Anesthesiologist and pain management doctor at UB utilizes minimally invasive pain-blocking techniques to help alleviate her patients’ pain — without the use of opioids
Q: As an anesthesiologist, what kind of interactions do you have with patients?
A: Our interventional pain management practice actually utilizes minimally invasive pain-blocking techniques to help disrupt the pain cycle, which helps make day-to-day activities less difficult for patients and effectively restores quality of life. We evaluate each patient to help understand the underlying problem and to create an individualized treatment plan. That may involve surgery, nerve-blockers or an implantable drug delivery system as a last resort. These are all part of the treatment processes. We offer a variety of interventional procedures and injections to help reduce or eliminate pain symptoms and reduce reliance on opioids. We also offer on-site imaging.
Q: What kinds of conditions do you treat?
A: I implement a comprehensive approach in order to diagnose and treat acute chronic pain generated from the spine, peripheral joints, as well as the head and face. Some of these conditions include arthritis, chronic pain, coccydynia, complex regional pain syndrome, degenerative disc disease, myofascial pain, occipital neuralgia, radiculopathies, sacroiliac joint disease, scoliosis, spinal stenosis, spondylosis, as well as trigeminal neuralgia.
Q: How do we measure pain now? I understand there was some controversy with the idea of pain metrics as it relates to the opioid crisis. How do you gauge when pain intervention is needed?
A: When a patient comes to us we really want them to already be on a multi-modal pain management regimen that is not opioid. We work on the WHO pain scale ladder and use non-opioid medications for control of neuropathic and nociceptive pain. Nociceptive pain is pain due to inflammation, and neuropathic pain is pain related to nerve conditions. So we use medication that works on different receptors. So for nociceptive pain, for example, we prescribe Tylenol and NSAIDs [i.e. aspirin, ibuprofen], which help reduce inflammation. For neuropathic pain, we control pain using duloxetine, which is actually a psych med that’s also used for pain control, and a number of other medications for pain control. If the patient does not feel optimal pain control using non-opioid, multi-modal pain regimens, then we go to injections. Injections aren’t optimal right off the bat, so they’re a secondary approach. If that doesn’t work, then we do imaging and see what interventional procedures might work.
Q: Generally speaking, are these temporary interventions or ongoing?
A: It depends on the patient. For example, there could be patients with really severe stenosis that would definitely require surgical intervention to relieve pain. For example, for central stenosis we do epidurals to help them with pain control. If they still aren’t achieving the pain control results they want, then at that point we refer them to a surgeon for evaluation. So we essentially are here so that not every patient who needs pain control is going for surgery.
Q: Are there any risks that come with suppressing pain?
A: When a patient comes to our practice, we do all of the imaging because, prior to inserting a needle into the spinal cord, I always take MRIs of the spine as needed and analyze it before inserting the needle, so we know everything that’s going on with the body. So the chances of missing anything are very rare.
Q: What got you interested in anesthesiology and pain management?
A: In anesthesiology we do take care of pain, but the patient is sleeping and we don’t get to have a follow-up and really get to know the patient. With pain management, we get to follow up, see how they’re doing in their day-to-day, how they function in society. That gives me a lot of contentment in my practice.
Q: What kinds of new pain management techniques are emerging?
A: I am highly trained in cutting edge technologies such as doing spinal cord stimulator trials, dorsal root ganglion trials and peripheral nerve root stimulator placement.
Q: What is a spinal cord stimulator?
A: A spinal cord stimulator works for masking pain signals before they reach the brain. A stimulator device delivers electric pulses to electrodes placed over the spinal cord. I do spinal cord stimulator trials that involve placing temporary leads into the back and connecting them to an external battery. No incisions were made during the trial. This is not a surgery. The leads are placed using a small needle. The indications for spinal cord stimulator trial include failed back surgery syndrome, chronic painful peripheral neuropathy, complex regional pain syndrome and diabetic neuropathy. It only takes a half an hour to an hour to put in.
Q: How diverse are your patients age-wise?
A: I’m actually the only person in my practice who sees young kids. For me, age is no barrier. My youngest patient is 16. Usually with young kids, they’ll come in with an injury related to contact sports. And I’ll usually help them with injections that will help them be more active in the sport. My oldest patient is 94. With older patients is often cervical stenosis or lumbar stenosis, joint pain, arthritis.
Q: For patients who are on or are trying to get off opioids, is there a particular protocol for helping them?
A: We don’t actually prescribe any medication; we’re interventional. But when a patient comes to me, I always evaluate their pain regimen and try to make recommendations to primary care about how we can tweak it and target different receptors without opioids. Once all these things are covered, then we can consider opioids. Opioids are always as-needed, they can never be a scheduled medication. They’re the last resort, not the first. With a multi-modal approach I think we’re moving in the right direction to save our society from the opioid crisis.
Name: Harpreet Dhiman, D.O.
Position: Anesthesiologist and clinical assistant professor at the University at Buffalo. Affiliated with UBNS (Neurosurgery — University at Buffalo)
Hometown: Delhi, India
Education: Received her Bachelor of Science degree from the University of Pittsburgh, her medical degree from Touro College of Osteopathic Medicine (New York City). Did her residency training in anesthesiology at Albany Medical Center, and pain fellowship with SUNY Upstate Medical Center
Affiliations: Catholic Health System; Kaleida Health System
Organizations: American Board of Anesthesiology