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LOUISIANA PAIN
QUARTERLY | Vol. 23
PERSONALIZED
MEDICINE:
New Developments in
Pharmacogenomics
OUR SPRING
RECIPE
SPINAL CORD
STIMULATORS
WORKERS’
COMPENSATION
Flavorful Fare from MoPho
What You Need To Know
Without Stress
CONTENTS
VOL. 23
01
02
03
04
06
08
10
14
Editor: Sarah Ravits, Deseri Ireland
Design: Addie Mirabella
Published by: Xanthus
If you are interested in a magazine for
your practice contact Nick Ryan at
[email protected]
WELCOME
New Orleans during the springtime is a magical time of year.
RECIPE
The MoPho Som Tam
HAPPENINGS THIS QUARTER
Check out events happening in the New Orleans area for spring!
SPINAL CORD STIMULATION
Hope for patients who have not responded to other treatments
PHARMACOGENOMICS:
The Intersection of Pharmacology and Genomics
WORKERS’ COMPENSATION
Louisiana Pain Efficiently Navigates Workers’ Compensation
CONSIDERING THE MIND
Mindfulness & Chronic Pain
PUZZLE
Check out the spring word search!
Vol. 23 | LOUISIANA PAIN QUARTERLY
1
WELCOME
ew Orleans during the springtime is a magical time of year,
but for those suffering from pain it can offer new challenges
as people become more active and social as the weather
warms up.
If you’re experiencing any type of pain, there is hope: We offer a wide
variety of treatments and procedures that are personalized just for your
specific needs, so that can get you can be in good health and living life to
the fullest.
In this issue, you will find a recipe from one of New Orleans’ most
popular new restaurants, MoPho (pg. 2.) We also suggest a few enjoyable
activities in “Happenings This Quarter” (pg. 3). Find out more about our
workers’ comp program (pg. 8); the field of Pharmacogenomics (pg.
6) and spinal cord stimulation technology (pg. 4), along with other useful
information.
We hope that you enjoy the nice weather and all that New Orleans has
to offer, including a pain-free, healthy lifestyle! N
Dr. Firas Hijazi
From our families to yours
Dr. Firas Hijazi
Dr. Satvik Munshi Louisiana Pain Specialists
Dr. Satvik Munshi
LOUISIANA PAIN SPECIALISTS LOCATIONS:
KENNER
231 West Esplanade Avenue, Suite B
Kenner, LA 70065
NEW ORLEANS EAST
5621 Read Boulevard
New Orleans, LA 70127
NEW ORLEANS
3439 Prytania Street, Suite 501
New Orleans, LA 70115
MARRERO
4520 Wichers Drive, Suite 205
Marrero, LA 70072
LAPLACE
502 Rue De Sante, Suite 303
LaPlace, LA 70068
TULANE MEDICAL CENTER
1415 Tulane Avenue, 4th Floor
New Orleans, LA 70112
CONTACT US: 504-434-7750 or LouisianaPain.com
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LOUISIANA PAIN QUARTERLY | Vol. 23
THE MOPHO SOM TAM
I
•
•
•
•
•
•
ngredients:
For the vinaigrette
• 3 each Louisiana dried shrimp, lightly
toasted in a hot pan
3 cloves garlic, peeled
1 tablespoon shaved palm sugar
5 slices of Thai chili
½ cup tamarind water (1 tablespoon tamarind
paste warmed with 2 cups of water and then
strained)
2 tablespoons fish sauce
2 limes, split
Cooking Directions:
1. In a mortar and pestle pound together the dried
shrimp, garlic, sliced chili and palm sugar until it
forms a paste.
2. Gently work in the fish sauce, tamarind water and
juice of two limes.
3. Drain the cucuzza squash from the chilled water and
add it to the mortar and pestle.
4. Bruise the squash lightly with the pestle allowing the
vinaigrette to penetrate the cells of the squash.
5. Pour the bruised squash and vinaigrette into a large
bowl and toss in the remaining ingredients.
6. Serve immediately. Serves 6 guests.
For the salad
•
•
•
•
•
•
•
•
•
4 cups of peeled, seeded and julienned cucuzza
squash, reserved in chilled water
2 peaches, seeded and large diced
½ cup blueberries
½ cup cooked black-eyed peas, fresh if possible
12 each cherry tomatoes, halved and salted
1 cup blanched, sliced green beans
½ cup minced cilantro leaves and stems
2 links Vietnamese Style Sweet Fermented Sausage,
sliced thinly lengthwise
½ cup toasted peanuts
(Alternately the vinaigrette can be made in a blender if
no mortar and pestle is available. Once the vinaigrette
is made in the blender mix it with the drained cacuzza
squash and let them marinate together of 10 minutes
and then toss in the remaining ingredient.)
MOPHO:
514 City Park Ave.
New Orleans
(504) 482-6845
www.mophonola.com
Vol. 23 | LOUISIANA PAIN QUARTERLY
3
Photo: Crescent Connection Bridge Run
HAPPENINGS
THIS QUARTER
April
May
ne of the city’s most
anticipated events –
drawing in the biggest
crowds after Mardi
Gras – is the New Orleans Jazz &
Heritage Festival presented by Shell.
The seven-day celebration, held
at the New Orleans Fair Grounds,
starts on April 24 and ends May
3. It’s family-friendly and appealing
to all ages, offering a showcase of
local and international music, art,
food and fun. Headliners this year
include Elton John, John Legend,
Allen Toussaint, Keith Urban, Hozier
and Jimmy Buffett.
he Mid-City Bayou
Boogaloo is a festival
along Bayou St. John,
held May 16-18 that
features music, art, food and a
variety of healthy activities suitable
for all ages. One of the highlights
is a “Zulu Run to Ride 5K” which
takes place on Saturday, May 1618. Other activities include a yoga
class for all levels, a bicycle second
line. There will also be massage
students doing demonstrations and
a community printmaking class that
will walk participants through the
process and show examples of art
and textiles that can be made with
the craft. The festival is free and
open to the public.
O
T
For more information, visit
www.bayouboogaloo
Photo: Bayou Boogaloo Music Festival
Photo: Douglas Mason
For more information, visit
www.nojazzfest.com
June
xercising and being
outside can release
endorphins, which
can reduce physical
pain and also be a source of stressrelief. On the evening of June 6, the
Crescent City Connection four-mile
bridge run draws in thousands
of participants to enjoy the early
days of summer, with breathtaking
views of the city’s skyline at sunset,
300 feet over the Mississippi
River. Participants are invited to
run or walk, starting on the city’s
West Bank. The Bridge Run is an
annual favorite among both serious
runners and those who just want to
get some fresh air.
E
For more information, visit
www.ccc10k.com/crescentconnection-bridge-run
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LOUISIANA PAIN QUARTERLY | Vol. 23
Image courtesy of
St. Jude Medical, Inc.
SPINAL CORD
STIMULATION
Hope for patients who have not responded to other treatments
or patients who have endured chronic
pain in the neck, back, arms or legs;
neuropathic pain (burning, tingling or
numbing sensations); or inadequate
surgeries, Louisiana Pain Specialists offer an alternative
solution that has proven to be quite successful for many
of its patients: spinal cord stimulation (SCS), which was
F
approved by the FDA in 1998. Think of it as analgesia
“on demand,” though the patient must go through an
extensive prescreen before the trial can be done.
In a 2009 study published in the Journal of Clinical
Monitoring and Computing, researchers noted that it is
“effective in reducing intensity, duration and frequency of
pain experienced by the patient.”
Vol. 23 | LOUISIANA PAIN QUARTERLY
How It Works
The SCS system consists of a pulse generator with
remote controls, implanted to stimulate electrodes
and conducting wires (known as “leads”) that connect
the electrodes to the generator, which is similar to a
pacemaker. To qualify for permanent implantation, a
patient must undergo a trial period of about a week;
during this time, a temporary stimulator device is
implanted by the physician after a local anesthetic or
sedative is administered.
5
The physician places the leads under the skin,
guided by an X-Ray machine and a radiology technician.
The leads are then attached to a small, hand-held
generator that the patient can control. The generator
then sends electrical pulses to the spinal cord, thus
interfering with the nerve impulses that cause the
feeling of pain.
The system replaces pain with a feeling of
massaging – or merely just the absence of pain. It can
allow for reduced pain medication and help the patient
improve mobility. Often times, patients experience relief
immediately, though the leads may occasionally need to
be adjusted for optimum performance. The spinal cord stimulation devices at Louisiana
Pain Specialists are supplied by St. Jude Medical,
whose motto is “Power over pain.” The company has a
longstanding relationship with the physicians and are
able to directly answer patients’ questions or help them
out with maintenance of the device.
Says Rob Juul of St. Jude Medical, “We provide
the stimulation device and become the first line
when dealing with it. We have a long and very good
relationship with Louisiana Pain Specialists...We were
there when they opened, and we are very ingrained in
the practice and have a very good relationship with the
staff.”
You may be eligible for this treatment if you
experience the following:
• Chronic back pain with or without leg pain
• Chronic neck pain with or without arm pain
• Prior back surgery (or surgeries) but pain
remains (or worsens)
• Peripheral neuropathy
• Peripheral vascular disease
• Reflex Sympathetic Dystrophy (RSD)
• Refractory angina
• Other treatments have not helped
reduce your pain
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LOUISIANA PAIN QUARTERLY | Vol. 23
PHARMACOGENOMICS:
The Intersection of Pharmacology and Genomics
By Sarah Ravits
ave you ever had an adverse reaction
to a drug or treatment? Each individual
responds to medication differently, which
is why strict regulations are in place and
why doctors are so careful in writing prescriptions.
While one patient may experience alleviated
symptoms after ingesting a pill, another patient of the
H
same height and weight who takes the same medication
may experience a completely different reaction. You
often see seemingly contradictory side effects listed
on a prescription, such as “euphoria” and “depression.”
That’s because individuals’ metabolisms – the way we
break down substances – are vastly different, due to our
unique genetic codes.
LOUISIANA PAIN QUARTERLY
After medicine is ingested by an individual, it reacts
with thousands of proteins as it travels throughout
the body. Small differences in the compositions of our
proteins affect how it works for each person. For some, adverse drug reactions can even lead
to death. In a 1998 study published by the Journal of
American Medicine, researchers found that 106,000
deaths and 2.2 million serious events caused by adverse
drug reactions occurred each year. As such, adverse
drug reactions are responsible for 5-7 percent of
hospital admissions in the U.S. and Europe.
“Based on your DNA, we can tell what
your metabolism is like and doctors can
base the doses off that.”
Two years after the JAMA study was published,
in 2000, the National Institutes of Health launched
a nationwide collaboration of hundreds of scientists
focused on understanding how genes affect the way
a person responds to medication. It’s the intersection
of pharmacology (the science of drugs) and genomics
(the study of genes and their functions) known as
pharmacogenomics, and it is extremely important.
This network of individuals is collectively known as
the Pharmacogenetics Research Network (PGRN), and
they have been hard at work for 15 years now, studying
genes and medications pertaining to a wide range of
ailments, including chronic pain, asthma, depression,
cancer and heart disease. Much of the current research
involves studying variation in genes involved in drug
metabolism, with a vested interest on improving drug
safety.
Dr. Tarun Jolly of Louisiana Pain Specialists says
that pharmacogenomics is, at its essence “personalized
medicine, tailoring medicine and dosages according to
an individual’s DNA.”
Dr. Jolly uses the example of pharmacogenomics as
7
it applies to blood thinners.
“If somebody has a heart attack, they are given
stents which open up the vessels,” he says. “When you
get that stent, you get put on blood thinners so the stent
doesn’t clot. But if someone has a fast metabolism for
a blood thinner, it would break down, thin their blood
too much and cause a stroke.” Conversely, “if someone
is a slow metabolizer, it wouldn’t thin the blood enough.
That’s why pharmacogenomics is so powerful – and
that’s why it means so much … Based on your DNA, we
can tell what your metabolism is like and doctors can
base the doses off that.”
Applying The Research To Pain Management
“A patient suffering from back pain, for example,
could relate a long history of uncontrolled pain, multiple
medication trials and drug sensitivities,” says Dr. Satvik
Munshi of Louisiana Pain Specialists. “This patient
could be a candidate for one of several FDA-approved
medications that carry pharmacogenetic information on
their labeling.”
If the patient is also being treated for co-morbid
conditions, or is taking herbal supplements or
recreational drugs, he says the potential for serious
adverse drug interactions increases significantly.
Until recently, pain management specialists had
little choice but to prescribe medicine without knowing
in advance just exactly how their patients could
respond. But now, thanks to this ever-expanding field of
research, doctors and researchers have developed an
understanding of certain medications that will be the
most effective, based on individual profiles. Currently, there are more than 150 FDA-approved
medications that incorporate pharmacogenetic
information, and Dr. Firas Hijazi says Louisiana Pain
Specialists “will continue to work on integrating this new
technology into the company’s practice.”
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LOUISIANA PAIN QUARTERLY | Vol. 23
LOUISIANA PAIN
EFFICIENTLY NAVIGATES
WORKERS’ COMPENSATION
orkers’
compensation is a
form of insurance
that provides wage
replacement and medical benefits
to employees injured on the job, in
exchange for the employee’s right
to sue the employer. For someone
W
suffering from a work injury, this can
be confusing, frustrating and timeconsuming, and when it comes to
proper care and treatment, time is
of the essence to prevent the injury
from getting worse and getting
the patient healed. Fortunately,
Louisiana Pain has an efficient
system that gets patients on track
right away – often within just a day.
Robin Lopez, medical billing
and insurance specialist, handles all
referrals – from physicians, lawyers,
and insurance adjusters – and
makes the process as seamless as
possible.
Vol. 23 | LOUISIANA PAIN QUARTERLY
“I think we have a very good
and thorough system,” she says.
“From the time that they are sent to
me, I am the patient’s one contact.”
This is crucial, as lines can
become crossed when dealing with
too many people. We’ve all had the
experience of “too many cooks in
the kitchen” and the concept is
extra frazzling when dealing with
health care or legal issues.
But by serving as an efficient,
well-organized middleman, Lopez
alleviates patients’ stress and
ensures that those suffering from
work-related injuries only need to
focus on healing, instead of cutting
through pesky, bureaucratic red tape.
“I contact the Workman’s Comp
adjuster for that patient and get
authorization for treatment within
24 to 48 hours for a new patient
appointment,” says Lopez.
Another reason workers’ comp
cases work so well is because
Louisiana Pain has a long-standing
relationship with many insurance
adjusters. “Many of them give the
clinic a quick response because
they are familiar with the practice
and how well Louisiana Pain
handles patients while under its
care,” she explains.
Louisiana Pain takes pride on its
personalized care and relationships
with patients, and it’s obvious that
the bedside manner pays off.
“Workers’ comp patients are
offered all the same courtesies as
regular patients,” says Lopez. “We
do our best to accommodate all that
the insurance companies requests.
Many of our patients call me during
their treatment, expressing how
grateful they are that their pain has
been managed.”
9
She adds, “Those phone
calls are always so enjoyable. The
patients become more comfortable
when they see that someone
genuinely cares and is working to
make sure they are able to live a
better healthy and happy life.”
Louisiana Pain ensures that
all paperwork is in place and welldocumented, Lopez adds.
“Those phone calls are always so enjoyable. The patients
become more comfortable when they see that someone
genuinely cares and is working to make sure they are
able to live a better healthy and happy life.”
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LOUISIANA PAIN QUARTERLY | Vol. 23
CONSIDERING THE MIND
Mindfulness & Chronic Pain
By Dr. Mark Skellie
he concept of “mindfulness” has
recently become popular, yet it is often
misunderstood, particularly when
applied to individuals living with chronic
pain. Mindfulness is the process of paying attention
moment-to-moment with purpose but without judgment,
trying to look at things from a different perspective. By
intentionally focusing our attention to how things actually
are in this moment, we can recognize how our minds
follow mental routines in a kind of auto-pilot much of the
time. This attention can help us make more conscious
choices about what we do in the next moment.
Mindfulness practice has been shown to have great
benefits in the areas of stress reduction, emotional
regulation and developing compassion for others, as well
as a long list of benefits for chronic health conditions
from psoriasis to chronic pain.
I would wager you might be thinking focusing
on moment-to-moment awareness sounds like the
exact opposite of what you would ever do when you
are experiencing pain. When you’re in pain, you want
it to come to an end. Immediately. This is extremely
understandable for individuals living with the debilitating
T
and aggravating chronic pain. The last thing you want
to do is pay more attention to your pain. But that’s the
idea behind mindfulness, a highly effective practice for
chronic pain. The thing that makes mindfulness practice
different is that it is the combination of awareness and
the effort to reduce or eliminate our mind evaluating and
judging our experience. This is why mindfulness is so
helpful. Instead of focusing on how badly you want the
pain to stop, you pay attention to your pain with a new
curiosity and without judgment.
This approach is very different from what our brains
naturally do when we experience the physiological
sensation of pain. Our minds tend to jump into a tirade
of judgments and negative thoughts. For example,
some people will obsess about how much they hate
the pain and want to wish it away. When you judge your
pain, this process can only make it worse. In fact, our
negative thoughts and judgments not only exacerbate
the pain, but they also fuel anxiety, depression and other
stressful emotional reactions. Our negative thoughts and
judgments can be like a spiral of increasingly unpleasant
emotional reactions. Everyone with chronic pain has
likely experienced moments when their emotional state
Vol. 23 | LOUISIANA PAIN QUARTERLY
has influenced their pain, either with anxiety making
pain feel more unbearable, or a positive mood helping
you ignore or cope with your pain more effectively. It
is very hard to change your emotional state while your
mind continues to judge away.
Mindfulness teaches people with chronic pain to
be curious about the intensity of their pain, instead of
letting their minds jump into thoughts such as: “This is
horrible” or “I can’t take anymore of this.” It also teaches
individuals to let go of goals and expectations. When
you expect something will ease your pain, and it doesn’t
– or it doesn’t as much as you’d like – your mind goes
into alarm-mode or solution-mode. You start thinking
thoughts like, “Nothing ever works.” A simple way to
describe the goals of mindfulness is to do as best as you
can to engage with the pain just as it is and learn ways
to relate to your pain in a new way. It is about finding
a way to switch from the stress response alarm to an
open learning mindset. In other words, as you’re applying
mindfulness to your pain, you might consider your
experience and ask yourself: “What can I learn about
this pain? What do I notice?”
Mindfulness practice also helps us become more
kind to ourselves. Instead of thinking, “I’m a terrible
person for being unable to do the things I used to do
before my chronic pain condition” you can start to think,
“I can recognize my thinking as a pointless and unfair
judgment against myself. Instead of getting anxious
about my anxiety, or mad at my anger, sad about my
depression, or distressed by my pain, I can give myself
permission to feel whatever I am already feeling, and
make a conscious choice about how to take care of
myself.” We often spend huge amounts of time and
energy battling ourselves.
Interestingly, practicing mindfulness not only reduces
stress, but a “side effect” of being present in what you
are doing allows you to get more done. When you are
writing a report, you become better able to just write
11
that report without constantly worrying about all the
other reports you haven’t written yet. You begin to
realize that you can only be present in the moment you
are in, and while you may sometimes choose to take
the time to plan for the future or learn from the past,
you live less in your head and more in your life. All of
your experiences can become more enriched when
you actually show up for them. The simplest way to
think about mindfulness is that it is a type of mediation
practice that does not have to be connected with any
specific faith or set of religious values.
Practical Application
So how do you practice mindfulness? To practice
mindfulness, start by sitting in a comfortable but alert
posture. Gently close your eyes. Take a couple of deep
breaths, and, as you exhale, settle into your body, relaxing
any obvious tension or holding. Then, breathing normally,
bring your awareness to your body, sensing for a short
while how the body presents itself to you. There is no
particular way to be; just notice how you are at this
moment.
Then, from within the body, as part of the body,
become aware of your breathing, however it happens
to appear. There is no right or wrong way to breathe
while practicing mindfulness; the key is to simply notice
how it actually is right now. Let the breath breathe itself,
allowing it to be received in awareness. Notice where in
your body you feel the breath most clearly. This may be
the abdomen rising and falling, the chest expanding and
contracting, or the tactile sensations of the air passing
through the nostrils or over the upper lip. Wherever the
breath tends to appear most clearly, allow that area to
be the home, the center of your attention.
To help maintain contact between awareness and
the breath, you may use a label or mental note. Softly,
like a whisper in the mind, label the in-breath and outbreath, encouraging the awareness to stay present with
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LOUISIANA PAIN QUARTERLY | Vol. 23
the breath. You can label the inhalations and exhalations
as “in” and “out,” or perhaps use “rising” and “falling” for
the movement of the abdomen or the chest. Don’t worry
about finding the right word, just use something that will
help you stay connected.
There is no need to force the attention on the
breath; to strengthen your ability to become mindful
and present, use the gentle power of repeatedly, nonjudgmentally returning and resting with the breath.
When a strong physical sensation makes it difficult
for you to stay with the breath, simply switch your
awareness to this new predominant experience. The art
of mindfulness is recognizing what is predominant and
then sustaining an intimate mindfulness on whatever that
is. As if your entire body was a sensing organ, sense or
feel the physical experience. Simply allow it to be there.
Drop whatever commentary or evaluations you may
have about the experience in favor of seeing and sensing
the experience directly in and of itself. Carefully explore
the particular sensations that make it up – hardness
or softness, warmth or coolness, tingling, tenseness,
pressure, burning, throbbing, lightness and so on. Let your
awareness become as intimate with the experience as
you can. Notice what happens to the sensations as you
are mindful of them. Do they become stronger or weaker,
larger or smaller, or do they stay the same?
As an aid, you can ever so softly label the
experience. The labeling is a gentle, ongoing whisper in
the mind that keeps the attention steady on the object
of mindfulness. You should primarily sense directly
the experience and what happens to it as you are
present for it. This can sound like: “neck, burning, neck,
tingling, hand, neck …” Once a physical sensation has
disappeared or is no longer compelling, you can return
to mindfulness of breathing until some other sensation
calls your attention.
Three-Minute Breathing Space
I know this exercise may seem strange and it is
counter-intuitive that working on refining your
attention without judgment could actually help you
cope with your pain. Please try this exercise or at
least the “3 Minute Breathing Space” before you write
this off. If you have any questions, concerns, or would
like to tell me about your reactions to this article, or
previous Considering the Mind articles, please email
Dr. Skellie at [email protected].
Three-Minute Breathing Space
AWARENESS – Bring yourself to the present moment
by deliberately adopting an erect and dignified
posture. If possible, close your eyes. Then ask yourself:
• What is my experience right now … in thoughts …
in feelings … in bodily sensations (a few moments)
• Acknowledge and register your experience, even
if unwanted.
COLLECTING – Then, gently redirect your full attention
to breathing, to each in breath and to each out breath
as they follow, one after another:
• Your breath can function as an anchor to bring
you into the present and help you tune into a state
of awareness and stillness
EXPANDING – Expand the field of your awareness
around your breathing, so that it includes a sense
of the body as a whole, your posture, and facial
expression.
(Segal, Williams, & Teasdale, 2002)
I will continue to provide new relation strategies in
every new Louisiana Pain Quarterly Magazine because
the best way to manage stress and chronic pain is to
develop a tool box full of different strategies that you can
deploy when needed. Nearly all of the future strategies
build on deep breathing, so don’t forget to practice!
Dr. Satvik Munshi
Dr. Firas Hijazi
Raised in the New Orleans area, a comprehensive
pain management specialist with advanced training
in interventional pain therapies, double board
certified in pain management and physical medicine
and rehabilitation.
With Louisiana Pain Specialists since 2012, double
board certified in interventional pain management
and anesthesia, trained at Tulane University and the
University of New Mexico, special expertise in
procedures to treat back and neck pain. Your Louisiana Pain Doctors!
Interventional Pain Treatments • Diagnostic Testing • Medication Management