December 8, 2019
SECOND OPINION | Chronic Pain Management | APT | Full Episode

SECOND OPINION | Chronic Pain Management | APT | Full Episode

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association,
an association of independent, locally operated, and community based Blue Cross and Blue Shield
Companies, supporting solutions that make safe, quality, affordable healthcare available
to all Americans. Second Opinion is produced in association
with the University of Rochester Medical Center, Rochester, New York. (DR. PETER SALGO)
Welcome to Second Opinion, where each week you get to see first hand how some of the
country’s leading healthcare professionals tackle health issues that are important to
you. Each week our studio guests are put on the
spot with medical cases that are based on real life experiences and by the end of the
program, you’ll learn the outcome of this week’s case and be better able to take charge
of your own healthcare. I’m your host, Dr. Peter Salgo, and today,
our panel includes anesthesiologist, Dr. Joe Kent, from the Unviersity of Rochester Medical
Center; physiatrist, Dr. Richard Seroussi, from Seattle Sports and Spine Medicine; business
owner, Robin Naughton; internist, Dr. Jacob Teitelbaum, from the National Fibromyalgia
and fatigue centers; and Second Opinion Primary Care Physician, Dr. Lisa Harris. Welcome back Lisa, nice to see you. (DR. LISA HARRIS)
Thank you. (DR. PETER SALGO)
Alright, it’s time to get to work. We’re going to talk about a patient of course
and this time our patient’s name is Jacqueline. She’s 59 years old, she has been living
for almost twenty years with arthritis and the chart doesn’t specify specifically what
kind. Jacqueline began to notice changes in her
hands at about age 40 and it’s gotten worse with time. Today, she’s in her PCP’s office because
she’s concerned about her job. She’s a nurse; she works long hours and
finds that by the end of the day, the chart says, The pain that began in my hands effects
“every joint in my body.” So, first of all, let’s take a step back. When we feel pain, what’s going on in our
Well, pain is like the red flashing light on our body’s dashboard telling us that
something needs attention. It’s not the enemy, although it has to be
treated. (DR. JOEL KENT)
It’s a perception, it’s a response, usually that’s some type of injury, but people can
feel pain when they’re not even injured, so the easiest way to understand it is to
think in terms of a model of someone being injured, but there are other versions of pain
where we can’t even find an injury. It’s a hard thing to articulate. (DR. RICHARD SEROUSSI)
In order to understand pain, you really have to understand that it’s not just a physical
phenomenon, there’s often an emotional component and this is all wrapped together, I mean,
even the definition of pain. The International Association for the Study
of Pain which is a kind of premier organization, they acknowledge both a physical and an emotional
component. (DR. PETER SALGO)
There was an overview here, a subtext of pain can be a good thing, you said that. At this point, I can tell you, Jacqueline
wouldn’t describe her pain as anything cloth to good, useful, protective, or glad to have
you around Mr. Pain. In fact, her pain is making is increasingly
difficult to function in her job. Is it likely that her job is all that she’s
worried about here, Lisa? (DR. LISA HARRIS)
I think she’s probably worried about her lifestyle, her ability to continue doing the
things that she’s used to doing and how this is going to impact her life as she gets
older, so you know, what does this mean for me? If I can’t work, does it mean that I also
can’t interact with my family, that I can’t go on vacations, that I can’t travel and
do the things that I enjoy? (DR. PETER SALGO)
There’s a lot of stuff going on here, not just, “I can’t do my shift at the hospital.” Robin, tell us about your pain experience. (ROBIN NAUGHTON)
Well, I was just thinking about my wrist that is broken and it’s an injury from an early
onset of osteoporosis from when I was dancing professionally. I ignore it because I want to do the activities
that I love, so I do yoga, I love to cook, so I just put up with the pain. (DR. PETER SALGO)
Now, you’re a dancer? Were a dancer? (ROBIN NAUGHTON)
I was, yeah. (DR. PETER SALGO)
Dancers are athletes. Athletes get hurt all the time. What injuries have you had? (ROBIN NAUGHTON)
A lot of sprained ankles. I now have Morton’s Neuroma in both of my
feet, I fractured my ribs multiple times, I have hip injuries, so I’ve got a lot of
injuries all over. (DR. PETER SALGO)
Do you hurt all the time? (ROBIN NAUGHTON)
Every day. (DR. PETER SALGO)
You don’t look like you’re in pain sitting here. (ROBIN NAUGHTON)
Well, I try not to. I just try to ignore it. As a ballet dancer, you learn to disassociate
the pain from your actions, so you can actually do a lot under a lot of pain. (DR. LISA HARRIS)
That speaks a little bit to what Richard was saying earlier, there’s an emotional component
to pain where people who are in acute pain who never suffered from chronic pain may respond
very differently from someone who lives with pain every day and your body learns to adapt
to that, so you don’t even see the same physical exam findings in someone with chronic
pain, like an elevated heart rate or blood pressure or things like that, that you see
in people with chronic pain. (DR. PETER SALGO)
I want to define chronic pain verses acute pain. What’s the difference? (DR. JOEL KENT)
Acute pain is what Jacob talked about early on. It’s that red light that warns you something
is dangerous, like hands on a stove. Chronic pain doesn’t serve that protective
function, so it doesn’t serve the patient very well at all. It tends to undermine their productivity and
quality of life. (DR. PETER SALGO)
You’re telling me what chronic pain does, but what is chronic pain? (DR. RICHARD SEROUSSI)
You can define chronic pain as something lasting more than three to six months, something like
that. I think what Joel is trying to get at is that
chronic pain has a larger dimension than simply a time duration. It typically, as we think of chronic pain,
and those of us who treat chronic pain, well, we have one person in chronic pain and the
rest of us treat chronic pain, we think in terms of something that has been long lasting
and affecting one’s function. As a physiatrist, I’m very concerned about
function, so you worry that someone could no longer do their basic activities of living,
such as what Lisa talked about with our patient. That’s when chronic pain starts to take
on a larger dimension. (DR. PETER SALGO)
So what you’ve done is just broadened the definition a bit. Most people, when they think of pain, trying
to define it would be how it feels, but you have a much bigger definition. It’s what it feels like and what you can
do when you have it. (DR. LISA HARRIS)
Part of the difficulty with pain is what the patient describes and it can be very different
from patient to patient, from moment to moment, from episode to episode, and that’s why
it’s so difficult to really wrap your hands around what’s going on. (DR. JACOB TEITELBAUM)
We talk sometimes about things being subjective, almost to kind of put patients down in that
way. I know you don’t, but a lot of doctors do
that. I’m going to go back to what the supreme
court said when they defined obscenity. They said, we don’t have a good definition,
but we know it when we see it. I think the same applies to pain. If a patient says they’re in chronic pain,
they’re in chronic pain. (DR. PETER SALGO)
Patients who have chronic pain, they’re coming to their doctor complaining of pain
all the time. They’ve got a bad rap and they’re called
all sorts of bad names behind their backs by docs and one of the worst names is “drug
seekers.” Help me, help me, help me! Has that been your experience? (ROBIN NAUGHTON)
I don’t think I’ve gotten that from my doctor, but I definitely feel it just in my
own way. You don’t want to complain and you don’t
want to pose a question of, well what do we do about it? I don’t know what to do and I don’t know
who to see you know? There are so many different things going on
that where do I go? (DR. PETER SALGO)
Well, we’re going to try and unravel some of that, but let’s just get a vote. Is it fair to say that she doesn’t know
what to do, she doesn’t know who to see, a lot of doctors think the same thing? (DR. JOEL KENT)
That would be very fair. (DR. LISA HARRIS)
I think that’s very true. (DR. RICHARD SEROUSSI)
You almost get as many answers as Physicians you would ask, or care providers, not even
physicians; it can be massage therapists, physical therapist, etc. (DR. PETER SALGO)
Remember Jacqueline, our lovely patient who is having pain, her pain is related to arthritis. What else causes chronic pain? (DR. RICHARD SEROUSSI)
You sometimes don’t find an actual arthritis, but there can be what used to be called soft
tissue rheumatism. Sometimes in its most advanced form is called
fibromyalgia. (DR. LISA HARRIS)
Neuropathic pain. (DR. RICHARD SEROUSSI)
Neuropathic pain, which is pain that the central nervous system, if you will, has ramped up
your initial pain response. It takes on a life of its own. (DR. PETER SALGO)
Jacqueline says her pain starts in her hands, but as the day goes on, it radiates all around
her body. Is this arthritis at work, or is it something
sort of that you alluded to? Can chronic pain I guess change our bodies
because it’s there and change our brains because it’s there, which then feeds back
and then cause’s pain again. (DR. JACOB TEITELBAUM)
You’ll see central sensation which is kind of like when one baby in a nursery starts
crying, they all start crying and it gets louder and louder, and you’ll see with chronic
pain, the volume in the brain actually goes up and the pain gets more and more. When you’re saying that it’s spreading
throughout the body and over areas that are not joints, I suggest that it’s a soft tissue
issue. A very good question to ask if someone has
chronic widespread pain, you ask them a simple question “Can you get a good night’s sleep?” If they say “No I have horrible insomnia”
and then in addition, they’ve got what’s called brain fog, fatigue, you’ve got fibromyalgia
or a fibromyalgia related process, pretty much until proven otherwise. (DR. PETER SALGO)
Do we understand, Richard, what happens in the brain at all physiologically, electrically,
with all of this going on? (DR. RICHARD SEROUSSI)
Well, you know, I’m not a brain physiologist, if you will, but I know that if anything,
the movement in pain research has gone from thinking of chronic pain as being a primarily
emotional experience to a much more of a physiologic experience. There’s clearly this phenomenon called wind
up which occurs initially at the dorsal horn or the spinal cord, so where sensory neurons
kind of first meet the central nervous system from the periphery, there’s some sort of
winding up of the pain response at that level and then there are higher centers of the brain
where this process seems to amplify. (DR. PETER SALGO)
Is it fair to say that the vast majority of people who come to you complaining of this
are not crazy malingerers or drug seekers? There’s real change in the nerves, in the
chemicals, in the brain, is that fair? (DR. LISA HARRIS)
I think, you know, the people who we label as “drug seekers” have been artificially
created by the medical community. That’s what we’ve done, you know, you’re
hurting here, let’s throw something at you, and then we teach them to beg for medications
because they have to prove they hurt. (DR. PETER SALGO)
Alright, let’s pause for just a minute and sum up what we’ve been talking about. Pain can be useful. It can alert us to the fact that something
isn’t right, but chronic pain can become the problem rather than the symptom. Chronic pain can be mild or excruciating,
occasional or continuous, merely inconvenient or totally incapacitating, a huge spectrum. The emotional toll of chronic pain can also
make pain worse and cause changes in the way that our brains work. Pain can beget pain and pain can beget other
problems as well. We doing okay so far? All on the same page? Good. Let’s mix it up because we’re talking
about Jacqueline and she’s been dealing with the pain of arthritis for nearly twenty
years. Now, Lisa, Jacqueline’s in your office,
she’s worried, Jacqueline is, that the pain from arthritis is worsened to the point where
it’s affecting her performance at work. She’s at her wits end, okay, what do you
want to do to help her? How do you approach it? (DR. LISA HARRIS)
Well, the first thing I want to find out from her is that there’s been an assumption that
this is due to arthritis and I’m not sure that it is. I really think there’s probably some other
processes, so as I’ve already mentioned today, I’d want to find out how she’s
sleeping, how well she’s sleeping, and I know we probably don’t have all of that
in the chart, but these are the things I’d want to ask her. (DR. PETER SALGO)
Well, I can tell you that she did try to sleep longer and when she succeeded at that, she
felt better. That’s one thing anyway. (DR. LISA HARRIS)
Okay, so it’s important to understand that this is probably not all osteoarthritis. There may be some component of fibromyalgia
that’s occurring with it as well. (DR. PETER SALGO)
I can tell you that she’s been treating her arthritis herself. (DR. LISA HARRIS)
Over the counter medications, supplements, and she tried a copper bracelet that didn’t
work. She has hypertension, which she’s treating
with medication; her lipids are treated with an anti-lipid drug. A statin. (DR. LISA HARRIS)
She does take some NSAIDS’s like Aspirin, I guess, and she said they occasionally help. She’s tried some low impact exercise and
that seems to help. That’s it, that’s the history. What do you think? (DR. LISA HARRIS)
I think, we haven’t really done enough for her to help her control her pain. She certainly has not been on an adequate
pain regimen, we have not addressed her sleep, we have not addressed her nutrition or any
of the other things that would really help her. (DR. PETER SALGO)
Let me ask a real big softball question. What’s our goal? What do we want to do for her and what does
she expect us as physicians to do for her? What is the goal? Doesn’t it help to define that first? (DR. JACOB TEITELBAUM)
Goal number one is to figure out what’s causing the pain and goal number two is to
eliminate the pain, and they should be happening side by side. This woman sounds like she may have metabolic
syndrome, she may have sleep apnea associated with a high blood pressure, it would be interesting
to see what her weight is, what her sedrate is, she could have low thyroid. (DR. LISA HARRIS)
I would like to adjust that a little bit, I want to know, what does she want? It’s not necessarily what my goals are,
but what is it that she wants to achieve? She may not have an expectation to be pain
free. She may have an expectation that she’d be
able to do her daily activities. (DR. PETER SALGO)
Is there a difference between what you want and what you expect? You’ve been there, right? I would expect that you would want to be completely
pain free, but realistically, what do you expect from somebody who’s going to treat
your chronic pain? (ROBIN NAUGHTON)
Education and guidance on, okay, what is possible and what can I achieve in this life that fear
as we get older, this is going to start to become more and more preventing me from enjoying
my life. It’s very scary. (DR. JACOB TEITELBAUM)
What scares me is that you’re afraid to ask. You’re even afraid to bring it up to your
doctor, you feel gun shy. (ROBIN NAUGHTON)
That scares me. (DR. JOEL KENT)
Another thing a lot of patients want is validation. I think a lot of patients come into the medical
community fearing that they’re not even going to be believed. (DR. RICHARD SEROUSSI)
You know, it’s interesting that sometimes I’ve had patients for years and we finish
care, and they say, thank you so much, and I look at the pain levels, and they haven’t
really changed that much. They might say, look, but you took me seriously,
you made sure there was no stone uncovered. I think that’s what you’re speaking to,
Robin, and this idea being taken seriously and just making sure we cover the bases. (DR. PETER SALGO)
Let me go back because I’m intrigued by something that you said that you weren’t
even willing to ask. You felt intimidated and you said yes. What was the intimidation? (ROBIN NAUGHTON)
Well, it’s the intimidation of who do I ask, my primary care physician? Sports medicine? I really don’t know where to go on some
of these things. It seems like I have to go to a lot of different
doctors and be the conduit of this information, so who do I start with and then, you know,
the whole idea of will you be taken seriously, also, will they be able to tell you where
to go and what to do? (DR. JACOB NAUGHTON)
I want you to know what’s going on Robin and to understand your problem, but I also
want you to be pain free. It’s not enough for me that you’re not
pain free. (DR. PETER SALGO)
Let’s get back to Jacqueline for just a minute because she’s still suffering every
day, getting less and less able to function as a nurse, what can you offer her in terms
of you’re going to do a workup. So, you’re going to get a specific, if you
can, a cause, but let’s assume that you really can’t pin that down. What can you offer her to make her as pain
free as possible? (DR. RICHARD SEROUSSI)
Early on, the first thing you want to do is try to improve sleep. I would argue that if she’s not having restorative
sleep, that’s going to change things almost out of the gate. So, in conjunction with your diagnostic work
up, there’s nothing wrong with providing treatment before you have any more definitive
Let me give a two stage thing. Certainly we need to do the work up and that’s
key, to get people sleeping, good for restless leg syndrome, look for sleep apnea, and if
this woman is at high risk for sleep apnea, I don’t know what her weight or size is,
but given the high blood pressure and high cholesterol, hormones. Low thyroid, despite normal tests, will trigger
high cholesterol, will trigger the weight gain that has caused the high blood pressure
and will trigger the pain. So, sleep, hormones, infections, nutritional
support will make a big difference, exercise will help most forms, while there’s arthritis,
rheumatoid arthritis, fibromyalgia, lupus, the exercise, walking program, preferably
in the sunshine, will help and then natural remedies. (DR. PETER SALGO)
That’s a program, at least there’s something you’ve elucidated that’s concrete. These are things that you can try; people
are going to come to you, what medicines are out there, analgesics and otherwise that can
help people with chronic pain? (DR. JOEL KENT)
There are lots of analgesics, the key is to maintain this comprehensive approach and not
be focused just on a pharmacologic cure. The pharmacology is important, we can help
people a lot with pharmacology, but you need a balanced approach. The short answer to your question would be
NSAID’s are not steroidal, anti-inflammatory drugs. (DR. JOEL KENT)
That’s correct. (DR. PETER SALGO)
Okay, like aspirin? (DR. JOEL KENT)
Yeah, and Motrin, ibuprofen. Yes, correct. Then there are the opioid class of analgesics. The morphine and its cousins. (DR. PETER SALGO)
Okay, so that’s narcotics. (DR. JOEL KENT)
Correct. (DR. PETER SALGO)
Aren’t they bad? Don’t you get addicted to them and that’s
the end of life as you know it? (DR. JOEL KENT)
It’s a complicated story. Some patients can take opioids and improve
function and feel better and we see those patients. Some patients can develop addiction, that’s
one of the most challenging corners of pain management is to discriminate between those
processes. Determine who we’re going to be able to
help and who we may harm with the same class of drug. (DR. PETER SALGO)
Now if inflammation causes pain, there’s some doctors who give steroids which are anti-inflammatory
drugs, what about those? (DR. RICHARD SEROUSSI)
I occasionally will use steroids and there are a couple of places to do that. When I use them, I use them short term, but
I give a pretty healthy dose sometimes and if a patient is really flared up, it can be
quite helpful. (DR. LISA HARRIS)
We have some other classes of medications that we haven’t really talked about. (DR. PETER SALGO)
Like what? (DR. LISA HARRIS)
Anti-seizure medications, such as Gabapentin, has been used successfully. (DR. PETER SALGO)
Those are actually fibromyalgia related therapeutics. (DR. LISA HARRIS)
Well, chronic pain. It doesn’t necessarily have to be fibromyalgia. Neuropathic pain, it works very well in appropriate
doses. (DR. PETER SALGO)
What about going away from medication? A lot of folks today say, “I don’t want
drugs, I want acupuncture.” Does it work? (DR. JOEL KENT)
Acupuncture does work. (DR. PETER SALGO)
You say that with such authority. How do you know? (DR. JOEL KENT)
It’s been studied and it’s got a 5,000 year experience within the human condition. It helps many patients. It’s not a panacea, just like ibuprofen
and morphine are not panacea. It’s another valuable tool. (DR. JOEL KENT)
Yoga, stretching exercising. (DR. JACOB TEITELBAUM)
Clearly helps. (DR. PETER SALGO)
Clearly helps? Do we have studies on this? (DR. JACOB TEITELBAUM)
Alright. What about massage? (DR. LISA HARRIS)
Deep heat friction massage is one of my favorite modalities. (DR. JACOB TEITELBAUM)
But we’re talking about muscles that are stuck in a shortened position in a lot of
patients. The way to tell is if you have these tender
marbles, somebody gives you a back rub and they push on these things like tender marbles,
that muscle is bunched up and that trigger point is the belly of the muscle. Seventy percent of acupuncture points correspond
with the trigger points of the body. You put a needle in the acupuncture point
or in the tender marble, the muscle will release and the pain will go away or if you stretch
the muscle with massage, the muscle will release and the pain will go away. So, whatever you do to stretch the muscle
will help, but then you’ve got to see what caused the muscle to shorten in the first
place and then you’ve got to go after that. (DR. RICHARD SEROUSSI)
The one thing that I’d want to say is that you try these things, but you try them within
reason. You don’t really drink any single Kool-Aid
and sell only one Kool-Aid. You try what you can and it’s an interactive
process with the patient. (DR. PETER SALGO)
Now, funny you mention something to eat or drink because the new thing that I keep hearing
and maybe not even that new, is special diets. But do they work? (DR. JACOB TEITELBAUM)
Some do and some are a bunch of hype. If you cut out sugar, sugar is really pro-inflammatory. We have 150 pounds of sugar added to our diet
each year in food processing and it has really severe effects on immune and muscle function. So, low sugar, high protein, natural diet,
or put differently, common sense, but when you look at these things that I think there’s
a lot of marketing hype behind it, you can do as well in the supermarket, just eat whole
foods. (DR. PETER SALGO)
What’s common sense about changing your diet and improving your pain? (DR. JOEL KENT)
You know, it gets back to that holistic approach of trying to improve people’s lifestyle
who are going to medically treat their pain as best as possible but we also want to promote
their overall health because that’s going to help them feel better. So, helping them sleep better, helps them
eat better, because with a healthier diet, you do feel better. (ROBIN NAUGHTON)
Is chronic pain an issue in the United States primarily? Or does this happen around the world? (DR. JACOB TEITELBAUM)
It’s worldwide. You have one out of four Americans in chronic
pain, but it’s a worldwide thing, but if you look at epidemiologic studies, as we get
a Western diet coming into countries, pain. (DR. PETER SALGO)
Jacqueline’s doctor wants her to go, at least as an option to consider, to a pain
clinic. What is a pain clinic? (DR. JOEL KENT)
A pain clinic is a comprehensive assessment that does good diagnostic work that we were
talking about earlier and then comprehensive treatment that will include medical management,
nutritional assessment, functional outcome assessment, that kind of meets all the goals
that we’ve all shared here. (DR. RICHARD SEROUSSI)
I think one thing about a typical pain clinic that’s using a multi-disciplinary approach,
the physician, the occupational therapist, the physical therapist, psychological, vocational
counselor, the typical emphasis in such, first of all, it’s kind of a little bit of an
end stage program. It’s like when everything else didn’t
work and you were saying you’d like to get rid of the pain, well, some patients, at least
in my experience, you can’t get of the pain, then you say, “Okay, pain is here, now we’re
going to focus on function.” (DR. PETER SALGO)
You’ve been to a pain clinic, right? (ROBIN NAUGHTON)
A pain clinic, no. I’ve never heard of a pain clinic. (DR. JACOB TEITELBAUM)
Can I give you some thoughts on them, just from some of the things you’ve told me. You’re a ballet dancer, you have early onset
osteoporosis, did you have a history of irregular periods or loss of periods? (ROBIN NAUGHTON)
You have probably what’s called female athlete triad, just from what you’re telling me
so far, which is a hypothalamic dis-function and a hormonal dis-function. You haven’t’ even scratched the surface
and I’ve met you for how many minutes? These are obvious things that jump out that
you haven’t even had approached yet. (DR. LISA HARRIS)
Same as Jacqueline. (DR. PETER SALGO)
You, and I suspect Jacqueline too, express this frustration that you don’t know where
to go, you don’t know who to ask, but we’re all sitting there in this pain clinic, I guess,
is that fair? (DR. JOEL KENT)
I think there are a lot of dedicated physicians who want to treat patients like you. (DR. PETER SALGO)
Let’s pause for a minute. We’ve covered a lot of ground again; the
goal of chronic pain management isn’t necessarily to make the pain go away completely, but to
make the patient’s life more livable and less painful. Being able to live the most normal, active
and functional life with the least amount of pain, is still a good goal. Jacqueline is still struggling with the pain;
she is receiving regular acupuncture treatments and has worked at a good medication regimen
to control some of her pain. She continues to keep her hands as flexible
as possible using massage and using exercise, so at least for now, my sense with the chart
is she’s not completely satisfied, she’s not completely pain free, but she’s better
than she was and she, I think, sees some light at the end of her tunnel. How are you doing, Robin? (ROBING NAUGHTON)
I’m doing okay, thanks. (DR. PETER SALGO)
Thank you and goodnight, tell me more. (ROBIN NAUGHTON)
Yeah, exactly. (DR. PETER SALGO)
How do you define okay? (ROBIN NAUGHTON)
As we’re sitting here and I’m thinking about the various areas of my body that hurt,
I’m also thinking about the various areas of my life that I really have been actively
working to change and it does come to the power of touch and the power of happiness,
too, and being around people that I really love and you know, the things that I really
value, because that does decrease, also, the amount of pain I feel. So, you know, I’m doing okay. (DR. PETER SALGO)
That sounds great, but you know what’s really important about what you said, is that it’s
hard to qualify all of this. Power of love, the power of touch, being with
people that you love. (ROBIN NAUGHTON)
Thank you all, so very much, for being here, and especially you for sharing your experiences. (ROBIN NAUGHTON)
You know, if you missed any part of this show, the transcript is available on our website,
you can also find links to resources, that’s secondopinion/ Again, thank you for watching, thank all of
you for being here. I’m Dr. Peter Salgo and I’ll see you next
time for another Second Opinion. (ANNOUNCER)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association,
an association of independent, locally operated, and community based Blue Cross and Blue Shield
Companies, supporting solutions that make safe, quality, affordable healthcare available
to all Americans. Second Opinion is produced in association
with the University of Rochester Medical Center, Rochester, New York.

1 thought on “SECOND OPINION | Chronic Pain Management | APT | Full Episode

  1. Part 2 of my post regarding PAIN on "Second Opinion" It would be nice if the host could be given the platform or understand to drill down with particular guests like Dr. Teitelbaum. The host seemed in my opinion to leave the impression we should seek pain clinics, and that is far too broad and can lead to very harmful treatment again in my personal opinion. 23

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