At the same time, our regional amputation center was struggling to keep up. Several VHA hospitals funneled all of their amputations our way, making us one of the largest amputation centers on the East Coast. Suddenly we were seeing not only a very large number of amputations but also a combination of new amputation patients with pain coupled with severe chronic postamputation debilitating disorders. We now had to manage a large group of amputations who had been quite suddenly taken off all analgesics except their acetaminophen and maybe some low-dose NSAIDS.
That really spurred us to try new things. For example, we already had a strong background in our pain training using electricity to assist pain. We had many years of placing and managing spinal cord stimulators and other topical and implantable electrical devices to manage pain, and we understood that electricity applied to a patient’s nerves, spinal cord, skin or even parts of the brain can be more effective in some situations—especially for neuropathic pain. So we were not fearful of trying new methods of instilling electricity as a primary analgesic. When innovation for electrical implantable analgesia entered the market (such as the temporary peripheral nerve stimulating implant and even the permanent peripheral nerve stimulator) we were ready.
Also, ultrasound guidance has become so very much more available to us over the past ten to 15 years. Once it became commonplace in our pain center we were able to implant the peripheral nerve stimulators in our clinic procedure rooms without having to delay cases awaiting operating rooms.
Lastly, we were primed to create a brand-new interventional pain research program at our facility. We had wanted to take on more research for quite some time over the years, but with clinical duties a priority and our busy administrative schedules on local, regional and national VHA committees, research just seemed like a goal without a plan. Then in 2017 our facility was looking to award five startup grants of 50,000 each to incentivize physicians to begin research projects on their service. Several of my colleagues, including anesthesiologists Dr. Brooke Trainer, Dr. Rob Trainer and Dr. Erik Baker and physiatrists Dr. Doug Murphy, Dr. Thomas Phan and Dr. Meenu Bindal got together and said, “How can we use this ‘perfect storm’ to benefit our veterans?” We applied for the grant and our interventional pain research team was born.
Dr. Rob Trainer and I are the co-directors of the interventional pain research team housing about 20 investigators and we have been the primary investigators of several studies since that time, including our four-year “Perioperative Temporary Peripheral Nerve Stimulation Implant Post Amputation” study, which Dr. Brooke Trainer will be publishing this year, our “Temporary Peripheral Nerve Stimulation Implant for Chronic Low Back Pain” study, which will be ongoing for the next four years under Dr. Meenu Bindal ,and our retrospective review by Dr. Rob Trainer of several hundred temporary peripheral nerve stimulating implants for neuropathic pain since 2017. We feel that this research benefits not only our veterans currently but also their future as well as the future of our pain fellows, residents and ACGME approved pain programs at CVHSC.
What would you most like your fellow physicians to know about non-opioid alternatives to analgesic modalities?
It is a very exciting time for both electricity-induced analgesia and also regenerative medicine for pain control. It’s so easy and quick to place peripheral nerve stimulating implants at the source of pain. It doesn’t require a prolonged surgery or recovery time and the skill set is easily achieved using ultrasound guidance. Also -with the new temporary leads on the market it is less committal when compared to life-long implants -as patients can have their providers remove them at 60 days and achieve a “hangover” pain relieving effect sometimes past one year or longer.
Regenerative medicine is also an up-and-coming alternative to opioids There are many new studies introducing the concepts of using cellular materials (such as plasma, and even amniotic tissues) to promote pain control. The future is vast with non-opioid therapies.
You’re also a well-known advocate and educator to increase opioid-abuse awareness and prevention in your community. What are some of the programs you work with?
The list of opioid awareness and prevention projects that I work on is quite long, but my primary project involves working in the community in a program called Silent No More. This program is an opioid awareness immersion program in Virginia middle schools and high schools. Since 2019 I have been traveling throughout middle schools and high schools in the Richmond Virginia area monthly teaching a two-hour “neurobiology of addition” program as part of a team including Dr. Robert Trainer as well as two mothers that share their experience with high school sons who suffered with opioid use disorder and succumbed to the disease. There are also presentations by the DEA, the federal prosecutor, and slideshows and videos that demonstrate the impact of not only the decision to start opioids but also the biological, domestic and legal consequences of the same.
We are very excited to be one of the exceptions to the rule where we have a speaker who understands and lectures on the connection between mental health disorders and overuse disorders. Our last presenter on the team is a survivor voice who discusses hope in recovery. We engage with the kids right in the aisles of their high school auditorium! We have them do interactive challenges on stage demonstrating the activity of the Prefrontal Cortex versus the Nucleus Accumbens. Yes, sledgehammers are part of the skit! According to post education student surveys this interaction helps them remember the target points. We touch on treatment and especially being “silent no more” as evidenced by their “chanting” that slogan loudly and emphatically as I end my lecture.
Many of the kids have thanked us and most of the kids report knowing someone who is suffering with the disorder. Kids have rushed down to the front of the auditorium post-lecture to tell us they have been using substances since they were 10 or 12 and they want to stop. Kids have said they wish they knew the brain pleasure center was being “hijacked” and that’s one of the reasons their dad had such difficulty with relapses before they lost him. It has indeed been an emotional rollercoaster teaching the kids and hearing their stories, but it has also been an immense pleasure working on the mission. I believe it makes a difference.
Our team is also partnering with the board of education for state of Virginia to align teaching with the standard of care discussions on substance use disorder. We are also starting a new project where we are trying to facilitate a partnership with emergency medicine walk in overdose and peer support recovery. We are all very thankful to Kim Ulmet and Olivia Norman from the United States Attorney’s office for their vision and consistent hard work for this program since 2019.
In addition to Silent No More, I’m also a member of the Central Virginia Overdose Working Group (CVOWG), a group of experts from a variety of disciplines that work together toward preventing overdose in Virginia, among other initiatives and projects.
What can others do if they’d like to get involved with these types of efforts?
There are many ways to help and volunteer time or donations to the opioid awareness campaigns. With the rise of Stimulant Overuse Disorder many more resources are needed, and physicians can play a major role in assisting their communities. A large organization ASAM (American Society of Addiction Medicine) consistently has information on their website on how to become and advocate of prevention and recovery in overuse disorders. Additional organizations include Voices for Non-Opioid Choices and SAMSHA (Substance Abuse and Mental Health Services Administration). Local hospitals are always appreciative for physicians as well as your local and state school boards and departments of education. Of course, if you live near the Richmond area and you’d like to hear more about working with me on Silent No More please feel free to contact me.
Is there anything we haven’t discussed that you’d like to talk about here?
I don’t often talk about all aspects of my life publicly but today I will talk about another healthy community activity I’ve done for more than half of my life: fitness instruction. I’ll tell you why. We all know that being a doctor and “doctoring” your patients involves more than just knowing their MRI results, knowing their lab values or the results of their flexion/extension films in pain management. It truly is about connecting. You only have about 10-15 minutes in your clinic visit despite what it says on your clinic schedule. During that time you have to decide not just what’s going on in their spine or in their knee joint but just…”what’s going on,” period. Depression, suicidal ideation, anxiety, domestic violence, substance use disorder, divorce, abandonment, homelessness, court dates…some of our veterans are going through things we have only ever seen on the big screen. You need to develop the connection with your patients that they can trust you. So, in that 15-minute visit you can not only decide what’s next for their spine pain but also what’s next for their life experience.
One of the ways that I’ve become such a skilled “connector” is by serving the community as a community fitness instructor for over 20 years. It started out as a (really really) fun hobby—in fact, I have now accumulated over 40 current mixed fitness certifications (yoga, spin, boxing, lifting, etc. and teach fitness daily). I soon realized that when I connected with my fitness students something felt very familiar. My fitness students had similar goals. They wanted a feeling. They were interested in just being better than yesterday. They wanted to move better and emotionally feel better and live better—and that’s exactly what my pain patients wanted, too. Fitness exercise drills involve the expression of dopamine at the CNS and so does pain relief after years of chronic pain. My pain patients wanted me to look at them and not judge. To choose to look but not judge them for their obesity or their anxiety or substance use disorder behaviors. They wanted me to listen to them and not quickly give my opinions. They wanted me to guide and not direct. So, I say all of this to inspire all of you to remember to remain the best connector that you can be with your patients, so that they can help you help them.
Denise Lester, MD, is a Board-Certified Anesthesiologist and Pain Management physician. She is the director of Peripheral Nerve Stimulation Implant Program and Co-Director of Interventional Pain Research at the Central Virginia VA Health Services Center. She obtained her MD degree at the New Jersey Medical School and completed her anesthesiology residency and Pain Management training at Thomas Jefferson University Hospital. Dr. Lester has held academic and clinical interventional pain physician positions for the past 24 years. She has served as teaching staff for the Virginia Commonwealth University Pain Fellowship since 1998. She has extensive experience in the use of central and peripheral neuromodulation for peri-operative, chronic and cancer pain.