discussion that takes place between the physician, the pain physician in this case, and the patient should not be limited only to the patient. It's so critical and important to include early enough, not later during the treatment period, but early enough with the family members or even friends or other relatives if the patient prefers so. The most important aspect is to educate them, educate them about pain, educate them about the options the patient has as far as the treatment is concerned so that he has a better quality of life. Bruce appropriately pointed out that it doesn't affect only the physical status of the patient; it also affects the psychological status. It is a stress to the patient as well as to the whole family, and in order to minimize that or avoid, possibly avoid that, it's so critical to include the relatives, the family members in the treatment and why physicians choose certain types of medications, especially opioids, which do have a stigma attached to them, and also the effect of side effects. The whole thing about the treatment options needs to be addressed with the patient as well as the family members. It's really important to avoid all the misunderstanding. Right, right. Now, it doesn't mean that it's could completely eradicate this misunderstanding, but you could at least minimize it by investing time in education of the whole family members. Appropriate Treatment for Different Types of Pain Dr. Abdi, I have a question for you here. You're very passionate, which is great, and we have a lot of information we're going to cover today. So, Bruce ticked off a bunch of pain medicines. Many people have heard of some of those pain medicines that he took that didn't work for him. I have the impression in anesthesiology now and pain management that you have many, many different tools for pain management. Absolutely. And a lot of the discussion is really what approach is right for the pain you have and when you have it. Like that background pain. The breakthrough pain, and what is causing your pain, and so you have, if you will, I see you have like a piano with 88 keys on it, and you have a lot of notes you can play; some alone and some together, and so you need that dialogue, and what medicines didn't work for Bruce though might work for someone else. 6

7 Absolutely. That's why it's very critical for the physicians to make the right diagnosis. Now, cancer pain is not just cancer pain. There are different categories of pain. Specifically the physician who treats Bruce or other cancer patients needs to understand and try to dig out is the pain coming from the cancer cells invading nerve tissue; is there inflammation going on; if there is scar tissue after radiation treatment for example; did the patient develop pain after chemotherapy? What's the cause of the pain, and what type of pain syndrome does the patient have? Generally speaking, we categorize this type of chronic cancer pain into two different categories. One is the so-called neuropathic pain, which basically means that pain induced by a certain degree of nerve injury. It could be anatomical injury, as I mentioned cancer cells invading for example nerve tissue, or it could be just abnormal functioning of the nerve. There is also a different type of pain, inflammatory related pain, which needs to be treated completely differently than the neuropathic pain. For the neuropathic pain, generally the patient's present with a certain degree of burning, tingling sensation, a lancinating-type of pain around the area where the nerve is involved, and that type of pain responds relatively well when a physician utilizes anti-seizure/anti-depressive medications for pain. I'm not talking primarily for depression or seizure but for pain, for this type of pain. Whereas the inflammatory pain, the nociceptive-type of pain, seems to respond relatively well with morphine or its derivatives, but we also have a very cheap, simple medication, which we usually combine with morphine other agents such as antiinflammatory, nonsteroidal antiinflammatory medications; cheap, very, very effective, especially for bony-type of pain due to metastases. So really, as a physician, we have to differentiate and know the etiology of the type of pain the patient's present with so talking about general cancer pain, it's a little bit too global. I generally would like to specifically address the type of pain that specific cancer patients present to me. So, that is very, very important because you tailor your treatment according to the underlying type of pain that patients have. Right. That brings up another point. We're going to take a break in a minute, but I think Bruce you listening to this and me, and Bruce I think there may be some advice for you out of all this, and I know you get treatment through the Veteran's Administration, and hopefully they have a resource for you. So, Dr. Abdi is a leading pain expert and is director of a pain management service, and these tend to be often at bigger university medical centers and places like that. If someone is suffering from chronic pain and particularly something like cancer pain whereas you were just saying, Dr. Abdi, there can be a lot of different causes or one overlaps the other and it's different. You need to 7

8 consult, just like we know in so many; if you're going to have a heart transplant, you go to a doctor who does heart transplant, and it's not just somebody who takes out gallbladders or something like that. We all know that, but I think we need to see pain management as a specialty where if you're suffering from this you need that very specialized workup and help too. Dr. Abdi, I'm sure you agree, and so somebody in Bruce's case who every day wants to go on with his life, wants to have the medicines that work right for him so he can do the things that are important, connecting with a pain center and not just somebody who is just going to give you a one-shot, you know, shot in your back, which I know is a legitimate pain approach, but it's more complicated than that. Yes, absolutely. You really have to look into a good pain physician, and one thing that I really would like to also emphasize is the fact that patients who have got cancer pain, they need to understand that they have the right and they have the option to see a pain specialist. They need to discuss that issue early enough with their oncologist as well as primary care physician. It's very frustrating to know that there are still some physicians out there who do not know that there are pain specialists around. So, it's very, very important to bring up to your doctor, to your primary care physician and oncologist, that it might be worthwhile to go to a pain clinic or see a pain physician early enough. The earlier you treat the pain the better chance of a better outcome you have by not waiting too long. We're going to take a break. We're going to talk a lot more about it. We've been getting in some questions. It's all on Patient Power as we continue on HealthRadio Network. We'll be right back. Welcome back live on HealthRadio Network to Patient Power. This is what we do day after day connect you with leading experts and delve in depth into very important, significant health issues. Today we're talking about chronic pain, and we're sort of zeroing in on cancer pain. That may be the pain from the spread of cancer, or it also could be from the effects of treatment, and that's, the whole balancing act in cancer care is you want to fight the cancer aggressively, but sometimes there's a quality of life cost that follows, and Bruce Towers who joins us from little old Tool, Texas, southeast of Dallas, he's been suffering from that, and all he wants to do is be an active dad and grandpa and soccer coach and knock the pain back so he can do what he wants to do, and that's like a lot of us, so you deserve that. I want to mention a couple of other things about Patient Power. First of all, we're very, very excited. Pretty soon, maybe in a day or so, you'll be able to go on the new Microsoft health search engine, which right now you can get to it at and type 8

9 in a topic, and if it's one we've covered, our shows and our content is going to pop up right there. You've been on the ground floor of it, our regular listeners, as this gets more exposed to people around the world, so we're very excited about it. We also want to thank the folks at the Miller School of Medicine at the University of Miami, one of our leading medical institutions in the country for helping us connect with our expert today, Dr. Salahadin Abdi, and he is Chief of the Division of Pain Medicine in the Department of Anesthesiology there at the University of Miami, and as you've been hearing, if you've been listening already, he's very passionate about people getting the pain management that they deserve. We're going to ask you some questions that we've already received in a second, Dr. Abdi, but it sounds like so far in some areas of the country, and it may be this way in Tool, Texas, and lots of places in the country or even in the heart of big cities where there's sort of a disconnect, and that is people start suffering with pain, and let's use the cancer pain as an example, and they're being treated for their cancer, but their pain is sort of not getting it's due, or if there is some consultation with a pain specialist, it may not be a specialist who has all the tools that they're experienced with to manage what may be a complex situation. How do people get past that? What should they be saying to their primary doctor, maybe that's an oncologist, so that they get the care that they deserve? What should they say? Andrew, it's very important to understand, the patient needs to understand that they need to play an active role. They need to be proactive discussing with their primary care physician or the oncologist to be referred to a pain doctor. Fortunately now a lot of primary care physicians and oncologists are able to take care of mild-to-moderate pain without significant problem; however, cancer pain specifically with metastasis is associated with a significant pain syndrome, so I think it's very important that the patient addresses this issue with the primary care physician or oncologist and ask those physicians to get a referral to a pain specialist because the earlier the pain specialist sees that patient the better outcome result that physician might have. So, it's very, very important to be aware of their right to discuss this issue with their physician. Be active. Ask for treatment option by a pain physician. Ask for the referral. The earlier you do it the better outcome, generally speaking, the better outcome you have. You were telling me during the commercial break that one of the frustrations you and your colleagues in pain management have is often the patient who is referred to you gets to you late. 9

10 Very late. Where maybe they were on high doses of a drug that maybe was a pain management drug but wasn't right for them and sort of the "horse was out of the barn" so to speak. So when would the optimal referral take place? There is no specific timeline, but the earlier the better it is. As I said, if the physician, the oncologist, the primary care physician feels comfortable and understands, which most of them do understand, the underlying pain mechanism. It is very important to know where the pain is coming from and what type of pain the patients have. If they are comfortable diagnosing that and treating it appropriately, it is okay to put the patients on certain treatment options whether it's medication or an interventional procedure. With the interventional procedure I should really mention that the patients have to see a pain specialist, and we can talk later on about different types of interventional procedures, but if the patients feel, 'Well, you know, I'm not getting enough pain relief with the medication that the physician is giving me,' I think it's worthwhile to discuss with that physician, 'I'd like to see a pain specialist and see the others options that I have whether it's medication or an interventional procedure or other treatment options.' There are a number of other treatment options. So I think generally speaking, the earlier you do it the better it is. We're going to get to those treatment options in a minute. Bruce, you listen to all this. You're in a rural area. You're way down the road from the big city. When you think about your journey in trying to deal with the pain, are you a little frustrated in the way it went that it took you so long to try to get to medicines that were more effective for you? Oh, very much so. The problem, I kept bringing it up from one specialist to another specialist. Now, you have to realize I deal with oncology, I deal with infectious disease, I deal with renal, I deal with urology, and because I have nephrostomy tubes I'm dealing with radiology as well, and I could never seem to get a communication through that I have this pain, and I need some help, and to be quite honest it was an intern who happened to ask, after I went to the emergency room, happened to ask how am I managing my pain. My advice to him was, well, I've been asking for help, but I don't seem to be getting any help there, and that's how I was fortunate enough to get on a regimen of being able to manage my pain. 10

11 Dr. Abdi, let's just talk about some treatments for a minute. So we think of pills, and then we heard about a liquid form. Bruce mentioned along the way a pump, and I know there's some kind of pump that can actually pump pain medicine in, for example, into the spine if people have metastases to the spine. Is that what you were talking about? Like an interventional procedure is putting in a pump, or are there others as well? There are others as well, Andrew. Before I touch that, if I may comment on two things very quickly? Sure. Bruce brought up the issue of he was being sent from physician to physician, and finally an intern asked him about pain. There are two problems there. The first problem is that unfortunately a lot of physicians do not have time to ask and listen to their patients, so it s very, very critical for us to get the appropriate history from the patient, but if the patient comes for let's say a cancer-related issue to the oncologist, we always need to add the issue of asking questions about pain level, but we also need to examine them appropriately. So, it's very, very important to take our time to listen to our patients to examine them and come up with a plan of treatment. Coming back to your question, there are a number of treatment options for cancer patients. You mentioned about medications. There are three different important groups of medications out there. It's not just narcotics or opioids such as morphine or morphine derivatives, which Bruce is getting, but there are also two other groups of medications, which we commonly use and which could be very, very beneficial if indicated. Those two groups of medications are antiseizure medications and antidepressive medications. Now, specifically those two groups of medications are very beneficial for the so-called neuropathic pain syndrome where the nerve is abnormally functioning due to anatomical damage or chemical damage. So it's very, very important to tease out from the cancer patients if there is any nerve injury involved or not, if there is any component of neuropathic pain or not. Patients with radiation, a lot of cancer patients do get radiation. Radiation can damage nerves as well too. So patients subsequently develop neuropathic pain syndrome, and those patients will benefit better with antiseizure, antidepressive medication, or a combination of the two compared to narcotics, so it's very, very important again to understand what the etiology of the pain is. Now, there are other treatments if the pain physician has an anesthesiology background especially. We do a lot of interventional procedures that are minor interventional procedures such as simple nerve blocks. For example, if the prostate cancer is 11

12 metastasizing to the rib area, we could easily do the so-called intercostal nerve block where patients generally get a good pain relief, so it's very important to understand there are relatively simple blocks out there that could benefit the patients, but there are also a little bit advanced and complex types of procedures such as intrathecal pumps, which Bruce was mentioning and he's thinking about. Intrathecal pump is the placement of a catheter into the spine area, the so-called intrathecal space, where a continuous highconcentration, low volume of narcotics, especially morphine, could be infused continuously 24 hours a day with a reservoir, which is generally placed around the abdominal area and filled with the morphine or other agents such as local anesthetics. So there are advanced and not-so-advanced procedures that are available for cancer patients, but the most important thing is really identifying what's the cause of pain. Other patients, for example, might benefit from the so-called spinal cord stimulator. If they have neuropathic pain due to cancer, they might be a candidate for a spinal cord stimulator for the neuropathic pain syndrome, but now again, this has to be addressed with the specific pain physician who understands these procedures and the risk and the benefit of these procedures and evaluate the patients for whether they are candidates for this procedure or not. I also need to mention, which is very, very important, chronic pain a lot of times has a certain degree of a psychological problem associated with that. We know from the criteria that about 30% to 70% of chronic pain patients, which includes cancer patients, could develop over time clinical depression, so that needs to be addressed as well. There should be a consultation with a psychologist or even if it's needed a psychiatrist to address this issue. Pain treatment, especially cancer pain treatment, is not just a single modality. It should be a multimodality approach where you could use different types of medications and different types of procedures as needed, behavior treatment as needed, and these days we do have options of complimentary alternative medicine, which could help some patients. It doesn't mean that everybody who has this pain will benefit to that but it's worthwhile to think about it and to discuss and see and evaluate the patient if that patient will benefit from all these options or not. Alternative Treatments for Chronic Pain Here's a question. We got a question from Cheyenne who's listening in Las Vegas about just that, so let me read this question to you because it deals with alternative approaches. 'My mother was diagnosed with lung cancer, which spread to her right arm, and she had a lot of pain and has been taking oxycodone for relief. In the last few weeks she has been doing really well as far as her pain management; however, she started radiation on her arm for palliative care only, not for her lung tumor, and she's been experiencing much 12

13 more pain in her arm now and is experiencing a lot of fatigue. Are there alternative treatments for chronic pain such as hypnosis and others?' Yes, yes, absolutely. Now, that patient needs to see a pain specialist to find out again, which I always emphasize, why the patient all of a sudden has got more pain after radiation. Is it because the radiation has damaged the nerve tissue there, or is it because of the progression of the disease or something? So that needs to be teased out first of all. Once the physician understands what's the etiology, the reason why the patient has increased pain, then the physician could decide with the patient the type of treatment because again there are a number of alternative treatments, which includes hypnosis by the way, or acupuncture for example, which the patient might or might not be benefiting from. So those patients need to be evaluated by an acupuncturist if the patient and the physician prefer to try alternative treatments such as acupuncture. An acupuncturist will evaluate the patient. Not everybody who walks through the door to an acupuncturist will benefit from acupuncture, so that patient needs to be evaluated. Yes, to answer the question, there are alternative options, but it just has to be evaluated by people who understand those options. So it's very, very important to work with the pain physician very closely and find out whether that patient needs to get a referral to a psychologist to get diagnosed with experience in the hypnosis area to get that treatment or to an acupuncturist to get acupuncture treatment. Really, sometimes what we forget is the fact that it's not just one treatment. It's not just the acupuncture or just the hypnosis. A lot of times we really need a combination of different treatments. Again, the so-called multimodal approach rather than just one type they should approach. So, we just need to keep that in mind. The Benefit of Using a Multidisciplinary Approach Right. Now, we did an earlier program on chronic pain management, and these were PH. Ds who were making that exact case. One of the things that I was unhappy to hear is they thought that this sort of multidisciplinary approach that really can work was the funding for that was not always there, but at the University of Miami, it sounds like you've worked hard so that whatever the right tool is, and there could be one of many, that's what you're thinking about as pain specialist for what's right for that patient. Absolutely. We certainly do not look into money issues. The first thing we look into is the patient's benefit. That's the most important aspect really. I do understand where if people complain about the funding is not there. You know, it really depends where you practice at, but I should say at the University level I think multidisciplinary approach is the way to 13

14 go. There's no doubt about that. You always need the help from a psychologist, psychiatrist, physical therapists who we haven't talked about. It's so important. I'm so happy to hear that Bruce is so active with his football, I guess, but there are a lot of patients who get depressed and do not do any activity at all. That is a vicious cycle. You don't get better by just sitting at home, unfortunately, but you need to actively seek treatment so that you become more active in life. That's the key. Physical therapy is very, very important. Water therapy could help a lot of different types of patients; not every patient but a lot of patients. There are other treatment options such as transcutaneous electrical stimulation for muscle-related pain, a secondary problem for cancer pain sometimes. Patients do have cramp pains, so transcutaneous electrical stimulation might be worthwhile at least for a trial. So as you can see, there are a number of options out there as far as treatment is concerned. The most important part is for the patients, again, to be actively seeking advice with the help of their primary care physician and oncologist to seek an appropriate pain physician and asking the pain physician what are the options? What do I have? If the physician thinks that certain drugs are important for the patients, for example, also don't hesitate to ask about the dose, how often do I need to take it, what are the side effects, and how long do I need to take it? All those questions need to be addressed, so it's very, very important to seek help early enough and look for all the options available for the patients. When is Enough, Enough? Bruce, let me ask you a question. I bet you're a pretty tough guy. So, there must have been some point where you made the shift from what somebody would say well, just grin and bear it, or you're saying it to yourself, and where 'I need help,' and that shift is not, you know, for a lot of Americans that shift is not easy. You want to be tough, right, and you're a coach. Be tough. You know, get back out on the field, but this was beyond that, right? How did you make that shift? Well, every cancer patient, and if they tell you they don't they're lying, I mean, you go through enough is enough, should I continue? I've always demanded my teams to give me 110% and felt like I'd be a hypocrite if I didn't do the same, and when it got to the point that I literally sat around starting to feel sorry for myself and just simply said I need to do something about this. The pain's getting the better of me, and that's when I just actively started asking questions, and I was fortunate enough to get involved with "A Right to Live" and "Care to Live" which for prostate cancer, if you look at or you'll get some very good input on those people's suffering from prostate cancer, especially terminal prostate cancer patients, and there's legislation going on. That involvement then demanded that I have to have some 14

15 medication to get me through that because of the pain of walking in a rally, standing and speaking for a long period of time in front of groups of people, and I just kept asking and kept asking. Fortunately it came from an intern, and my assumption was that that's something that is probably more en vogue today than it was ten years ago. I mean, pain management, I'd never even heard it mentioned ten years ago. So, I thank that intern actually coming up and asking me about it. Right. I want to make a couple of comments. First of all, I want to point out to our audience, and I know there are listeners sending in questions, Scott did. Bruce, you are a wonderful example of a powerful patient, and you've been coping and getting the help you need hopefully now and maybe will go to an actual pain clinic before all this is over, but you're speaking out as a patient so that we can get legislation, the approvals that I think many new medicines deserve, but just what you're doing to speak out and also to continue coaching, just, you're a great guy, and I want to thank you for being with us today. Dr. Abdi, he did mention something along the way just related to the intern and sort of generational things in medicine. You're a medical school professor, sir, so I imagine when people rotate through your area you're pretty passionate in telling these young minds in medicine how important it is for the benefit of their patients to be really a caring physician that they have to talk about pain management. Absolutely. I think it's each pain physician's responsibility to reach out to educate other physicians including interns, residents, fellows, or even attending physicians, senior physicians in other disciplines such as internal medicine, surgery, or any other medical field to educate them about the pain but also to educate them in the number of options pain physicians and pain patients have these days. But most importantly it's also our duty I think to go out to the community to talk about pain to people so that they understand that they do have options. Unfortunately a lot of cancer patients still today think that pain is just part of their bad luck, but they need to understand that they have not only the right but also the option of getting pain relief by getting appropriate treatment. So, it is very important for us to reach out, to go out to the community as well as to other departments to educate our colleague physicians. It's very, very important. I want to thank you for your dedication to it. We've been visiting with Dr. Salahadin Abdi, and he is Professor of Clinical Anesthesiology and Chief of the Division of Pain Medicine in the Department of Anesthesiology at the University of Miami Leonard M. Miller School of Medicine. Thank you Dr. Abdi for your passion and your devotion to this. We'll have you back, and I hope the next time then we can look back on this and we can say we've made 15

16 some progress that physicians are more aware, that patients are more outspoken. I want to thank you for being with us today, sir. Thank you, and I'm very hopeful. Yes, I think so too, and Bruce, all the best to you, and thanks for the advocacy you do, and good luck with your soccer team. Thank you very much, and I wish I'd met Dr. Abdi about seven years ago. All the best Bruce. I think you are a very good patient and very, very strong. Thank you. We're going to go, but this is what we do on Patient Power, and as you heard a perfect example, knowledge can be the best medicine of all. So if you're suffering from chronic pain, cancer pain, you want to connect with a knowledgeable specialist like someone like Dr. Abdi and his team at the University of Miami. Tomorrow we're going to switch gears, and we're doing some a whole different; complications of pregnancy, preeclampsia. That's tomorrow on Patient Power. Thank you for being with us. Have a great day. In Seattle, I'm Andrew Schorr, signing off. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 16