Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr.

Managing Pain from Shingles Webcast August 22, 2011 George Pasvankas, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction: Postherpetic Neuralgia Shingles, a viral infection of the nerve roots caused by the chickenpox virus, can sometimes lead to a painful complication called postherpetic neuralgia. The burning pain of this condition can be severe, even interfering with appetite and sleep. Coming up, pain management specialist Dr. George Pasvankas from UCSF Medical Center explains the most recent treatment options including a skin patch that uses a hot pepper compound--the same found in jalapenos--to treat the pain. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr. Well, pain can be debilitating, and it can be caused by all sorts of things. One cause that many people are not familiar with is it can be caused by a reactivation of the chickenpox you may have had as a child. You don't have chickenpox again, but you have another condition called shingles. And in the medical communities it's known as postherpetic neuralgia pain, and I understand it affects about one million people in America a year have this reactivation. Now, I suffered it, briefly, fortunately, because it can be very severe, when I was going through cancer therapy in my late 40s, and people certainly with weakened immune systems this can happen. It also happens as people get older, and so we're going to learn all about that and what treatments are now available that can help. Our guest is Dr. George Pasvankas. He's the medical director of the UCSF Pain Management Center. Dr. Pasvankas is an anesthesiologist who specializes in pain management. Doctor, am I right, about a million people a year have this reactivation? That's correct. The estimate is an incidence of about a million for reactivation of the chickenpox virus in terms of causing cases of shingles, and the estimate is that about 10 to 20 percent of those people will have to some degree the complication of postherpetic neuralgia, which essentially is the maintenance of that pain problem into a chronic state rather than it just resolving and working its way out as an acute 1

problem. Oh, my. All right. First of all, what's the connection with chickenpox? So, many of us have had it as children, and then we thought that that's the end of it. What's happened? Yeah. It can be quite dismaying to patients to all of a sudden have a pain problem and have it traced back when they have their conversation with their doctor to an episode of childhood chickenpox which may have happened 50 or 60 years before. But essentially while the clinical problems from chickenpox clear up at that time the virus itself never really completely leaves the body, and it sort of lies in a dormant state in the nervous system, sitting around, waiting. And in some people it never becomes an issue again, but, as you point out, whether it is age or debility or other medical problems or treatments for those medical problems, some people have the unfortunate circumstance where that virus sort of rears its ugly head again and causes an outbreak of shingles. So is it an inflammation of like a nerve root? Is that what it is? Yeah. Essentially it's a reactivation of the virus along one of the nerve roots, and inflammation is certainly one of the processes that's going on at that point in time that causes pain in that distribution. All right. So what are the symptoms of shingles? It can kind of depend on the individual person. Some people will--before it progresses to a frank painful problem--just start to notice something a little bit off in a sort of single pattern area of the body, and often that's just a clue-in for people that they're seeing it in such a kind of a cutout or geographic distribution of an area. And it can start just with noticing that you don't quite feel things right on that area. The area can just feel a little bit more sensitive if you're brushing over it or putting your clothes on it or maybe sensitivity to temperature or something along those lines. For some people the first thing they actually notice is the rash that tends to come up in that area. For other people it will really be a frankly painful sensation in that area as the first thing they notice. When you say "rash," what does it look like? I mean, we've all had--i had poison ivy as a kid. I mean, what does it look like? 2

Sure. The rash, initially like many rashes, the first thing somebody may just notice is a color change and a reddening up in that area, but typically it will progress to what we call a vesicular rash, which is basically small eruptions that will eventually if it progresses, can become sort of weeping and crusted over and can even leave some permanent discoloration or marking. Now, would this be in straight line, almost like there's a nerve highway underneath, and it's just like a straight line typically? That's kind of exactly how it will appear for people, and that highway, as you put it, could be going in many different directions, depending on where it is that that particular nerve root happens to be in the body for somebody. For some people it can be on the face and affect one particular distribution of the face. Oftentimes it will run across a shoulder or down an arm. In the chest area it will usually run a pattern that sort of circles along the chest wall horizontally. Or could run in a pattern for example down towards the groin or down towards the leg. Now, as I was in some cancer treatment years ago receiving some pretty heavy-duty medicines and certainly my immune system was weakened both from the cancer or even from the drugs trying to fight the cancer, I noticed just one day sitting at lunch with a friend that I had a sensitivity in a straight line down the left side of my chest. And in mentioning it to this friend, who happened to be a physician, he said sounds like shingles to me, and I was put on an antiviral, and we'll talk about that in a minute. But would that just sensitivity, that's what you're talking about? It could be just as subtle as that? Because I'd never anything like that before. It can absolutely be as subtle as that. Yeah, again, for some people it will depend what the order of things, some people will have the symptoms before the rash, some people will have the rash before the symptoms. I would say then in your particular circumstance you'd probably almost call it lucky that you had a sort of vague sense and a sensitivity going on there before you ended up with a full-blown rash eruption or what sounds like a full-blown really neurologic pain going on. Early Treatment with Antivirals All right. Now, that particular physician, a primary care doctor, prescribed an antiviral medicine. A lot of us are used to the fact that when you're told you have a virus like a cold or, something like that they say, It's a virus, there's nothing we can do. But you do have some antivirals that can help with this, right? 3

That's correct. Yeah, I mean most of these patients are presenting to their primary care physicians or to urgent care centers or emergency rooms perhaps more than they're presenting at that point to a pain management doctor, but the tendency for certain, since this is a circumstance where we know that this can progress to cause a chronic problem like this, and since it is a circumstance where we do have a medication that's effective against this particular virus that most patients will be treated from the outset with an antiviral medication if it's caught early. Let's talk about early. So for somebody like me who got this early warning sign or somebody who started to see a rash, getting medical attention quickly is important because otherwise we mentioned earlier about how severe the pain can be? I think it's very important to get started both or treating the discomfort and on treating the underlying problem as early as possible. All right. So antivirals, do they always work? Well, I think like anything, like any treatment it's very variable, and I think in particular what we have to think about is we don't exactly know for certain that you can catch the process at this exact gate point in time and prevent it from becoming X amount of pain or reduce the chances that it's going to become a chronic pain problem by Y amount or something along those lines, so I would put it more broadly into the picture of it's important to start treating it early, and anything that we can point to would tell us that the earlier is better and whatever effect you are able to get from it by treating it early is better. Unfortunately, we can't say that there's a particular cutoff or a particular level of efficacy that's going to prevent this particular pain problem, unfortunately, though. All right. A couple of things before we go on to other treatments. I know pain--perception of pain--varies by people, but when people see you, and I know pain doctors often say, On a scale of one to 10, 10 being the worst pain you've ever had, what's this? What kind of numbers do people give you related to shingles pain? Well, I'll tell you, we do a lot of sort of after the fact talking with people about what was going on during their initial phase of things, to be honest with you, since we're mostly seeing people with more the chronic problem, and we'll have people tell us that it is among the most difficult and painful things that they've gone through. There's something about the neurologic character of this pain that's so burning and so intense and to electric shooting that it tends to get high pain scores. And also I think there's the fact that there's that hypersensitivity, so as opposed to a pain that's maybe severe 4

but going on somewhere where there's not a lot external that's making it worse, this is something where simple things like showers or socks or clothes or just somebody bumping into them by accident can really cause things to go off the charts. So it's absolutely possible to see numbers up at the top of the pain scale for the acute events, and unfortunately as well even for the worst cases of the chronic ones. Let's talk about chronic shingles. So people may have seen their primary care doctor but now you say there is a percentage of the time when it becomes chronic, and I imagine they get referred to a center such as yours, the UCSF Pain Management Center, and a specialist such as you. What's going on when it becomes chronic? What does that mean? Well, that's a great question. Just the simple definition of when does a pain problem become a chronic pain problem has its own large debate and its own investigation. Certainly, as we talked about, the expectation is that the disease process should run its course and that after the reactivation of the virus runs its course and goes away that the pain problem should typically wind its way down as well and hopefully in a span of weeks to sort of a month or a month and change, similarly disappear. When do we have a chronic pain problem now that hasn't resolved appropriately, certainly when you're looking at, I'd say, six months to a year everybody is in agreement you're really looking at a problem that's probably unlikely to fully resolve on its own and stay a chronic pain problem. And then somewhere in between there is a bit of a gray area, and I think that's an area where sometimes people are maybe under-treated or under-referred in terms of trying to get on top of whether or not this is becoming a chronic pain problem at that point. The Capsaicin Pain Patch All right. So they come see you. Now, I--obviously you have a range of approaches, but I understand there's one particular approach, and I mentioned it at the beginning, connection with jalapeno peppers. Tell us about that, about how to treat this when it's become chronic like this and also why particularly in older people who may be taking a number of other medicines this is particular helpful. Sure. Well, there's a storied history particularly involving here at UCSF about the investigation of exactly what this hot substance in chili peppers is and on a chemical level and neurological level what it is that's going on behind that, which is obviously a little bit out of the scope of today's discussion. But as it turns out there are receptors on the small nerves, essentially the ones that are most peripheral in the body there at the skin and just underneath the skin that are helping to sense pain problems, and one particular receptor, one way that these things are activated is by this substance 5

that's naturally found in chili peppers which naturally gives them their heat. As it turns outs that unlike a lot of other circumstances in medicine where we're trying to block a certain pain transmission or block a certain problem, we're kind of using this substance to almost do the opposite. This substance will turn on that receptor, but the hope is that really by kind of turning it on in a high fashion and a long fashion as we're doing with this type of treatment you almost--and the pun is intended--you almost burn out these nerves from being able to do their job. So there's evidence that by doing that over time you have both the decrease in the number of nerves and receptors that are able to carry these pain problems and as well just a decrease in their overall ability to do that, the ones that are left. What is the substance called, by the way? The substance is called capsaicin. It's something that's been around for some time. We've had topical treatments for capsaicin before for quite some time, but the difficulty is that they were sort of nonprescription strength, so to speak, so they were a much more mild strength. They required quite a bit of repetitive appear application by patients, and there were lots of things that go along with that. So the chronic, sort of low level of discomfort from applying it because, as we talked about--it does activate it when it's first put on--as well as just sort of the slightly annoying nature of having to chronically put on a cream or a gel, especially in some of the areas where people will have these problems, has really been a limitation in the past. What is the medicine called? So the brand name for this patch is called the Qutenza patch, and what it basically is capsaicin 8 percent, and so it's a much stronger concentration of this than any of the topicals that people would have been able to put on for such a problem in the past when it was suggested. And why particularly in older people who may be on other oral medicines or cancer therapies, whatever it may be, why is a topical patch desirable? Yeah, it's something of a Holy Grail almost for physicians. When we find a pain problem that can be treated with a topical medication we're quite excited because, firstly, the medications that we're often using for pain otherwise, it's not that they're particularly targeted to some of these pain problems, and I don't mean to say that's always the case, but a lot of times it's just throwing one after another of somewhat nonspecific medicines, whether they're opioid painkiller medicines or what we would 6

describe as neuropathic pain medicines which can be antidepressants that are sort of being co-opted for other uses or anti-seizure medicines are being co-opted for other uses, you're just adding layer after layer of medications that is being exposed to the body systemically, and that has a lot of side effects. They interact with one another, they interact with other medications that patients are on, and they interact with other problems that the patient might be having in general if it's debility or memory impairment, or balance difficulty, all these sorts of things. So you don't want to give them a red pill to go with the green pill to go with the blue pill. This-- Exactly. --is more specific, and I can understand that. So what's your experience as far as helping people now with these tools you have, this included, where shingles pain has become chronic? Is there hope for relief? There certainly is. One of the things patients are always most interested in when they come in and they have a problem at this point that somebody has said, Oh, I think you need to see a pain doctor. This is a chronic problem. I'm not sure this is going go away. They may talk about a lot of other things during the visit, but one of the things that's on the forefront of their mind really is Will this go away? or, How will I be able to live with this? Sometimes it's a little bit discouraging not to be able to give them a concrete answer from the outset that says I can cure this or I will fix this, but I feel very confident letting people know that--especially at the juncture that we're at right now and the number of tools we have available to us--that we have a lot of things we can work on to potentially bring their pain problem to something that's no longer an issue at all for them, but if we can't do that to help bring it to a place where it's a lot more manageable for them and their quality of life and their functional status is a lot improved. Getting the Best Care So if someone has been suffering, so they went to their primary care doctor but they're still suffering, and maybe that is the right word. Their quality of life is limited or putting on clothes or somebody bumping into them or whatever it is, but this shingles problem is not going away, that's when seeing a pain specialist such as you makes sense. 7

Yeah. That's when patients usually come across our radar. They've been on the acute treatment for the outbreak and pain medications to get them over that hump. Many of them, depending on who it is that they're seeing and what their background is, will have already been started before they come to see us on maybe continued treatment with opioid pain medications. Maybe a long-acting one has been added in, maybe they've been tried on a few of the neuropathic or nerve pain medications we've talked about, but generally at that point we're being asked to get involved to bring in second- and third- line measures, consider other procedures, things along that line. Well, I'll make my pitch because this is called Patient Power. If it were me, where the medicine that I had where the early signs of shingles--and my dad, much older, had had shingles and I knew how painful it could be--if that's not working for you, I would recommend, for you the patient, that you have a consultation with someone like Dr. Pasvankas to really look at the whole landscape of what is available and what might apply to you. I think it makes a lot of sense. Doctor, so if someone has this outbreak, should they despair that there's another shoe that's going to drop a year or two years, five years down the road, and they're destined to have this again and again? And I don't mean the people in the chronic category. But for me, it happened once, I never want to see it again. Should I worry? Could there be another reactivation or maybe not likely? There could be another reactivation, but as we move into a better era of treatment with regards to vaccination, for a lot of these people who have an outbreak that becomes something that they can look into with their primary doctors to help reduce the likelihood that this will be an issue in the future. That, as well, I think a lot of those patients will be sort of better educated on the radar, know what to expect, and if they do start to move toward seeming like they're having a problem again they'll probably be very much on the forefront of seeking care for it and getting on top of it early. Okay. So really we're at, as you said, a better point now in trying to control shingles pain or what you call postherpetic neuralgia pain, and that's a good thing. Absolutely it's a good thing. And even when drug therapies are failing I think we're becoming more and more advanced with our pain management techniques for the more difficult patients, be that other interventional techniques, implanted devices. There's really a whole world of pain treatment options I think a lot of patients and a number of their referring physicians don't necessarily know about when they're in the early stages of treating some of these most difficult pain cases. 8

Right. There you go. Well, certainly if someone is suffering connecting with a subspecialist like Dr. Pasvankas makes sense. Thank you so much for being with us, Dr. George Pasvankas, medical director of the UCSF Pain Management Center. We appreciate you being with us. It's been a pleasure talking. Thank you. This is what we do on Patient Power, is connect you with experts such as Dr. Pasvankas to help relieve your pain and make sure that you get the diagnosis and treatment you deserve. Thank you so much for joining us. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 9