Sean Mackey, M.D., Ph.D.
speaker
373 appearances
1 recordings
1 series
first heard Apr 2025
last heard Apr 2025
Sean Mackey, M.D., Ph.D.’s voice in public audio — every appearance, attributed to the second.
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Most frequently when the outcome is not simple. So when the surgeon needs some help, when the internal medicine doc needs help, and it's beyond their comfort.
Yeah. These days, there's a lot of movement towards these ARAS protocols and enhanced recovery after surgery. And so fortunately, the field of medicine is moving more and more towards a team-based healthcare model where Surgeons, pain docs, anesthesiologists, nursing, rehab are all working in a collaborative manner.
They're putting together protocols to what is the best optimal approach to prehab a patient before surgery, move them through the intraoperative and then perioperative period. And it's gotten better and better and better. Can we still improve it? Yes. But the acute pain service does get involved, particularly, as you alluded, when we put in peripheral nerve catheters or epidural catheters.
And this is where we're running that local anesthetic, the numbing medication that stops the nerve impulses to provide pain relief after surgery. And so, yes, we do get deeply, deeply involved in that acute surgical pain space. And then also with internal medicine docs when patients are admitted into the hospital for whatever cause.
Right. You are right. And if a patient is listening to this, a person is listening and they have the ability, they have the wherewithal to go to their doc, their surgeon, and ask, what will pain management be like? Is there an opportunity to interface with an acute pain service, particularly if
if they're taking opioids now for a chronic pain problem, or even if they're not taking opioids for a chronic pain problem. So we will see them in our clinic before surgery. We will put together a presurgical plan for them, which will often include a regional anesthetic approach, meaning those nerve blocks or the catheters. We sometimes involve intravenous ketamine to augment.
We will put together the whole plan, communicate with the anesthesiologist, make sure there's a good handoff after surgery. And then we will follow them afterwards. And then we will typically follow them outside the hospital and help the surgeon out with the medication management and the pain management.
All of this is not just solely to reduce pain, but to put that person in an optimal state for rehab.
Everywhere.
Fentanyl, morphine, Dilaudid, yes. The PCA is a very common tool. And one, it puts pain control in the hands of the patient. Two, studies have been shown that PCA-delivered medication, opioids, they end up taking less than if it's nursing-delivered.
I wouldn't say necessarily because I think there are some surgeries that are going to clearly require prescribing an opioid after surgery. Remember, the name of the game is get people out of the hospital and have the care take place in their home. And people are going to need some degree of pain management and analgesics. And those analgesics can be Tylenol NSAIDs.
If it's more than mild, moderate pain, it may involve an opioid.
What we have learned is that there are vulnerabilities that people bring to an injury or surgery and being placed on opioids that set them up for more likelihood of persistent opioid use. And we've characterized, we and others through research studies, have characterized many of these factors. So some of these factors include preoperative depression and anxiety, higher levels of catastrophizing,
Early adverse child events, so a history of PTSD, history of physical, sexual, psychological trauma, all of these set someone up to have a higher likelihood of persistent pain and persistent opioid use. Now, you will note all these things I said, most of these things I said, people would normally put under the psychological umbrella.
The key message that I want to give, I think everyone's getting this, is when we talk about psychology and psychological factors, we're talking about neurosciences. We're talking about the brain. And we're talking about specific brain systems, regions, networks. So we did a study several years ago. This was led by Jennifer Ha. Ian Carroll was a key player, leader on this.
And we found that higher depression scores preoperatively predicted much more likelihood of persistent opioid use after surgery. And how are you screening for this? What tests are you using? Back then, we used something called the Beck Depression Inventory, which... Standard instrument, we don't use that anymore. There's more modern tools.
I thought what was cool about this, we did a factor analysis on the original paper, and you can break the BEC down into different components of depression, anhedonia, cognitive, blah, blah, blah. What we found is there was a particular factor. that drove almost entirely that prediction of depression, self-loathing. It was feeling like really bad about yourself.
Yeah. Conceptually, your argument holds. But now I'm going to come back to a lot of the things that you write about. which is the danger of drawing inferences from small population studies and generalizing that to the rest of the world.
That's exactly it. Unfortunately, there's not much will to do that in society.
I was on the Institute of Medicine panel, now the National Academy panel, and we did a report called Relieving Pain in America. And I remember sitting around back in 2010, And we were talking about the state of pain in the country and where we needed to go identify a perfect vision and also identify what are the biggest research questions to ask and answer.
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