A PM&R Pain Specialist Weighs in on the Opioid Epidemic

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Navdeep Jassal, MD is a physical medicine and rehabilitation (PM&R) physician, with a subspecialty in pain medicine. Jassal completed his medical school training at Ross University School of Medicine, and his PM&R residency at Hofstra Northwell School of Medicine (formerly known as North Shore-LIJ). Currently, he is based in Tampa, Florida, primarily working as a private practice clinician at Florida Pain Medicine. He is also affiliated with the University of South Florida (USF), where he completed his fellowship in Pain Medicine, as an assistant clinical professor.

1. How did you decide to go into physical medicine and rehabilitation, with an additional fellowship in pain medicine?

It actually started off by accident. I originally wanted to go to medical school to become a neurologist. I was passionate about neurodegenerative diseases, such as Alzheimer’s, because my mom was diagnosed when I was in high school. So, my first medical school rotation was in neurology, thinking that it was what I would formally set out to do.

However, during the rotation, I was actually very unhappy with it, because I realized it was mostly focused on diagnostics. There wasn’t a lot of treatment or follow-up care for patients as they progressed in their disease. The neurologist at the time then discussed with me that maybe I was better cut out for a career in physical medicine and rehabilitation. So, I then did a full rotation in PM&R, and it just clicked. I realized that I wanted to be a rehab specialist with a goal of optimizing function. From a musculoskeletal standpoint, from a neurodegenerative standpoint, from a spinal injury standpoint, it just seemed like a better fit for me.

Then, early in my PM&R residency, I felt that I wanted to hone in on specialty care, including pain management, with a focus on spine patients. That’s where my interests lied. I did a formal rotation in pain management, and thought, ‘why don’t I become the expert comprehensively in pain, and use my skill set as a neuromuscular specialist to help that?’ I felt like I should finish my training in the most complete manner possible. So, that’s kind of my path and how I picked what I do.

2. What are the main modalities and technologies that you use for pain management?

When you’re devising a pain management plan for your patient, you want to use a comprehensive, multidisciplinary approach.

A comprehensive plan of care really entails everything from PM&R modalities, such as physical and occupational therapy, range of motion exercises, Mckenzie based programs, core strengthening, quad strengthening, all depending on the pathology of the patient or disease — all the way to conservative care of appropriate medical management, which can be anything from anti inflammatories to certain types of neuro pain medications, such as neuromodulators, to topical creams.

And then, lastly, we move into the realms of low-dose opioid therapy — responsible opioid therapy. In the algorithm, before you can get there, I like to also offer a patient, if appropriate, possible injection therapy. I use nerve blocks which help with joint related pains, and, obviously, joint injections as well.

Another thing that I feel really passionate about is offering patients spinal cord stimulation. That field is called neuromodulation. Pain specialists do offer that, not all of them do. But, I do, and for the right candidates, it can really change their lives. I’ll offer something called spinal cord stimulator trial, which are minimally invasive surgical procedures that helps with neuropathic pain.

I also perform kyphoplasty which is inserting a small trochanter device to help employ a ballooning system on a compression fracture, restoring their height and putting cement in their intervertebral body. There is no incision, just a bandaid they walk out with. It’s really life changing.

One point that I’d like to make is that there isn’t a cookie cutter approach. The individualized treatment can be everything from physical therapy all the way to injection approach. And, really, non-opioid therapy should be the goal for the patient, and if not, at least low-dose opioid therapy for non-cancerous patients.

3. With the recent opioid epidemic, how do you fight overuse of pain medications?

That’s a great question. One thing that I want to stress is that, we have always known that opioids should be prescribed responsibly. And, we know that the pendulum on this goes back and forth.

At one point, we didn’t prescribe opioids at all. And, some patients, especially cancer patients, suffered without prescribed opioids. So then the pendulum swung the other way. Everyone was saying that we should prescribe opioids. There was no worry of abuse potential or overdose. And now, the pendulum has swung the opposite way again.

Over time, we realized that there absolutely is a ceiling dose, and we should proceed with caution for patients with non-cancer related pain. There are certain safety measures for people to prescribe opioids, especially when it comes to mixing them with other hazardous medications. [It’s very important] to prescribe appropriately and know, first and foremost, when to start medication on a patient, meaning that they have the failed trials with non-opioid based medications or therapies, and non-addictive nerve medications.

And, then, if they have failed those, are the physicians setting aside a game plan for their patients? Did [they] prescribe the lowest dose possible to help the patient? We have to always have a goal in mind, and the goal has to be both for pain and function.

For example, if you were a couch potato before, and you’re going to remain a couch potato, and I’m prescribing you low-dose opioid therapy, then that’s not accomplishing anything. But, if you’re a couch potato because you can’t walk or lose weight due to knee pain, and you’ve tried injections, and you can’t take anti-inflammatories because you’re on a blood thinner, then I think prescribing a very low-dose opioid therapy is reasonable, knowing that you shouldn’t escalate the dose too high.

The short answer is knowing when to start opioid medications, how to manage it, how to terminate it, and how to make sure the patient is using it responsibly and not diverting the medication.

4. Do you employ any natural or alternative forms of medicine?

It’s not tied directly into our practice, but I am a strong proponent of chiropractic care and naturalistic medicine. Especially being from a South-Asian background, I believe there is a lot of literature that certain yoga techniques can help with back pain and core strengthening.

I’m also a big proponent of using turmeric or other anti-inflammatory naturalistic medications or vitamins that can help with pain. Certain vitamins do help with therapy, such as B6 and B12. I do encourage use of stuff like that. Obviously, I’m not gonna claim myself as the expert; I’m always doing my own research to see if there’s scientific literature to support certain things. But, I think that something like that should be part of the complex algorithm.

And, if my patients are seeing a chiropractor, if they’re seeing a therapist, if they’re doing Reiki, if they’re using a pain psychologist, I’m all for it.

5. How does your expertise in pain medicine expand the breadth of patients that you see?

I see literally everything. From your typical geriatric patient with joint pain — knee, hip, or shoulder pain; to thoracic back or lumbar spine patients with sciatica and shooting pains down their leg; to patients with spinal compression fractures; to patients with abdominal pain after surgery, or thoracotomy pain, or post shingles pain; to even cancer patients with chronic pain that can be helped by opioid or non-opioid therapy.

I help with minimizing pain and suffering at end-of-life care for those patients. It’s pretty much a realm of any type of pain you can think of, from patients that are 18 years of age and have sports related injuries or stress fractures, all the way to geriatric patients with back pain, who just want to live without medication and play with their grandchildren.

6. What influenced your decision to join a private practice, rather than pursue hospital employment?

I think in this day and age, a lot of people feel more comfortable being employed by a big hospital system. In my mind, I always wanted to help manage a practice and be part of that bubble. I wanted to be a part of a process that employs other people — from a front desk medical assistant, to a nurse, to a radiology technician. That’s something that I wanted to do. I wanted to create jobs for people; and I wanted to be part of an entity that would grow, and that I was providing to. It’s always been something that I’ve been passionate about. I wanted to understand how to grow a practice that would allow me the opportunity to join a hospital system in the future, if I did want to.

And, to be honest, I also wanted to be my own boss. I wasn’t ready to be a part of an employee model. And I’m not saying [the employee model] is wrong in any way. That was just something I wanted to do. […] I feel, to each his own. I’m not saying that the academic model or being a hospital employee is something that I’m x-ing out. But, for now, I like my freedom and being a part of a process where I’m growing something. To me, I think that’s going to help me learn more at this early stage of my career.

7. Can you speak about your involvement in academic and educational medicine?

As a clinical professor, I am part of a lecture series at USF, so I help lecture pain management fellows. I am also involved in helping with the cadaver course in didactics to help them with their procedural aspect. Their training involves injections, spinal cord stimulation, kyphoplasty. I’m also involved in the clinical level, where the fellows come with me to my surgery center, to do various surgical procedures and injections, as well as to my clinic, where they’re involved in patient encounters and followups. So, I mentor them in the clinical aspect, as well as patient care, in addition to instructing them through lectures. […] I have a great passion for teaching. I think it’s really appropriate to teach the next generation how to be an ethical and competent multidisciplinary pain management physician.

8. What is a common misconception that you think people have about your specialty?

The common misconception, whether it’s from a patient or doctor, is that the only thing we have to treat a patient is opioid or narcotic-based pain medication. And, that is completely a fallacy. There is so much that we can offer a patient. There is an individualized plan of care for every patient. […] In fact, we try to minimize opioid-therapy as much as we can.

9. What is the most rewarding part of your clinical practice?

From a clinical perspective, one of the most rewarding parts happens when someone who has tried many things still [experiences] persistent pain; they come in, already on a high dose of narcotic medication from another doctor. So, we try something like spinal cord stimulation, starting with trials and then minimally invasive implantation. And, then, we reduce that patient’s narcotics to as much as 25% of their original dose. To me, that’s a life-changer for that patient. The second thing that I really enjoy doing, and something that’s very [rewarding], is teaching — teaching the pain management fellows. And, I still enjoy doing publications as well — case reports, case series, book chapters for board review books, presenting at national conferences. The only way for us to get better is to continue doing what we already have and giving strong evidence for what we do.

10. You’re doing a lot of different things. How do you balance it all?

I am very busy. It takes a lot out of you to run and grow a private practice. But, you always have to set time aside for yourself and your family. I spend a lot of time with my wife and my child. And my outlet to release is going running; I enjoy running. I try to go running on the weekends and once or twice during the week. It’s hard for me to vacation, but I also try to go on one international trip a year with my family for a couple days. Spending family time is really important to me. It’s one thing I hold very near and dear to me — my wife and my child.

11. What advice would you give to young or aspiring doctors who are interested in PM&R and/or pain medicine?

If you think you’ll be the type of doctor who wants to give a patient a diagnosis, but also help treat the patient from a clinical perspective and functional standpoint, while optimizing their quality of life, there’s really no better way to do it than to to pick a career in physical medicine and rehabilitation. And, if you want to be a comprehensive physician from a team management perspective, a subspecialty career in pain management is just icing on the cake. You are going to be that patient’s doctor from a continuity care perspective. You’re going to see them, you’re going to diagnose them, you’re going to help with their management, you’re going to help with their treatment, and you’re going to do follow up care after an injection or surgery. I, personally, wanted to be a part of that continuity. I wanted to optimize and restore function. So, if that’s what you’re looking for, there’s no better career.

Also, from a quality of life perspective, I think it’s a great field. You have a very balanced way of life. I have never met an unhappy physiatrist. We’re really happy doctors and really nice people, and we love what we do.

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