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Nima Nahiddi: [00:00:09] Welcome to PsychEd, the psychiatry podcast for medical learners by medical learners. In this episode, we'll be exploring the psychiatric aspects of chronic pain medicine. I'm Doctor Nima Nahiddi, a pgy3 at McGill University, and I'm joined by Doctor Sarah Hanafi, a fellow pgy3 at McGill.
Sarah Hanafi: [00:00:28] Hi everyone.
Nima Nahiddi: [00:00:29] And Audrey Lee, a fourth year medical student at McGill.
Audrey Lee: [00:00:33] Hello everyone.
Nima Nahiddi: [00:00:34] We're grateful to have our guest, Doctor Leon Turian this week to share his expertise. Doctor Turian, if you could introduce yourself.
Dr. Leon Tourian: [00:00:41] So I'm Leon Tran, I'm a psychiatrist at the Munk, and my branch of speciality, where I spend the vast majority of my clinical time, is as a pain psychiatrist at the Allen Edwards Pain Management Unit at the Munk.
Nima Nahiddi: [00:00:57] Thank you so much for joining us, Doctor Tour. And we're so happy, uh, that you took the time to be here with us today.
Dr. Leon Tourian: [00:01:04] Thanks for inviting me.
Nima Nahiddi: [00:01:05] During today's episode, we'll touch on several learning objectives. First, we'll explore the world of psychiatry in the management of pain. Then we'll discuss the epidemiology of psychiatric comorbidities and pain disorders. We'll outline the pathophysiology of pain and its relationship to psychiatric disorders. We'll outline the role of non-pharmacological management and treatment of pain. We'll discuss a general psychopharmacology approach and management of pain relief and psychiatric comorbidities with chronic pain. And finally, we'll discuss the intersection of pain medicine with somatic symptom and related disorders. So to begin, Doctor Turian, can you explore the role of psychiatrists in the management of pain?
Dr. Leon Tourian: [00:01:55] So that's a that's a fantastic question. So in essence, I think, um. Psychiatry has a very central role to play in pain management only by virtue of the comorbidity between psychiatric illness and chronic pain. So the main goal of psychiatry in the care of patients with chronic pain is actually decreasing the burden of mental health disorders in chronic pain to actually increase the prognosis of pain patients and their outcomes in pain. So the way I explain it to patients is you say, you know, you have pain. Pain causes depression. Depression increases pain. And so, you know, in mental health, we're very good at trying and supporting our patients in the treatment of depression and anxiety. And essentially that improves their outcomes, decreases, you know, decreases their morbidity and mortality related to pain and basically leads to a better quality of life.
Nima Nahiddi: [00:02:59] Is there a difference between, uh, you know, the role of someone who's working in general practice and perhaps someone who's working in a multidisciplinary pain management team?
Dr. Leon Tourian: [00:03:09] So that's an excellent question, because I think from a training standpoint and from, uh, I think, you know, uh, family, med residents and family medicine training and even in psychiatry training, I think that the exposure to pain is very limited. Um, I think there is very little exposure to pain training for trainees. Um, and so if you don't if you're not trained in it as a resident and if you don't practice in it in any shape or form, I think you develop what everybody develops in terms of their concerns about managing chronic pain patients, which is a phobia and a kind of a stigmatisation because they're complex. Uh, the medication lists are long, the complaints are long. And I think, um, the main, the main barrier for, for patients, for pain patients is the fact that if you're not kind of exposed to it on a regular basis and have a support team around you, it becomes very difficult to treat these patients because the needs are great. Um, and so I think the I think if I was a general psychiatrist treating pain patients, I think I would feel very overwhelmed, um, if I didn't have my colleagues in the pain unit at the pain unit, you know, it's a multidisciplinary, interdisciplinary approach.
Dr. Leon Tourian: [00:04:22] Um, and I think we support each other because this population has a lot of needs. Um, and the, the. Yeah, I can't even there's no way I could express it more than that. It's just, uh, doing it alone. It would be impossible. Um, so I find that I have a lot of respect for folks that are not in, in tertiary care areas, uh, managing pain patients and even in tertiary care areas. There's not a lot of psychiatrists managing these patients. Um, so I think one, you know, there's a bidirectional vulnerability in our health care system. Uh, so I think, you know, it's not it's kind of peculiar that, you know, there's only one psychiatrist right now in Quebec that, uh, uh, devotes most of their time for pain. And that's me. And now I'm very happy to say I have a psychiatrist who graduated last year who's, uh, visiting us from Quebec City, um, and who's, uh, seeing a bit of what I do. Um, but it's, you know, it's a tough crowd. So you need help. I guess that's where I put. I'll put it.
Audrey Lee: [00:05:20] Um, I wanted to go back to something that you had touched on Doctor Turian about this mental health burden that we have in these chronic pain patients. So when I was looking at the existing research, a lot of it talks about how psychiatric disorders and pain disorders both overlap and interact with one another. And, you know, given this dynamic, you had mentioned depression. But are there other psychiatric comorbidities that we frequently encounter in patients with chronic pain?
Dr. Leon Tourian: [00:05:46] Absolutely. So one that we one that we don't often talk about is anxiety, you know, generalised anxiety disorder, um, which is as deleterious in terms of outcomes in chronic pain as depression is. Ptsd is another one that comes up. And obviously, I'm very I'm very careful to approach the substance use issue because a lot of it is, you know, there's a there's a part of that that's very oestrogenic, um, it's a part that we've created, unfortunately, uh, by not not by any virtue of any fault or anything, it's just by virtue of not having enough tools and suddenly, you know, you have a patient who's on long terme opioids dealing with the effects of that, but also needing those opioids to function. So I would say that, yes, substance use issue is um, uh, is an issue, uh, in terms of our population and uh, it is something that is a bit of a, it's a delicate kind of topic because, you know, I think it's a very small proportion of patients that we treat that have long terme, you know, chronic pain that actually have a bonafide, uh, opioid use disorder, if you will. Uh, but, you know, part of the part of the physiological dependence that they've developed is just by virtue of the nature of the medications that we give them, um, and by virtue of poor pain control, not because we haven't explored other medications, but they just don't work. So you load up on opioids, opioids, you know, they work. If you load up more, your pain signals go down. And but you create a problem, right? You create a problem for these patients, unfortunately.
Audrey Lee: [00:07:19] Thank you for taking the time to kind of explain that aspect of pain psychiatry. Yeah. Are there certain pain characteristics, for example severity or duration of the pain that affect prognosis of of psychiatric comorbidities for the patient?
Dr. Leon Tourian: [00:07:34] Um, that's an excellent question. So I think there's a few ways to answer that question. So again we mentioned, you know, I think it's the most the most significant emphasis I could put in, in answering all of the objectives that you have for this podcast is as long as you remember that there's a bidirectional relationship between pain and psychiatric comorbidity, namely depression and anxiety. Uh, but any of them, in fact, um. I think that the more comorbidity you have on one end or the other, so the more medical comorbidities that you have, uh, the higher the risk and the more complex the depression. So, um, I think I would answer the question by this way, is that I think that it's just a question of balancing out. So it's just a question of accounting for how many medical comorbidities do you have? And the more you have, the more the heightened risk you have of developing depression, because individually, most medical illnesses that we know have a bidirectional relationship with depression. So you add those on and essentially you add on to the difficulty of treating depression. Uh, the difficulty of actually getting a like a response and getting closer to remission. So the more medical comorbidity you have, the more difficult it becomes to treat depression and vice versa. So I guess, yeah, I would respond that way to kind of oversimplify very complex interactions.
Audrey Lee: [00:08:56] So you're kind of talking about, um, the load of, of more having more conditions and how that affects, um, psychiatric comorbidities. But are there also any specific pain conditions that are associated with a higher suicide risk?
Dr. Leon Tourian: [00:09:11] So I think I'd answer it by not by identifying a condition, but identifying, um, how well they respond to pain management. Um, so I think, you know, there's many different pain diagnoses, I think for myself anyways, from a clinical standpoint, uh, you know, chronic regional pain syndrome remains the toughest one, uh, to be very frank. And then essentially, we have certain, you know, degenerative, uh, disorders, uh, you know, whether it's degenerative disc disease or rheumatoid arthritis or the whole, the whole dossier of fibromyalgia, um, become, you know, become potentially, uh, challenge to treat. But I think it's the response, if you have a positive response to treatment, then, you know, even if you have a very serious diagnosis, then your, your, you know, your prognosis will be good. I have patients who, you know, they the the pain is so intense. But, you know, they've kind of adhered to non-pharmacological and pharmacological methods of treatment. And they're doing well. But they have a lot of pain. They just, you know, they have function. Uh, whereas others, you know, uh, even despite their best intentions, uh, the pain is so unsurmountable that it, you know, it does impact quality of life. Um, and it doesn't allow them to function. So I guess it's not one diagnosis that will make it bad. It's actually how the patient copes with it. As you know, with everything else that we know in mental health. Right. Uh, but in pain, I think I've seen the worst pain diagnoses and the severity. And some patients do good and others not.
Sarah Hanafi: [00:10:43] Thank you for that, doctor. Torian. Um, I was hoping we could take a bit of a step back. I know we've been, you know, talking about this overlap between chronic pain and psychiatric disorders, thinking a little more along the lines of aetiology, though. How do we explain this, this link at a biological and psychological level?
Dr. Leon Tourian: [00:11:05] Uh, okay. So that's a that's a fantastic question. And the overlap and the from an ideological standpoint is very interesting. Uh, this is a massive oversimplification of a very complex relationship between these. But if we really want to bring it down to the basics, it's essentially is in our brain, you know, our regions that control pain, the regions that control, uh, mood and anxiety. So depression, anxiety, uh, mood in general and cognition actually are. The same regions. And there is a theory that kind of puts this all together. It's a limited resource theory. And it says that essentially if you override, you know, your electrical circuits. So if these three functions pain, mood and cognition are on one breaker, if you overload one of them, the other ones will decrease and become more vulnerable. So think about it. If you look at and this is this is really helpful for patients when you explain it this way. And it's very helpful for whether students or residents to understand because they see patients with pain and they don't understand why it is that they're complex. And it is by virtue of just wiring. Um, if and again, massive oversimplification. So look at it from the perspective of pain. So you have a lot of pain and essentially your two other circuits mood and cognition. Uh, basically they're more vulnerable. What are the most common complaints from pain patients. You know, they the depression is at the forefront and cognition is as well. And essentially, if you look at the group, the age group that has chronic pain, uh, in its preponderance is really, you know, you're looking at the age group of 40 to 60 year old, uh, patients and they'll start thinking, oh, my, am I getting demented or, you know, am I why am I forgetting things? Um, so you've loaded up on pain.
Dr. Leon Tourian: [00:12:54] That's how you explain the two other symptoms. But the explanation works for, uh, from a psychiatric perspective, to look at folks that have depression, you load up that circuit, you that kind of that electrical circuit is loaded up. We know that in depression, people present with physical pain and they present with cognitive complaints as well. So I did this whole this whole kind of, uh, circle to explain that. But in fact, that's what it is. That's why these, the, these are intertwined so intimately. And if you look at it from an evolutionary standpoint, it makes sense. These three functions of are, you know, of our being is need to be interlinked because, you know, way back we always use that example, you know, when, uh, you needed basically to be very aware, if you were injured, to mobilise your mood, mobilise your, you know, your organisation to take care of your wound. The problem now is, is that before that was, you know, very primitive kind of, you know, functioning people barely lived until 30 years old. Now we're leaving until 90 years old. And so dealing with these chronic issues is not exactly how the brain had intended this to be. Uh, initially that connection was meant to be very appropriate evolutionarily, now somewhat problematic because the signal is chronic, whereas before it was not.
Sarah Hanafi: [00:14:17] Now that makes a lot of sense. And I guess thinking a little more along the lines of psychological frameworks, I you know, I understand there's the fear avoidance model of pain. Could you speak a little bit to that and how that links psychiatric comorbidities and pain?
Dr. Leon Tourian: [00:14:34] Sure. So, um, obviously the way I kind of present it when we have learners at the pain clinic is really basing ourselves on the biopsychosocial model. Right? So in terms of from a psychological perspective, there's many theories. There's, you know, looking for solution, the harm like movement avoidance like so kinesiophobia develops. Um, and then there's, you know, the, the exterior like, so the locus of control where it's located. Uh, whereas if it's very external, that becomes a problem as well. Uh, so from, in terms of some of the basic tenants, you know, in terms of, uh, pain and pain management, uh, base ourselves on these tenants. So one of them being essentially looking for, um, avoidance of movement in terms of harming self, that's a huge, uh, that's a huge cognitive distortion that pain patients have, because in essence, they've lost control over their body and they are convinced that, uh, minor movement or any movement might harm them. Because you have to remember, some of these folks did, you know, got injured with a very basic movement, uh, at the source of it. Whereas we know that movement is actually key to, uh, you know, um, improving from a pain standpoint. Um, and then we have, you know, folks that look for, like, solutions in pills. Um, they think that the solution is only medication or treat a given treatment. Um, and then we have folks that, you know, really focus on somebody else managing them because they, they invest themselves in a sick role that is very much not involving them in the in the care process and not taking over, not taking over their own care.
Dr. Leon Tourian: [00:16:10] And I guess taking a step back to that, I think the main, the core element of pain management from the psychological perspective is actually taking over, you know, taking over that loss of control that people with chronic pain have. So, in essence, you know, if you remember the last time, you know, you're injured yourself and the experience that you had, you felt like you needed to mobilise yourself, but you knew that it was for a short period of time. Whereas chronic pain patients. They know that they're in this for the long haul. And essentially, depending on their psychological framework, when they, you know, when they're injured and they start trying to manage that is that there's a loss of control. Um, and they've lost control over their body, and there's a signal in their body that keeps basically interrupting their functioning. And so that leads to essentially pathways that could be either very healthy or not. And when you start going out too much of yourself and looking for, you know, solutions with different, you know, wanting to find a diagnosis, wanting to find the right pill. Right. You know, wanting to find the right intervention, um, and or avoiding, you know, movement or avoiding, you know, activity. You get yourself into, uh, more precarious situations. And that's when you benefit from a multidisciplinary team like the one we have to kind of break those fears down, explore what their reasons is and, and kind of get outcomes better.
Sarah Hanafi: [00:17:38] I'm glad you spoke about the biopsychosocial approach. Um, and a multimodal approach. I was going to be my next question. You know, when we're thinking about psychotherapy. Um, which specific frameworks do you find are beneficial in patients suffering from chronic pain?
Dr. Leon Tourian: [00:17:55] So the what we use at the pain clinic is that we're very lucky. We have a fantastic psychologist. And, you know, when I did my fellowship training at UBC, there was a lot of psychologists there. So the framework the what has the most evidence is CBT, right? Uh, so you kind of do the exploration of where there's, you know, where there is barriers to essentially increase, you know, increase resilience, increase level of activity, decrease fear of movement. Um, however, in that component, the behavioural aspect of CBT. Um, you know, from a basic, you know, behavioural activation to, you know, mindfulness meditation, hypnosis, um, all of the I think the branch of meditation is very important. And you have to again, tying it in very much to the, I guess, aetiology of pain and that loss of control. These techniques as you know. Right, bring back a sense of control because by virtue of mindfulness and meditation, you're basically taking ownership of how your body is in the moment and you're controlling a whole bunch of parameters just by virtue of, you know, the activity of meditating. Hypnosis is a, you know, an intense version of, um, meditation. Um, so that gives control back to patients. And that's fantastic. And so we do that a lot at the pain clinic. And we encourage patients, pain patients to do that. Another thing is biofeedback.
Dr. Leon Tourian: [00:19:22] So again in that behavioural aspect. Uh but again biofeedback you can do it through cardiac coherence or EEG or whatever technique you use. Uh, you essentially again give ownership back to patients of their body and their bodily function, which that's, that's what they feel that they've lost. Um, there is a lot of increasing evidence for acceptance and commitment therapy, uh, for pain patients. And I have to say that is, um, it's very ironic how things change over time. When I was in your stage and and even a little later, uh, you know, act was not very much, you know, taken seriously. It was kind of seen as a kind of a, uh. Anyways, it wasn't taken seriously. I don't want to say anything more, uh, because I regret that when I was a Pgy five finishing Psychiatry Act was, you know, nobody took it seriously. Everybody thought it was kind of a spin off of different therapies and kind of given a the same kind of thing, but given a given, another type of a costume, so to speak. However, now act is very much, you know, the centrepiece of some of the behavioural and cognitive interventions that we do. So I think it becomes a little eclectic. But acceptance and commitment therapy turned out for pain to be quite useful and increasing in its, uh, in its importance.
Sarah Hanafi: [00:20:42] Wonderful. And, you know, moving beyond psychotherapy, um, I was reading a little bit about central non-invasive neuromodulation strategies, and I was wondering whether that's something that, um, you've come across within your practice and is there a role for this population?
Dr. Leon Tourian: [00:21:01] So that's an excellent question. Um, how do I answer that? So in terms of our experience with it, um, I've only had, uh, just a few patients that have had interventions with Rtms, for example. Um, and I have to say, you know, there is an increasing evidence for the role of rtms, for example, in the management of chronic pain. Now, as you know. Right. Rtms is a massive commitment from a time perspective. You also have to have the right machines with the right kind of, um, settings to deal with pain versus depression versus, uh, other modalities. So, um, so we have some experience. It is limited. And I think, um, yeah, I think that essentially, you know, we always kind of think about it because we don't have access to it for our more severe cases. And so the outcomes are not very, you know, they're not amazingly encouraging, but sometimes they do work. So we have to think about it. Uh, but I think that it's an accessibility issue, even, you know, in Montreal we have four, five centres doing rtms now, but they're more geared towards, uh, primary mood disorders. Um, and so not for pain specifically, but they do help, uh, with the mood aspect. So they become a useful tool for chronic pain patients.
Nima Nahiddi: [00:22:16] I wanted to take some time and focus on, uh, the first part of the biopsychosocial, uh, approach, which is the biological, the pharmacological management. This is something which can particular interest our listeners, given your psychopharmacological expertise. Can you outline, uh, if you have a general pharmacological approach for the management of chronic pain?
Dr. Leon Tourian: [00:22:41] Sure. Um, so I think I think the first thing to remember is that there's guidelines, right. Um, and I think. It is very important to be mindful of guidelines. But we're not technicians, we're physicians and we're, you know, caring for human beings that are one like versus the other, uniquely different. And so that has to be taken into consideration. But the guidelines are your framework. So you start with the Canadian neuropathic pain guidelines, uh, which kind of give you an order of medications to go through for neuropathic pain. If you have visceral or somatic pain, you know, opioids remain the centrepiece. However, if it lasts long enough, there is a centralised component that becomes interesting and your pain guidelines kind of, uh, become relevant then. Uh, but essentially, as for the Canadian neuropathic pain guidelines, and essentially if you look at all the guidelines, they're all the same, pretty much in terms of what they recommend. Some of them vary in terms of what they've chosen as, uh, staying in a level one evidence, but as a first versus a first line, that will depend on, you know, different motivations and, uh, depending on what group is writing it. So in essence, your first line for neuropathic pain, for example, are the snris. So, you know, thinking about snris, it's very it's very helpful to be mindful of not the only two. We don't only have two snris or two antidepressants that modulate, uh, serotonin and noradrenaline, nor, uh, noradrenaline.
Dr. Leon Tourian: [00:24:12] So, you know, we have some, you know, duloxetine, Cymbalta. So and we have Effexor. Those are the common ones that we think about. But the ones that are not necessarily indicated in pain, but that work equally as well, obviously is Desvenlafaxine. Uh pristiq. We have to remember Wellbutrin bupropion. So bupropion actually does the job. You know, it does increase noradrenaline. So, um, it does reinforce our downward inhibitory pathways, um, and um, and are an effective management tool. Uh strattera. Um, you know, uh, the, the kind of ignored molecule in psychiatry because it kind of doesn't help with ADHD, or at least the evidence is not that strong. And it kind of doesn't do much for mood. But I always mention it because I do have, you know, one experience as a physician and helping one individual. And it worked. But so I keep mentioning it just because, you know, people listening to this might have a patient that nothing is working and maybe that will work. Um, so in essence, bear that bearing that in mind. Uh, so and then we have our tricyclic antidepressants. Right. So they are uh, they are really, you know, in terms of efficacy for neuropathic pain, very helpful, but associated with side effects. Right. The anticholinergic aspect of TCAs is problematic. The narrow therapeutic window is problematic. And so if you have somebody who's suicidal or who has had past suicide attempts with overdoses, you want to be careful with tricyclic antidepressants.
Dr. Leon Tourian: [00:25:39] But, you know, I've seen amazing stories of folks coming in, very lucky folks that their general practitioner did not give them any opioids for, and they diagnosed them with neuropathic pain, but did not want to go down the opioid pathway. And you know, thank you know, they're very lucky. And then you give them 10mg or 20mg of amitriptyline. And you know, they don't even come back to the pain clinic. Uh, they you know, they tell you, can you just renew this? And I'm good. Um, and then the GP takes over and you never hear from them. So TCAs remain there and the gabapentinoids so Lyrica, uh, pregabalin and gabapentin. So those are your first line. And then the second line, depending on what recommendations you're reading you fall into the opioids. Um, and then third line cannabis, ketamine uh, you know doesn't figure in in it. But for centralised pain it is really important. Um, and then your fourth line agents are the anticonvulsants SSRIs. There's not a lot of evidence for them. You know, when you look at the anticonvulsants, um, uh, you know, aside from carbamazepine, there's not a lot of good evidence for, uh, our anticonvulsants, like topiramate. Uh, um, valproic acid, lamotrigine, for example. Um, the studies are not very conclusive, so it's not very helpful. But that being said, it's really important for folks to remember that even if you have a negative study for a medication for a given diagnosis, you have patients in those studies that have responded to these molecules, but you just don't have a, you know, statistically, there's not a significant amount that but you have people that responded in these studies, and you might have a patient sitting in front of you that might potentially respond.
Dr. Leon Tourian: [00:27:18] And if you've tried everything non-pharmacological, and if you've tried things that are pharmacological and they haven't, but you have to offer it because they might want to try and guess what? You might be able to help them. But as long as they know. Right. Um, so we have a whole bunch of medications. You follow the evidence, um, and then you try to help them out. Uh, I think the other branch of pain management from a pharmacological standpoint is sleep. Sleep is a massive issue for pain patients, as you could easily imagine. So, you know, trying to. Tell the pain patients, hey, you know, how about you follow this sleep hygiene? Um, and you know, it's impossible. And, you know, I, I try. Uh, but I have the, you know, I have the greatest respect for my patients. Um, and, you know, even if you don't have chronic pain, following a sleep hygiene protocol is immensely difficult. Imagine trying to go to bed and all you feel is different. Aches and pains that might increase as a as a result of pain. Uh, so essentially in terms of pain, you know, you obviously always go for non-pharmacological methods, sleep hygiene, meditation, melatonin, for example.
Dr. Leon Tourian: [00:28:26] And then you fall into obviously the not a trap. I don't want to call it that, but unfortunately you do fall into giving the medications for sleep, uh, that have side effects. But that work, right? Uh, old medications that are reliable. But, uh, you know, so I use a lot of, um, I use a lot of method. Method. Trimipramine. So Nozickian, uh, for sleep, it does have some pain properties that is, uh, interesting, but again, riddled with side effects. Antihistaminergic. Uh, they folks, uh, gain weight. And, you know, you keep maintaining focus on these class of medications over time. You need to be mindful of the cognitive burden that that has as well. But they need to sleep as well. So it's a it's a very fine balancing act. I have to say. My training was in Psycho Pharm, uh, in going into chronic pain. Um, and one thing you realise very rapidly when you're very comfortable with meds is you realise what their limitations are. But the reality of our patients is that they do need medication because, you know, their body has failed them and you know, they need the non-pharmacological methods. They need to do mindfulness, hypnosis, the whole bit. But sometimes they need that boost. And medication is is unfortunately necessary. But if it's as long as it's used rationally, the minimum dose is, uh, necessary. Check for interactions. Uh, then you're pretty. You're good to go.
Nima Nahiddi: [00:29:47] Thank you, Doctor Turian. That was a really good overview. I think it would be very helpful if we went into some detail for some of the different categories. So the first question I had is kind of going right back to the beginning, because I realised maybe some of our listeners maybe want a clarification on what's the difference between neuropathic pain and central pain, something that you, that you've mentioned when talking about this pharmacological approach?
Speaker5: [00:30:17] Yeah.
Dr. Leon Tourian: [00:30:18] So we could go through the pathogenesis of neuropathic pain to kind of help. And then we could branch in the pharmacology in there one by one as well. So in essence, you know the types of pain the you have somatic pain somatic visceral pain. And you have neuropathic pain. So neuropathic pain is in the context where there's damage of the nervous system. Um, and essentially an aberrant repair of the nervous system leading to an ongoing, uh, an ongoing, um, electrical signal. So kind of like you could think about it along the lines of epilepsy. But if your sensory pathways. Um, and so if you look at it that way, actually, it makes, you know, it kind of starts decreasing the mystery of pain and kind of simplifies it. So somatic and visceral as you, as, you know. Right. So the motor system, the nervous system is not involved and it's tissue damage that um, that is you know, that has gone awry a bit. But essentially the experience of it is through our neural pathways anyways. Right. But the initial damage is really focussed on, on non-neural tissue. But if we focus on neural tissue. Right. So essentially what happens is, is that in the periphery you have a repair of your nervous tissue that in 90% of the cases your nervous tissue when damaged will repair itself adequately.
Dr. Leon Tourian: [00:31:36] And you know you'll move on 10% of the population, again using the biopsychosocial framework will develop neuropathic pain. Um, and so the biologic tenants of that is very much in the periphery. The central one is, uh, basically an aberration in the voltage gated sodium channels. So as you all know, right, you need the voltage gated sodium channels to have an action potential. And once you have an action potential, you have a pain signal. So it starts in the periphery. And so, you know, there's this has been researched a lot. There are various mutations of the voltage gated sodium channel, um, and essentially, uh, leading to essentially with low stimulation or none, uh, to a pain signal. Right. So if you look at the voltage gated sodium channels, what blocks them is our TCAs, the tricyclic antidepressants. That's why in an overdose situations they're toxic for cardiac because it's the same voltage gated sodium channels that you have in your heart. So the TCAs all block that and all the anticonvulsants. Right. Um, so when you go from, you know, keppra to, uh, valproic acid, lamotrigine, topamax, all of them block. So, uh, the voltage gated sodium channel efficacy not so great. Tca is fantastically efficacious, but some side effects. So in the periphery you have the voltage gated sodium channels that are really the prime target.
Dr. Leon Tourian: [00:32:58] Right. So when you go from the periphery to the central nervous system, so you kind of do a first stop right in the dorsal root of your, of your spinal column there. It's the calcium channels that are dysregulated. So voltage gated calcium channels again if you remember from your medical school courses from the signalling, you need calcium to release neurotransmitters in the synaptic cleft. Um and essentially calcium regulates that. And you need the voltage gated calcium channels to maintain calcium homeostasis. So uh, pregabalin and gabapentin block those. And essentially what you have is, is if you have an aberrant signal coming from the periphery, you inhibit those by using the gabapentinoids. So you've used your voltage gated sodium channel blockers, TCAs or anticonvulsants in the periphery in your dorsal root. And as you enter the central nervous system, you block them with a, um, calcium channels, blockers. And then you go to the central nervous system there. You also have a dysregulation of the voltage gated calcium, uh, voltage gated sodium channel. Sorry. So your TCAs will act centrally as well to modulate it. So in essence, without getting too complex in some of the pain phenomena, um, that is the periphery, that is the pathway going up. So but there is a pathway going down. What I mean by that is the brain has developed really awesome pathways to regulate pain and to diminish the pain signal coming from, um, coming from the periphery.
Dr. Leon Tourian: [00:34:28] And those are our downward inhibitory pathways. And, uh, to make this simple, for the purposes of this conversation, we'll limit it to about 4 or 5 classes, um, uh, 4 or 5 pathways and translates into, you know, the the same number of classes of medication. The first one is opioids, right. Our body has an. Natural opioid pathways, and its role and their role are very much in pain modulation excite from a whole bunch of other things that they do. Um, but that's why we have opioid medications, right? They enhance the pathways, we have the right receptors for them. And you go along from that pathway. The other one, obviously getting a lot of attention right now is cannabis. So the cannabinoid pathway. So that is another downward inhibitory pathway blocks pain signals coming from the periphery. And we can have a whole conversation about those. But let's I won't go there. Uh, related to you know, the some of the, the pros and cons of cannabinoids. Um, but again, a meaningful but not that well studied enough, uh, medication or class of medication, if you will. Um, and then we have the three medical pathways that kind of marry chronic pain management to psychiatry in by virtue of just the molecules are the same noradrenaline the most evidence one um, that we that we have the most efficacious one uh, serotonin.
Dr. Leon Tourian: [00:35:46] Not so great. I haven't had one person come and tell me. Oh, you know, Doctor Turian, it's been great. The celexa has really helped my neuropathic pain, and I've never heard that before. Uh, but I hear it with, you know, venlafaxine, uh, you know, uh, duloxetine and prestige. Um, desvenlafaxine. Um, so, but not with the serotonergic agents. And then you have dopamine, which is kind of unfortunately, the the, um, you know, nobody paid attention to dopamine. They kind of got wasted, like, it kind of got. Yeah. Not wasted. But there's an opportunity wasted there. But I think it's, uh, probably a very complex one in by virtue of how dopamine plays in with the pleasure centre and addiction, um, and by virtue also of, uh, you know, uh, the complexities of modulating that with ease without causing a whole bunch of other problems. Uh, but nonetheless, dopamine modulating agents, whether they're blocking or not, have been found to be somewhat efficacious, but absolutely no evidence for their use in a first, second or third line situation is that I think that kind of breaks it down with all the meds.
Nima Nahiddi: [00:36:49] That was incredibly helpful. Thank you. Talking about dopamine. So is is there any role of antipsychotics in the management of chronic pain.
Dr. Leon Tourian: [00:36:58] So that's a that's a fantastic question in in any official manner. No. Um, like from an evidence standpoint, there's nothing however, uh, being that this is going to go to folks that are either in psychiatry or have an interest in psychiatry, there's I'm going to throw a few nuggets of information for you to consider. One is if you have done if you've worked with chronic patients with schizophrenia, um, and you look at, uh, and observe, uh, when they injure themselves, what their pain thresholds are like, they are remarkably different than, you know, somebody who doesn't have a persistent psychotic disorder. Um, and it's less so, you know, folks with folks that have been Long Terme on Long Terme dopamine modulators, the antagonists have a very different way of appreciating pain because chronically, we've, uh, depressed, uh, the dopaminergic pathways. In terms of. So there's that. So that's the first thing to bear in mind. Another thing is, is that we do have a very you know, we don't talk about it very often because the evidence is not there, but the sigma pathway in the brain. Um, and so, uh, one of the antipsychotics that we have that modulate, that is haloperidol again, uh, you know, when I started out as faculty, we had a patient that had tried everything imaginable and possible, and me and one of my anaesthesia colleagues at the pain clinic were thinking, should we try Haldol? And we did, and it didn't help. But nonetheless, you know, there is biological evidence for the sigma pathway in our brain that modulates, uh, pain signal.
Dr. Leon Tourian: [00:38:39] Third and last observation, which I still have to get around to writing up, um, is the role of dopamine agonists, uh, or partial agonists? Uh, so, um, you know, as we know in, uh, as augmentation agents, we know that antipsychotics have a role. Novel antipsychotics, such as aripiprazole brexpiprazole have a partial agonistic profile. And I have, you know, I have a cluster of patients that have unfortunately not responded for a mood perspective but have actually significant decrease in neuropathic pain symptoms, but unfortunately, no improvement in mood, uh, which was really terribly you know, it was not what I wanted, but it turned out to actually be beneficial either way. Uh, so and, you know, there is one case report out there showing the efficacy of aripiprazole in the management of neuropathic pain. So dopamine is a really you know, I use I kind of use the word the rejected pathway because nobody pays attention to it. Uh, nobody wants to touch it. Um, uh, research has not gone there. We really focus on noradrenaline. And it really a shame because I think there's a lot to be done with the dopamine pathway. Uh, because I think that, uh, you know, we forget that dopamine, uh, you know, the, the regulation between dopamine and cognition, dopamine and pain. I think there's something really interesting to be done there. Um, but, yeah, no, not not as exploited as it should be. Uh, that pathway.
Nima Nahiddi: [00:40:11] Very interesting. Finally, for the to wrap up this biopsychosocial approach, uh, you had also mentioned the role of cannabinoids and cannabis, and I think this is something that many of our listeners might be interested in, given the recent legalisation of cannabis and how it's taken up importance in Canadian culture recently. Can you elaborate more on the current role of cannabis in the management of chronic pain, and perhaps how it is involved in a biopsychosocial approach for patients?
Dr. Leon Tourian: [00:40:46] Uh, okay. So yes, um, the first I'm going to say is in terms of its role in, again, in from an evidence based standpoint, it's still there's a long way to go in terms of having solid evidence for the role of cannabinoids in the management of chronic neuropathic pain. So that's my first statement. So again a lot of unknowns. Um, and so there we need to we need to do more research. However there is evidence showing that it does help. So I think that there is no we're not at a stage right now that we could kind of just brush off cannabinoids and say, oh, you know what? This is just, you know, this is just a, you know, a in Vogue right now. It's in style. We won't be talking about cannabis in ten years. That's impossible. We've been we've been, you know, we've been engaged in in cannabis in, in our culture for, uh, so many years. You know, uh, this is nothing new and it's not going away. So, um, and nor should it in the context that it has its place, but it needs to be studied more. So cannabis and its main two components, CBD, THC is both of them have analgesic properties so great they should not be and they are now. And that's a problem, uh, be heightened to the level as a safe alternative to opioids.
Dr. Leon Tourian: [00:42:06] There's no evidence for that statement, even though, uh, you know, cannabis companies are popping up all over the place and they're posing it as, oh, you know, your opioids not working for your chronic pain. Try cannabis. Absolutely not. That should not be what we're doing right now. I guess you know, that's what I'll say. If you look at the evidence in terms of cannabis, in chronic pain, um, uh, chronic pain diagnoses, in terms of FDA approvals or Health Canada approvals, it's only approved for spasticity related to multiple sclerosis right now. So that's another thing to consider. Um, so the evidence again for neuropathic pain does not have level one evidence. So there's that. So. I guess, you know, the main thing is, is twofold. One is, you know, we've legalised it. So essentially everybody's extremely curious about it. And because it's legal, everybody thinks it's safe. Just like alcohol and cigarettes. We all know that. That's not the fact, right? There's risks associated with cannabis. So I think that as psychiatrists, you know, I think we have you know, we have really one set of eyes on cannabis and it being, you know, bad for young people and heightening the risk for vulnerable populations to psychosis. So that's problematic in terms of THC. Now CBD is a whole different, uh, topic. Cbd is being posed right now, as you know, the miracle molecule and the pathway to be the curing, you know, from depression to psychosis to, uh, chronic pain to everything.
Dr. Leon Tourian: [00:43:37] Um, and that part, I think needs a lot of research, but and I think that part also is a bit of a, you know, a fad, uh, like it's in vogue now to talk about CBD. And in ten years, when the evidence hasn't, uh, you know, we don't have enough evidence, so we'll pass on to something else. But I think CBD has a lot of promise. Um, and, and I think that there's a lot to be done with, uh, with CBD research and seeing where it could go. Uh, but I think that one thing we tend to forget, um, and given the legalisation, actually physicians have fallen into this trap if they don't inform themselves enough is the deleterious effects of THC in certain age groups. And so we know that it's problematic in, in, in youth, but it's also very problematic in our cardiovascular patients. And that's something we don't often talk about. It is there is an heightened risk of cardiovascular events. So heart attack, stroke, um, in the use of THC and that we don't talk often enough about and not a lot of specialities are aware of it. Um, so I think that it's really important to consider that profile of THC in our more, you know, in our elderly patients, more elderly patients.
Dr. Leon Tourian: [00:44:44] I'm talking about, you know, the ones that are risk for these events. So we're talking about 50 plus, let's say, um, so it increases blood pressure. It increases heart rate. It increases risk of heart attack and stroke. So I think that we need to be mindful of how we use it. We need to inform folks that their side effects, um, and I think that there is a lot of promise, so I don't I started off my practice as a pain psychiatrist, being the anti-cannabis guy because of, you know, the training we get in psychiatry because we know the risks. Now, I'm very comfortable with using cannabis with the right patient at the right time, with the right profile, when other level one, level two, uh, medications have failed. So I guess, yeah, I've come a long way with cannabis. I have to say. Um, and, uh, I, I'm very comfortable with its limitations, but I'm not, um, I haven't, you know, I'm not as strict against its use because some patients, it changes their life. Um, and we do sometimes avoid using cannabis in certain patients. But again, you know, cannabis opioids, what's good what's bad there. You know, it's you're basically exchanging a side effect profiles for another side effect profile.
Audrey Lee: [00:45:57] Thank you for all the valuable insight you've been able to provide into the pharmacology of chronic pain management. Doctor Turan so to finish off, I wanted to go down a different avenue and explore the diagnosis of somatic symptom disorder and how that relates to pain disorders. So, you know, according to the the DSM five, the the following criteria are necessary to diagnose somatic symptom disorder. So criteria A is that the patient has to endorse one or more somatic symptoms that are distressing or result in significant disruption of their daily life. B is that they have to have excessive thoughts, feelings or behaviours related to somatic symptoms or associated health concerns, as manifested by at least one of the following. So one disproportionate or persistent thoughts about the seriousness of one's symptoms to persistently high levels of anxiety about health or symptoms. Three excessive time and energy devoted to those symptoms or health concerns. And then criteria C is. Although any one somatic symptom may not be continuously present, the state of being symptomatic must be persistent and typically more than six months then. Additionally, the criteria for somatic symptom disorder also includes a specifier for predominant pain or previously known as pain disorder, and this specifier is included for individuals whose somatic symptoms predominantly involve pain. So my first question about this is what distinguishes somatic symptom disorder with predominant pain from something. For example, like chronic pain with comorbid anxiety.
Dr. Leon Tourian: [00:47:29] Yeah, that's that's a fantastic question. So I'm gonna answer by stepping back a bit because, uh, I guess, you know, again, I'm ageing myself a little bit, but, um, I did my I did my whole college with DSM for T.r. Um, and you may not be familiar with that. And it pains me to say it like that because it wasn't that far off. Um, but, you know, you have to remember that the somatic symptom disorder and related, uh, somatic symptom and related disorders chapter, um, is a revamp of the Somatisation chapter, which was riddled with so many problems. Uh, like, you guys don't know the soma, you know, somatisation disorder. But that was a very complex diagnosis to be rendered. Um, and they simplified it, and they simplified it in a way that is very pro patient. And what I mean by that is that there's a reduction in stigmatisation of patients that present with unexplained, medically unexplained symptoms. And that's the core of the revision of DSM five is removal of that. So that has been very helpful. But now what is even more helpful I find is there is there's almost an, you know, there's almost an educational aspect to the diagnosis itself. And what I mean by that is very simple. When you look at the basic tenets of the requirements, it is cognitive, behavioural and emotional.
Dr. Leon Tourian: [00:48:47] Right. And those are tools we could use. If you look at if you spend a little time looking at the Somatisation disorder chapter, there's nothing in there that you could use to anchor and help your patients. The somatic symptom and related disorder. Fantastic revision. However, um, you know, there's limitations to it because if you look at those symptoms, you know, in essence, almost 100% of my patients would probably qualify for the three disruptions in cognition, behaviour and emotions. Um, so I think, you know, there's one needs to be mindful of that. Um, and so how it relates to chronic pain is the following. Is that in proportion to the seriousness of their their presentation and their medical illness, uh, the disproportionality needs to be proven. And that's where your symptoms lie. For somatic symptom disorder. However, one needs to be mindful before putting that diagnosis down because once you put that down, you've essentially, uh, labelled your patient as being, you know, somatic, which they're not. You know, our chronic patients, our chronic pain patients are not patients that have somatic symptom and related disorders. For the vast majority, I have to say, in my practice in the last, like I said, uh, most of the time I spend is in chronic pain. And in terms of maybe, I don't know, I think I've seen 7 or 800 patients in terms of diagnosing somebody with a clear somatic symptom disorder.
Dr. Leon Tourian: [00:50:18] I only have five. Five patients, where it was overtly clear in terms of the information that we got from our colleagues, the investigations that were done that there was no that the that the symptoms were much, you know, out of proportion. However, if you, you know, while the symptoms while the diagnostic criteria have been simplified, uh, they render itself too easily to be diagnosed and that's a problem. However, what I take from that is the tool. And the tool is, is that you have to intervene in chronic pain with, you know, looking at emotions, looking at behaviour, um, and looking at, uh, the cognitive distortions associated with that. And I think that that's where it's beneficial. So I know I did a huge loop there to try to explain this, but I think it's really important because as a pain psychiatrist, I feel like one of the biggest roles that I play in our patients, in my patients life, is to decrease the stigmatisation. So adding on another psychiatric illness, even though it fits diagnostically, may not be essentially the most helpful thing that you're doing with them using those diagnostic tools to help them. That's, you know, where you are able to essentially, you know, make it make a meaningful impact in their life.
Dr. Leon Tourian: [00:51:37] Uh, so pure somatic symptom disorder with predominant pain. Sure. You know, if you look at those criteria strictly, you know, a lot of our patients can meet that diagnostic criteria, um, where, you know, where it's helpful for them, the strict minority, because those five patients that I was relating to you, if we did anything from an interventional standpoint, if we, you know, referred them for surgery or anything, that would be terrible, right? That would be terrible because they don't have there is no substrate to treat. Whereas the vast majority of my patients need a multimodal intervention, need blocks need, you know, uh, you know, some kind of, uh, non or, you know, non-invasive or invasive procedures to help with their pain. And it's relevant because they warrant it. Uh, and I think that these, um, that category is really exclusively meant to alert us to folks that don't have an underlying, you know, uh, disorder and need, uh, you know, need to be identified as being really, truly, you know, uh, somatic in their presentation, whereas all the rest could just benefit from the tenets of that diagnostic framework and address, you know, uh, address the three main poles cognition, behaviour and emotions.
Audrey Lee: [00:52:57] Um, I really appreciate you addressing kind of how we have to be cautious about assigning patients this disorder and the downfalls that it can have for them. Um, going back to something that you had mentioned about, you know, the previous DSM where these this chapter on Somatisation was quite controversial. Um, when I was reading the literature, I saw that there was there's still a bit of controversy regarding somatic symptom disorder, as a lot of clinicians think, that it's stigmatising and overinclusive, like you said. So they've suggested perhaps to, um, change this to an adjustment disorder as a more appropriate and accurate diagnosis. So what do you think about that? And what differentiates somatic symptom disorder from adjustment disorder. And in terms of how they relate to chronic pain?
Dr. Leon Tourian: [00:53:41] Yeah, that is a very interesting question. And so how would I answer that? Okay. So I think that, you know, no matter how you simplify something, the more you simplify it and the more you put it somewhere else, the stigma is just going to follow the problem, right. The stigma is not related to a given diagnostic framework. It's related to how we feel about something that we know are not familiar with. I think that that's the main like the basic tenant of stigma is if you are unfamiliar with something, you get afraid of it and you can't. When you can't explain it for yourself, then you have two reactions. Either you avoid it or you, you know, you you kind of berate it and ignore it and kind of, you know, that's that's the misery, unfortunately, of chronic pain patients because, you know, they end up showing themselves in er, um, and essentially the doc goes, oh, you know, this is all in your head. And then, and then they sent a psychiatrist. And what does the psychiatrist say? Oh, you know, this is because of your blah, blah, blah, you know, whatever it is that you have. And that's where, you know, I really feel strongly that our patients, you know, you know, we need to educate folks about what is chronic pain. And just because you can't see it, it doesn't mean that they're not suffering from it. So I think though the main, um, the important aspect is, is that this chapter. Can be stigmatising if used inappropriately. And I think that if you appropriately use the diagnostic framework, it can be very protective of certain patients, but not as many as we think.
Dr. Leon Tourian: [00:55:07] Um, at least not in our population. And the one that we treat and the one that I kind of encounter at the mosque, or at least, you know, the consults that I've had across our network. So I think, you know, somatic symptom disorder versus adjustment disorder, I think they're very different things. An adjustment disorder is you look at us, you know, you look at a given stressor and you look at, you know, the the spectrum of reactions, uh, that you could have to it. And you're looking at a specific like a specific strata that are responding more intensely towards a given stressor. Somatic symptom disorder is really the manifestation, uh, potentially, of the stress through physical symptoms. So you could potentially oversimplify it and call, you know, create a new category of adjustment disorder with predominantly physical symptoms, you know, but the stigma is going to follow because the stigma is actually, you know, the unknown, the unknown being is that, you know, you don't know exactly why they're manifesting with physical symptoms and why aren't they just sad, you know? So that's the that's the kind of a massive oversimplification of an experience of patients that is, you know, that needs to be appreciated. And then we need to heed to and listen to. But no matter where you stick something you don't understand, the stigma will follow. I think that's really important. And I think I really, you know, I really am invested in trying to do these things like this podcast and like other things that I do at the pain clinic to make folks understand what the experience of chronic pain is so that it brings down the stigmatisation.
Dr. Leon Tourian: [00:56:35] The more medical students, the more residents kind of understand what chronic pain is, then the less you know you. Those individuals in context of ER or family practice or referral will be more understanding of these patients that have great need. And you know, it's not a benign number. We're looking at 10% of the population um with chronic pain. So and the older you get the higher those incidents becomes. And 5 to 7 you start off with 5 to 7. In paediatric populations that's not insignificant. And these are young folks. And as you go along it increases I think I hope that answered your question, but it's just very, um, it's very delicate putting a label on something that is very complex. Uh, and I think, I think if I was to summarise and to answer your question, I don't think it will it I don't think it needs I don't think it, it should be housed in the adjustment disorder because again, the stigma will follow. But I think though we should be very careful in how we use somatisation somatic symptom disorder diagnoses, because you have to appreciate that once you put that in a patient's chart, you will essentially, uh, you know, decrease the quality of care that's going to be delivered every time another doctor reviews that chart because they'll go, oh, you know what? It's in their head. And then you know what the trap there is. The patient gets poor care. And then at one point, you know, there is going to be something significant and it's going to be missed, and that's what you want to avoid.
Audrey Lee: [00:58:00] You had said how you had maybe only five patients in your practice that you actually found had somatic symptom disorder in those instances. How did you approach the treatment of that?
Dr. Leon Tourian: [00:58:12] So you approach it with one creating an alliance with patients, right? You can't just say, oh, you know what this is. You know, this is it. This is your diagnosis. Good luck. No, it's you have one is that I've never I've never actually done that with a one shot, like a one shot, uh, assessment. Um, and so it's been done. If I have done it, it's because I've had all the information from our psychologists who've met the patients multiple times, and we needed to stop the medicalisation of these patients. Um, so I think how we've done it is really, you know, either we've developed an alliance with them, I have or our team has, and you kind of sit down and you approach it in a multidisciplinary, interdisciplinary approach. So you sit down with a patient, with everybody around the table, and you go, you know what? You're suffering very real. And we are hearing it. However, you know, we at this point cannot find, uh, you know, a medical explanation for this. And these are the tools that you would get whether you had a medical explanation or not, because you're a chronic pain patient, you present it that way, and essentially you stop intervening from, you know, you stop intervening from interventions blocks. You wean off medications slowly, but you always focus on the suffering, not the cause. Because the cause, you know, the patient will always remain, you know, convinced of needing to identify. And that's the virtue. That's our nature. Right? We want to know why this XYZ is happening.
Dr. Leon Tourian: [00:59:39] But you focus on the suffering and then you give them tools. And the tools are, you know, minimal pharmacology. Uh, one person kind of managing these, these patients and essentially, you know, investigating appropriately but limited. And the GPS is usually at the core of that. And, uh, I think that there's ways of doing it, but you have to do it very respectfully. But you have to do it. You can't just say, oh, you know, we'll just kind of, you know, we'll glaze over the fact that this is we can't find. No, you have to tell them, listen, we haven't found any evidence matching, you know, we haven't found any evidence of a medical reason. But focus on the suffering, minimise interventions, minimise pharmacology and optimise, you know, uh, focus function and their independence. Um, and, you know, from a psychology standpoint, uh, our team is fantastic with that, uh, because we have honed our skills to identify these complex patients, um, and, and address them and refer them and do it with a lot of care and respect because, as you know. Right. The the number one stigma at the pain clinic, especially when they're referred to psychology or psychiatry, is, oh, you're going to tell me it's in my head, whereas, you know, it is in your head. It's all in our heads. Um, and, you know, our sensory pathways are located in our heads. And when you educate patients and make it makes a lot of sense to them, they're very reassured.
Audrey Lee: [01:01:02] So, so to to end off, I actually had one last question for you, Doctor Turian. Um, so, you know, throughout our discussion about somatic symptom disorder, we spoke a lot about about stigma. And you kind of touched on how, um, psychiatrists should do a better job at educating learners and, and medical students and residents about, about chronic pain and how you jump on these opportunities to educate people because you think that it can reduce the stigma. Um, how do you see the role of, of psychiatry in, in reducing the stigma around chronic pain patients?
Dr. Leon Tourian: [01:01:36] Um, so I just want to be clear, I don't like the psychiatrist in general. Don't do this. I do this because it's the virtue of my practice. Uh, but I think, you know, um, I think that the number one and I was actually, you know, uh, I was actually going to I think my closing remark in this is that, you know, education is at the core of understanding the chronic pain patient. If you understand how chronic pain comes about, then it's not a it's not a invisible diagnosis. Right? That's the problem with chronic pain. You don't have, you know, you don't see it on imaging unless, you know, of course, you have an injury that you could identify leading to it. Um, you it's just not tangible. And that's what makes it more vulnerable to stigmatisation. But if you understand it and if you can appreciate the complexity and how to manage it, then it doesn't become as problematic anymore. Um, and I think so in terms of Psychiatry's role in chronic pain, I think that as any speciality, we have to advocate for patients. And I think that, you know, we need to have more pain psychiatrists, for example, um, you know, there needs to be more people invested, uh, and more invested time in it. And you can't do it in a silo. You can't just be the consultant. You need to be really integrated in an interdisciplinary, interdisciplinary team. Because if you're not, then you essentially, you know, create a separation in the patient's mind that the brain is here, physical is here at the pain clinic. You know, I'm the I consider myself very lucky physician to have. A situation like the one I have is that we have a playing clinic. Everybody is part of the pain clinic. Our approach is very interdisciplinary and we tell the patients that it's all one.
Dr. Leon Tourian: [01:03:22] We are one. You're one. You're suffering, you know, is your brain is not separated from your your body. Um, and the experience is, you know, uh, is a bidirectional one. And we approach both and we really put a lot of emphasis on the. Patient taking ownership. Um, and I think so, I guess I guess one of the things is educating oneself. I think that, you know, it's not only psychiatry that's going to advocate for chronic pain patients, but also a whole bunch of other specialities. I think pain clinics are the advocates for patients. Um, and I think pain patients attracts folks that want to deal with more complex patients. And I think pain, chronic pain is by virtue of complex patient. Um, and I think that once you have folks doing that and advocating, then that's, that's that's one thing. The other thing is, if you look at the organisation of pain clinics across Canada, for example, you know, there's different ways in which they're organised. Not all of them have the luxury of having psychiatry, um, just by virtue of resource or by fear. Um, and I think that when you have folks coming to our unit and getting that experience, well, you know, they go elsewhere and they talk about it and they see how it's done. And we're lucky because there's not a lot of clinics that are set up the way we are. And there's not a lot of departments that have the luxury to have a psychiatrist being lodged and only doing or mostly doing, uh, pain. Uh, but it's education. Education is at the core of bringing down stigmatisation. Um, and we need advocates, and the advocates are folks that really have, uh.
Speaker5: [01:04:57] The well.
Dr. Leon Tourian: [01:04:57] The well being and and the. At the heart of what they want to do is really advocate for complex patients.
Nima Nahiddi: [01:05:06] Thank you once again, Doctor Turian. I can hear the passion that you have for this subject. Uh, you know, you've educated me today, so hopefully our listeners can also benefit from this wonderful conversation.
Audrey Lee: [01:05:20] Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Doctor Nemonychidae. Doctor Sara Hanafy and Audrey Lee. Audio editing by Audrey Lee. Show notes by Doctor Nemonychidae. The accompanying infographic for this episode was created by Doctor Luba Brozkova. Our theme song is Working Solutions by Olive music. A special thanks to our incredible guest, Doctor Leon Turian for serving as our expert on this episode. You can contact us at Psyched Podcast at gmail.com or visit us at Psyched Podcast. Org. Thank you so much for listening and we hope you'll tune in again next time.