Meet our Docs: Todd Hammond, M.D., says pain management is not all about curing pain, but controllin
By admin Aug 21, 2018
Since children first tried to touch a hot stove or a candle flame, people have been programmed to think of pain as our body’s warning system. Avoid the danger or fix the problem, the pain goes away.
“Our whole lives we’ve been taught that all we have to do is go to the doctor, find out what is causing the pain and fix it,” said Todd Hammond, M.D., an interventional pain management physician at Wyoming Pain Center in Casper. “It doesn’t work that way for chronic pain.”
Acute pain is the kind that is caused by an injury, think burning your hand on that hot stove or spraining an ankle. It is sudden and severe, but typically resolves when the injury has healed.
Chronic pain, on the other hand, persists long after an injury has healed. It is defined as lasting longer than three months and can get progressively worse. Think low back pain or joint pain.
Treating chronic pain is about management to improve a patient’s quality of life. Pain management specialists can also bridge the gap between primary care physicians and surgeons to help find the best diagnosis and devise the best treatment plans.
Hammond explains the role of the pain management specialist in the interview below.
Where did you grow up and how did you become interested in medicine?
I grew up in Cheyenne, so I am a native of Wyoming. I had zero interest in medicine growing up; I actually went to college to play baseball.
I would say 80 percent of my medical school class all came from families of physicians, and they knew from the time they were little that they wanted to be a physician. That is not me. I actually applied and got accepted to medical school on a bet with a friend.
Yes. I moved to California to go to school and play baseball at Fresno State. School was a secondary thought for me; I was there to play baseball. That was going pretty well, and then I injured my shoulder in my second year. I had to have a shoulder surgery, so I was doing a lot of rehab and physical therapy and so forth. I reinjured it during rehab, and I was going to require another surgery. The chance of me being able to come back and throw the way I needed to throw to get to the next level were pretty much zero.
I think I was 19 years old, and I had to determine what I was going to do with my life. I was doing physical therapy at the time, and I thought I would study that. But when I was volunteering in the hospital, I realized I’d rather be the doctor than the therapist.
So, I remember hanging out with my friends and I told them my idea. One of my friends said, “I will bet you $100 that you can’t get into medical school.” I said, “Okay,” and then I started the process to get into medical school. I took all my tests and graduated with my bachelor’s in biochemistry and I got accepted.
What made you think you’d rather be a doctor than a therapist.
One of the areas I was volunteering in was the inpatient physical therapy department, so they were just following orders from the physician. I thought I’d rather be the one evaluating the patient, diagnosing their problem, and come up with the treatment plans.
You specialized in anesthesiology.
Why did you choose that specialty? I like the procedure side of things, I like getting my hands on patients and actually doing things, but I was married at the time with three kids at the time of my residency. The lifestyle of the surgery residency is brutal, and it wasn’t a good fit for me. Anesthesia provided a nice middle ground: You still get to do a lot of things with your hands and care for patients, but the hours aren’t as hard on your family life.
I also loved the physiology and pharmacology side of anesthesia. My degree is in biochemistry, so I also liked the chemistry side of practicing anasthesia.
How did you move into pain management?
After residency, there was a job opening at Wyoming Medical Center for an anesthesiologist and I came to Casper. I started working a lot with the neurosurgeons when I first moved here. The neurosurgeons kept very long hours and I had just come out of residency so I was used to that lifestyle. I was recruited at the time to help with some of the interventional pain management.
Neurosurgeons often rely on interventional pain to help diagnose a specific problem. Pain and interventional injections are a subspecialty of anesthesia, so I already had some experience with it. I was still doing anesthesia when the interventional pain management practice started to grow really quickly, and it got to the point where I had to choose between the two. So I chose pain management and I have been working in interventional pain management exclusively for 14 years.
What is the physician’s goal in managing chronic pain?
The roots of the problem start with the fact that pain is really a reflex. It is a reflex that our bodies have to help protect us. If we didn’t have the pain reflex, we probably wouldn’t live very long. That really applies more to acute pain, like when you put your hand on something hot and pain tells you remove your hand immediately. That mechanism works very well for us.
The problem is the reflex also teaches us that when we feel pain, something is wrong; we fix what is wrong and the pain goes away. That doesn’t work when you are talking about chronic pain. There are many different types of chronic pain, but really what you are dealing with is a non-lethal disease that persists. When patients come in with chronic pain, and you explain to them we don’t have a cure for chronic pain, we have a bunch of band aids to help manage it, it is very difficult for them to understand. So that is the first step: Getting people to understand that we are dealing with a true chronic illness, that we are not going to be able to completely take their pain away, but we are going to do our best to help manage it and improve their life.
There has been a lot of news about the opioid epidemic in this country.
What safeguards exist to help protect against the abuse of prescription drugs? It used to be that there weren’t any real guidelines by the CDC or any government agencies, which potentially led to some of the crisis. It was left up to the discretion of the person prescribing the medications. Quite frankly, for the longest time, medical schools and residencies did a very, very poor job educating physicians on the dangers of opioids. In fact, Big Pharma would present to the physicians that “OxyContin is not addictive, it’s a great medicine and physicians were undertreating pain."
Pain was considered the fifth vital sign at one point and doctors were under a ton of scrutiny for not treating it. We still get a lot of pressure to manage pain. It is one of the key questions that patients get asked: “Is your pain controlled?” It can put physicians in a really tough position. Finding the balance becomes on-the-job training that you have to learn.
The new CDC regulations help because instead of the patient looking at their physician as have a blank check to prescribe whatever they want. We can now turn to guidelines to educate healthcare providers and patients about safe practice and proper use of opioids.
What are some of those rules?
Now, there is a statewide PDMP (Prescription Drug Monitoring Program), which is basically a pharmacy background check. So, we are able to see where patients have been getting their pain medications – whether they’re getting them from multiple providers, doctor shopping and so forth. We let them know we are going to do that and that has to be clean.
We have a pain contract which says that if they are going to be taking pain medications on a chronic basis, that they are only going to get their medications from one provider and you are going to use the same pharmacy, unless you are travelling out of town or something. That is closely monitored. The contract also stipulates that we do urine drug testing for other illegal drugs, because we cannot have patients on those while you are on opioids. We also need to see patients every three months to see how you are doing.
What are some options for treating pain without medications?
Apart from managing chronic pain, a big part of our practice is working with the surgeons to help diagnose problems causing pain. One of the other issues we have with that is when a patient comes to us with new pain, they think we will have all the answers once we get the MRI. We don’t.
Take back pain for an example. An MRI might show a patient has a disc bulge, a small herniation or arthritis in their spine. But if you were to take 1,000 people randomly off the street who don’t have back pain and put them in the MRI scanner, you would see very similar findings and they have no pain whatsoever. So the MRI or imaging is helpful, but it certainly isn’t enough evidence for a surgeon to say, “Aha! I see this disc bulge, so if I take you to the operating room and fix this disc bulge your back pain is going to get better.”
We need to be better than that, so we do a lot of diagnostic things. We look at patient history, the physical exam, the imaging and all these pieces point to a list of suspects. It is our job to try to determine which of those suspects may or may not be causing the pain. For example, if we see a joint with a lot of arthritis in the back, but we also see a disc bulge that is pressing on a nerve, we will go in and select one specific area at a time to treat with local anesthetic and steroid and watch the response. So obviously, if the pain goes away and the result is repeatable, statistically that is pretty good evidence we have discovered where the pain is. For surgeons, that is extremely helpful.
We also treat a lot of acute pain. For example a patient who comes in with a small disc bulge from picking up something heavy. A lot of times, if it is not severe, we can do injections with a little bit of steroid and anti-inflammatories and get them on their way. There is a lot of evidence to support that when you treat acute pain early on, not always, but you have an increased chance of preventing it from turning into a chronic type of pain.
Explain the role of pain management in the continuum of care.
Pain management physicians should be the step between conservative treatment prescribed by primary care and a surgeon.
Someone who is otherwise healthy, for example, and all of a sudden tweaks their back during yard work, will normally give it a few days and see if the pain goes away. If it doesn’t, then ideally they would make an appointment with their primary care provider who could prescribe a muscle relaxer or physical therapy. Most people will feel better after this.
If the pain doesn’t resolve, people shouldn’t necessarily jump to the surgeon. That’s where we come in. We try to pinpoint the source of the pain and see if it can be treated with interventional procedures. Once we work through that process, there will be an even smaller percentage of people who actually need to see a surgeon, and we will help refer them. That systems works really well when you get everyone to participate.
Do people need a referral for your practice?
No, but I would recommend them discussing their options with their primary care provider. If someone has already gone through several weeks of pain, and the treatment plan doesn’t seem to be working, they can call and we will get them in.
Dr. Hammond is an experienced anesthesiologist who chose to leave the operating room and dedicate his career to pain management. He is a member of the Wyoming Medical Society and the International Spine Intervention Society. Dr. Hammond has received extensive specialized training in pain management, and he performs a complete array of patient-centered, modern interventional pain management procedures.