Second video in our series about pain management during the coronavirus (COVID-19) pandemic
I’m a board-certified pain management doctor. I’m executive director of the Ainsworth Institute of Pain Management. I’m an assistant clinical professor at the Icahn School of Medicine at Mount Sinai. The majority of my life I’ve really spent doing research, mostly aimed at a new breakthrough medications, and new breakthrough treatments, a lot of work in stem cell therapy and medical devices, but this is something that no one has been prepared for. This wasn’t anything that anyone in any specialty knew what to do, or knows what to do. Even a good friend of mine who is a virologist…this is brand new territory. It’s caught all specialties off guard. A lot of what we’re doing, we’re picking it up as we go along. I wanted to do this today to help put some good information out there, kind of combat some of the misinformation that’s going on and help people seek out the truth from the lies.
So this is the world that we live in now. As of March 2020 we’re really going into the world; “social distancing” is now a word that…it’s everywhere, hearing the words “flatten the curve”, looking at maps and seeing huge red dots, as of today we surpass China with the most cases in the world. This is our world. It’s going to be this way for a while now, so we might as well get used to it.
Now, what is COVID-19? I think a lot of people already know what this is, but I wanted to just go over it since that’s what this is about. Some people have been asking over and over again, why can’t we just use antibiotics? Well, it’s a virus. Viruses don’t respond to antibiotics, and I know this is confusing because people were talking about using azithromycin or a Z-Pak. Viruses don’t work against antibiotics and antibiotics are for bacteria. That’s why this is so difficult to treat.
Coronavirus isn’t new. This is a new strain. You can pick up what everybody has right now in their house, they’re are Clorox wipes and you’ll actually see “coronavirus” on there, but this is a new strain. So this is something that mutated, it evolved, it changed in some way, and that’s why people are calling it “novel”. It attacks the upper respiratory system. When it causes pneumonia, in which people end up having shortness of breath, what pneumonia is, it’s what we call a consolidation or water that fills up the lungs. It takes up the lung volume space and then people can’t fill their lungs with enough air. So they’re not able to take as deep of a breath.
It’s extremely contagious. People can be carrying it and they can go on detected for days at a time. And think of all the people you can come into contact with in just a couple of hours. If you’re living your day normally. It can take up to two weeks to incubate, which means that you can have it and carry it and give it to people for two weeks without knowing it. This is more dangerous than flu. Some people are calling it the flu. This is not by any means. Believe me, the world does not want to shut down. No one wants to have their employees work from home, if they can help it. People don’t want to be laying people off. People don’t want to be unemployed. If this was the flu, we wouldn’t be in the situation we’re in.
To go through a couple of things that are out there, hydroxychloroquine or plaquenil, this is an anti-malarial medication has been around for decades. Is it real or a hoax? Some people have put out some information from other parts of the world saying that this is it, this is the silver bullet. There was a study that came out a couple of days ago and showed that it was no better than placebo, so we don’t know yet. They’re trying it, but it is not a drug to be taken lightly. It has what’s called a very narrow therapeutic window. Too little doesn’t do anything, too much you can overdose and die. So like any prescription medication, it needs to be written by a doctor, but if you are a doctor, don’t go prescribing this for yourself. It’s a dangerous medication when taken improperly. So we don’t know yet. The jury is still out if this works or if it doesn’t work.
Unfortunately there are people some very unethical people, some say very evil people, out there that are trying to take advantage of the situation. One thing that we use in pain management or gender medicine is something called exosomes. Exosomes are this new hot topic for getting the body to regenerate itself. Believe it or not, there is a company out there that’s trying to tout exosomes as a treatment and it’s all over their website. They have all this gray zone verbiage like a car commercial on TV. It’s not real. This is not a real therapy. It’s not a real treatment. It hasn’t even been studied formally for pain yet. It hasn’t been in any randomized controlled trials yet. So the fact that they were able to put out this website is really slimy, just to get people to kind of buy into their company.
Stem cell therapies, again they’re still not even approved in the United States yet. For most things they’re in clinical trials. We’re in a handful of the clinical trials, but these are for things like knee pain or retina detachments and things like that. It hasn’t been formally studied yet. So these are not real treatments even for other things, let alone COVID-19.
Immune system boosters, again not real. Holistic treatments, I think those are really just…personally as a allopathic doctor with an MD I’m not a big fan of these to begin with, but even less so for this. There is no cure and there is no vaccine and a vaccine is at least a year away. People are in clinical trials right now for the vaccine. There’s a number of companies that are racing to get vaccines, but it will be a while before these are out ladies and gentlemen. So we need to hold tight.
The most important thing here is I want everybody to know that no matter what you see or hear people talking about, there is no cure for COVID-19. There are things that people are talking about. We’ll get there eventually, but there is no cure. When in doubt, call your primary care physician or seek the care of a board-certified medical doctor, an M.D., a D.O., a nurse practitioner. Naturopaths, people that taught some of these snake oils, don’t take your word from them. Take your word from a physician.
So what now? This is where the idea for hosting this webinar came from. The world is on pause, but not my pain. I’ve had a number of patients over the last two weeks that have been emailing me and they’re concerned and they don’t know what to do. The world is telling them to stay inside, but they need help. They need treatment. So pain is really in the middle. It’s one of these things where you’re not dying, as far as in the eyes of the rest of the world, but you may as well be when you’re in so much pain you can’t even sit, you can’t even open your eyes, you can’t lie down. And then staying at home…for some people their pain gets worse when they sit. They’re being told to stay inside and all they can do is sit, all they can do is sit there in agony. So what I wanted to do was host this webinar to have some information for those of you that are out there, or for maybe patients that just suddenly developed pain in the last two weeks and they can’t get out to see a doctor and they want to know what to do next. The impact on medicine is palpable.
One of the biggest questions or words as it pertains to my specialty is the word “elective”. The impact on medicine as it pertains to pain management is probably in the top five that have been most impacted by this because our entire field, in the eyes of many, is considered elective. Now, the reason why elective procedures have been postponed indefinitely is for a number of reasons.
One of them, and the most important one, is to conserve supplies. Right now there are things that are in massive shortage. Doctors doing pain management procedures, they’ll wear face masks, they wear gloves, and things like that. These are the things that we need to preserve the most. We need gloves, we need face masks. Some of my colleagues are out there risking life and limb and they really don’t have the right face mask and God blessing them and thank you for really busting your ass for the people out there that need it. So if we don’t need to use face masks, we need to be conserving them, and it frees up doctors. I wasn’t an anesthesiologist by training, but the vast majority of pain management is. We need their help intubating patients who are short of breath and can’t take a breath on their own. So it frees up those people to do other things.
The next one, operating rooms, I never knew this and when I heard it, it gave me chills, but operating rooms can be converted to ICU beds. This is actually a protocol that was developed decades ago in case anything happened like a nuclear war, back in the fifties and sixties and it was something that they had taken into account. Operating rooms operate on what’s called negative pressure. It sucks everything out of the room so that way it keeps everything sterile and ICU is opposite. It’s positive pressure, keeps everything in. So if a person has an infection, it keeps the infection in the room. So what they’re doing is freeing up all these operating rooms from these elective procedures and they’re converting them into ICU beds. Around the country there’s less than a million hospital beds. When you think about how many ICU beds there are, there’s less than one hundred thousand ICU beds nationwide. Hospitals have sometimes 5, 10, even 20 times more operating rooms than they do ICU beds, so by converting those from operating rooms they’re freeing up a ton of resources for people.
Most importantly it reduces hospital volume. It’s keeping the healthy people away from the infected. The vast majority of people in a hospital right now are the people that are being treated, unfortunately, for COVID-19. People that are going for elective procedures, they are probably healthy, and you’re now mixing the infected with the healthy. So it’s keeping people at home, off the streets, and it’s preventing sick people from infecting healthcare professionals most importantly. For someone who might be sitting there doing an eye exam on somebody, and they might unknowingly be treating someone who has COVID-19, and they’re just inches from their face and getting them sick. So it’s keeping the sick people away and it’s keeping the healthy people away.
How does this pertain to pain management? I had a number of patients ask me this. I probably had 20 emails in the last 3-days alone asking, “I understand elective and emergency, but which one am I and how do I know the difference?”. In a broad sense, elective medicine is really just some of the simple things; cosmetic surgery, cosmetic procedures, LASIK eye surgery, cataract repair, varicose veins, knee replacements, things that can be put off, things that people can wait for. Things that people can’t wait for; open heart surgery or kidney transplant, childbirth…you can’t make that wait, chemotherapy…you can’t ask a person to wait 6-weeks before they can resume their care because that would basically be handing them a death sentence. These are things in the most obvious sense. Pain is very much in a gray zone.
What is something that’s elective in pain? This is what I came up with as a cursory list. Joint injections for arthritis, for the most part I would just say, and there’s always exceptions to every rule, but a joint injection for arthritis, people can generally live through some of the issues with arthritis. You can take NSAIDs [non steroidal anti-inflammatory drugs]. I’ll go into NSAIDs in a second. But this is something that can probably wait. In general terms, anything that can be easily postponed.
So ask yourself, what if I were to put it off for a couple of weeks? Would I be in dire straits? If you say you can put it off, then yours is elective. Pain that can be managed with over the counter medications. If you can take a Tylenol and you’re able to get your pain down below 5 out of 10, I would say wait. Emergent are people that can’t wait; someone who’s in a pain crisis.
Probably one of the most understandable pain crisis is out there is imagine when you have the worst headache you’ve had in your life. People with facial pain, trigeminal neuralgia, and atypical facial pain, they deal with this on a daily basis. If you’re thinking to yourself about the worst headache you’ve ever had, you’re completely incapacitated, you have to go into a room and turn off the lights, shut your eyes and block out all the noise…that’s a pain crisis. So if your pain is like that, then maybe it’s emergent.
People with intrathecal pumps. I have a number of these patients in my practice. These pumps will run dry. You can’t tell a patient, “I’ll see you in a few weeks, and then we can restart the medication”. This medication is going directly in your central nervous system. It bypasses everything. If this just suddenly stops, in a matter of minutes people can start going into acute withdrawal and the effects of withdrawal can be devastating or even cause a heart attack. These are patients that are emergencies.
I’ve put in a number of spinal cord stimulators and if a person has an infection – I’ve never had one, thank God – but if a person were to suddenly develop an infection in their pocket or the device is protruding from their skin, that would be an emergency…or in general, someone who just can’t seem to control their pain without needing new opioids or requiring more opioids. Now I’m going to go into opioids in a second, but these are general terms. So whichever one you think you fit in, you’d be able to figure it out.
This is a quote from one of my patients, but I think it applies to everybody, “What am I supposed to do? I just can’t wait in pain for the next 2-months.” This is, I think, what every pain patient is asking themselves right now. What am I supposed to do? How am I supposed to wait for the world to get back to the way it was? I can’t wait. So this part is geared towards you.
Ibuprofen, this is something that I think has been very controversial for the last couple of weeks. A few weeks ago, the French had made a statement saying the ibuprofen seems to make the virus worse. Now, ibuprofen, there are a couple of different types of anti-inflammatories out there. There’s Cox one, there’s Cox two inhibitors, things like Mobic and Celebrex are Cox two inhibitors where they don’t affect the lining of the stomach. Ibuprofen is a regular anti-inflammatory. What the French were saying was it creates an enzyme that seems to feed the COVID-19 virus. Then the World Health Organization came out and backed it and said it’s true, don’t take it. I think it was last week or the week before where they retracted that statement and they said that it’s actually okay to take. So those of you out there watching this; if you’re in pain, ibuprofen is safe to take and I encourage you to take it within the recommended doses. So again, it’s not dangerous. The World Health Organization retracted it, so you can take ibuprofen.
Opioids, this is one that I’m very passionate about in general. My mother was a prescription drug addict. Anybody that knows me and my practice knows I’m very much against opioids and I have very few patients in my practice [on opioids] and I’m very proud to say that I’m always in the bottom 3% of prescribers nationally, every single year. A couple of my patients asked “can I just take some pain prescription killers in the meantime” or “I can’t come in and get my injections because I’m afraid to come outside so can you just prescribe me some Percocet to get me through?”. The answer is no. Evidence is very, very clear over the last 20 – almost 30 – years that opioids have a direct negative impact on your immune system. So in other words, the more opioids you take the worse your immune system is.
If you’re hearing the news about some people that are getting it and it’s very mild, like Tom Hanks and his wife, they had it and they didn’t really present any symptoms. Idris Elba…we’re hearing about this from the celebrities that are out there, but there’s a number of people that are getting it, they’re testing positive for it, and they’re not showing any symptoms. The reason is because their immune systems are fighting it off because they have an effective immune system. So, God willing, hopefully none of you will get it, but if you do you need your immune system to be the best it can to fight this thing off. The worst chances you can give yourself is to start taking more narcotics because it will hinder your immune system in and lessen your ability to fight it. So if you’re on opioids, don’t take any more than you already do, and if you haven’t started any, this is not the time to start.
Supplements, some people very much into holistic remedies or things that are out there and they want to know in general, are there any remedies or supplements I can take to help my chances? The only one that I found that I would really endorse to a certain extent would be zinc. There’s some limited evidence showing that it could be effective, but I just want to be perfectly clear that this is not substitute for social distancing, nor does it substitute for conventional medical care. I don’t want people to take this and think that they can just go back outside and they have nothing to worry about. Again, this is something that you can take that if it’s unavoidable that you run into somebody and end up contracting COVID-19, this could help your chances. Again, take the recommended daily doses of it. It’s not going to hurt you unless your doctor’s told you that you shouldn’t take zinc for whatever reason. This is something you can take. It does seem to bolster their immune system. My best friend back home swears by whenever he gets a cold. It’s something you can take to help you.
I’ve met a couple of new patients over the last week or two, because their existing doctor closed up. “My doctor closed so what I do now?” Your doctor closed because he or she was doing their part, they’re trying to keep their staff safe. They’re able to close, they’re staff where they work in a hospital and the hospital gave them guidance that they had to, or maybe they operate out of a surgery center. The department of health has closed all surgery centers. So don’t be mad at your doctor for closing. I haven’t because I’ve been trying to stay open and do my part because I have a lot of patients that need me and I can’t close up. But if they have closed, again, don’t be angry with them.
But what do I do?. First thing, most importantly stay home if at all possible, but if you can’t, we’re here. We at the Ainsworth Institute, again, we’re staying open on a very limited basis for select patients. Anybody who has mild pain or somebody that we can manage from a distance, we’re telling them to stay home and we’ll pick back up in a couple of weeks. We’re not going anywhere. For the patients that need us, patients that are in acute pain, patients that just really can’t wait a couple of weeks for this to be over, we’re here for them.
So one of the things that we’re doing is telemedicine. Telemedicine has been approved, I think it was about two years ago, but unfortunately, like a lot of things that get approved, the insurance companies don’t want to pay for it. No insurance company was covering telemedicine. If they were there making you see their healthcare professionals, which defeats the purpose of it, right? Because you want to see your doctor, but thankfully right now the federal government across the entire board covered every single telemedicine visit. So everything from, Medicare to Medicaid, Obamacare to United, Oxford, Blue Cross, Aetna, Cigna, 1199, ARP, even workers’ comp….workers’ comp was the last one to cover it, but fortunately workers’ compensation is under the jurisdiction of the governor and here in New York – governor Cuomo is doing a fantastic job and God bless him for the work he’s doing for us – they have to abide by what the governor says. So it’s all covered.
For my existing patients, we’re able to help them stay at home. We’re able to keep them off the streets and we’re able to continue our care with them and do our part for them. One of the things that we’re able to do also is see new patients. This was something that came out. We’re able to see new patients now with telemedicine. If you have a doctor and you can’t get ahold of your doctor, maybe they’re not doing telemedicine, maybe they don’t know how or they’re not able. We’re doing telemedicine, for even new patients. I saw a new patient yesterday, looking forward to meeting him and his wife in person in a couple of weeks, but we’re able to see patients now, even new people we’ve never met before, over telemedicine.
One of the things right now is they’re making it very easy for people. We can do telemedicine over FaceTime or Skype, that’s not going to last forever. Normally you have to do telemedicine over an approved platform that’s HIPAA compliant, which is to make sure that your privacy is, optimally protected. So once this is all over, telemedicine unfortunately won’t be approved forever. As soon as the viruses kind of gets under control telemedicine, we’ll go back to being a cash service. Also, I imagine when it does we’ll have to go back to using conventional platforms. Right now it’s covered by all insurances. You may have an additional copay for it. Some insurance companies are charging $50 for a copay for telemedicine. Medicare is not charging any more than they would, but check with your insurance to see how much it will cost, but they’re all covered. You can do it if you have an iPhone, you can just use FaceTime for it.
One of the things for us [to help you] is we have an office based procedure suite. Because of that, we’re a private facility and we’re a sterile facility. So we don’t have – as far as we know – we have not had a single sick or COVID patient come in or anyone who’s tested positive. None of the tenants in our building have tested positive. So as of right now, we’re a safe sterile facility, which makes us, I guess, preferable to someplace like a hospital, where even if they were open and they’re not, but if they were – and they shouldn’t be – they can’t really make that claim because there are patients that are sick that are walking around those halls. So we’re safe, we’re open for a limited amount of patients, and as a sterile facility we’re able to operate privately.
One thing that we do for all of our patients that qualify, or that are candidates for it, is IV infusion therapy. This is something that’s even more important right now. Most of the injections that we do in pain management use steroids, and steroids are great anti-inflammatories, but they also have a lot of side effects to them and we don’t know the exact effect of what it’s going to do on the COVID virus. So a lot of us are just kind of…the debate has been ongoing in the last couple of weeks amongst a lot of us, but what we’ve all agreed is maybe we should just, if we can’t avoid it, to use lower doses or use a much less potent one. For me, what I’m doing with some of my patients is using ketamine infusion. This is something that is a very powerful pain medication.
It can be given in a controlled way. There’s really zero risk of infection from it other than just the IV and it doesn’t hamper your immune system in any way. So this is something that’s very powerful, very effective. We go through patient’s insurance, which is something that most people don’t do for ketamine; they charge cash for it. The only cost that people would have with the ketamine is the cost of the ketamine itself, which is $10 to $15. So this is something that’s very effective and we feel good about using it in the midst of the coronavirus pandemic that it is not going to hinder someone’s immune system and it’s generally safe to do and we’ve been using ketamine in my office ever since we opened. We usually have a pretty long wait list for it, but it’s something we’re offering now. If someone is in pain, and maybe you’re not a candidate for getting a steroid injection, we can use intravenous ketamine for and help you get through this.
So what do I do next? Well, if you have a fever or cough, stay home. If you’re 65 years or older, I think it goes without saying stay home. Any recent traveling or have you come in contact with anybody who’s infected? Don’t even think twice. Stay home.
If you need us, you can call us and you can schedule a telemedicine visit and we can perform the consult virtually. Even if you’re not a new patient, if you’re someone we’ve never met before, you can schedule the consult virtually. We can send you all the paperwork electronically. You can fill it out, send it back to us over email, and you can stay home and we can still treat you as best we can. We can’t do a physical exam, but we can do what we can within the best of our ability.
The beauty of being in an electronic era is this, if you need a prescription we can send it electronically. You don’t have to get a paper prescription to come in and see us. We can send it to a pharmacy. There are pharmacies that deliver. So if you find one, and let’s say that’s something you need, you have arthritis in your knee, we can send you a topical anti-inflammatory. We can send it to a pharmacy that’s nearby and hopefully they can deliver it. We can see you and treat you without you ever having to leave your home.
For those of you that can’t stay home, for those of you that need to come in for a treatment, for whatever it may be, depending on the severity, we can schedule you for an in-office treatment.
Again, this will be based on severity, based on priority, based on safety, and really be based on our best judgment. So if we tell you that we don’t think it’s a good idea…some people I’ve had to tell them, and they were upset about it, just because I didn’t feel comfortable having them come in. You know, I hope you know it’s not personal. We’re just looking out for your safety, but we’ll do the best we can to get some people in and do the best we can to make sure that the people that are staying home, we can keep them comfortable.