As an anesthesiologist, pain medicine specialist, and clinical epidemiologist, my research interests span development of novel psychotherapeutic interventions at the intersection of pain, prescription opioid addiction, and psychology. As an NIH-funded researcher I am working to develop novel interventions (behavioral, medical technology, medical device) to prevent continued pain and opioid use after surgery. My clinical interests include treatment of chronic pelvic pain conditions including painful bladder syndrome/interstitial cystitis, endometriosis, pelvic floor myofascial pain, pudendal neuralgia, peripheral nerve entrapments, pelvic adhesions, vulvodynia, and chronic constipation.
- Pelvic Pain
- Interstitial Cystitis
- Painful Bladder Syndrome
- Perioperative Pain Management
Instructor, Anesthesiology, Perioperative and Pain Medicine
Residency:Cleveland Clinic Foundation Heart Center (2007) OH
Internship:Cleveland Clinic Foundation Heart Center (2007) OH
Board Certification: Anesthesiology, American Board of Anesthesiology (2010)
Fellowship:Stanford University Hospital - Pain Medicine (2010) CA
Residency:Stanford University Hospital - Anesthesia Dept (2009) CA
M.S., Stanford University, Epidemiology (2013)
Board Certification: Pain Medicine, American Board of Anesthesiology (2011)
Medical Education:Northeastern Ohio Universities (2005) OH
Current Research and Scholarly Interests
Perioperative Recovery of Opioids Mood and Pain Trial
Perioperative Recovery of Moods, Opioids, and Pain Trial (PROMPT)
The investigators aim to characterize the relationship between changes in emotional distress, opioid use, and pain throughout surgery and recovery. Additionally, the investigators aim to compare the effectiveness of post-surgical motivational interviewing and physician-guided opioid weaning vs. usual care on reducing persistent opioid use. Overall, the proposed research will advance knowledge regarding the role of psychological factors contributing to persistent opioid use after surgery.
Predictors of Daily Pain Medication Use in Individuals with Recurrent Back Pain
INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE
2018; 25 (2): 252–58
A key component to chronic pain management regimens is the use of analgesic medications. Psychological factors, such as mood states, may also affect the use of pain medications for individuals with chronic pain, but few observational studies have examined how these factors may predict pain medication use at the daily level.Daily assessments from 104 individuals with back pain were used to examine fluctuations in daily pain intensity, mood, sleep quality, and physical activity as predictors of the likelihood of pain medication (opioid and non-opioid) use and levels of medication use on the same day.Pain intensity and mood ratings significantly predicted whether participants used pain medication on the same day, while only pain intensity predicted whether participants used more medication than usual. Further, current opioid users were more likely to increase the amount of their medication use on days of higher pain.This article identifies fluctuations in daily pain intensity and mood as salient predictors of daily pain medication use in individuals with recurrent back pain. The current study is among the first to highlight both pain and mood states as predictors of daily pain medication use in individuals with back pain, though future studies may expand on these findings through the use of higher-resolution daily medication use variables.
View details for DOI 10.1007/s12529-017-9686-8
View details for Web of Science ID 000427632300012
View details for PubMedID 28875436
View details for PubMedCentralID PMC5837935
- Defining Postoperative Opioid Needs Among Preoperative Opioid Users. JAMA surgery 2018
Factors associated with prescription opioid misuse in a cross-sectional cohort of patients with chronic non-cancer pain
JOURNAL OF PAIN RESEARCH
2017; 10: 979-987
To examine demographic features, psychosocial characteristics, pain-specific behavioral factors, substance abuse history, sleep, and indicators of overall physical function as predictors of opioid misuse in patients presenting for new patient evaluation at a tertiary pain clinic.Overall, 625 patients with chronic non-cancer pain prospectively completed the Collaborative Health Outcomes Information Registry, assessing pain catastrophizing, National Institutes of Health Patient-Reported Outcomes Measurement Information System standardized measures (pain intensity, pain behavior, pain interference, physical function, sleep disturbance, sleep-related impairment, anger, depression, anxiety, and fatigue), and substance use history. Additional information regarding current opioid prescriptions and opioid misuse was examined through retrospective chart review.In all, 41 (6.6%) patients presented with some indication of prescription opioid misuse. In the final multivariable logistic regression model, those with a history of illicit drug use (odds ratio [OR] 5.45, 95% confidence interval [CI] 2.48-11.98, p<0.0001) and a current opioid prescription (OR 4.06, 95% CI 1.62-10.18, p=0.003) were at elevated risk for opioid misuse. Conversely, every 1-h increase in average hours of nightly sleep decreased the risk of opioid misuse by 20% (OR 0.80, 95% CI 0.66-0.97, p=0.02).These findings indicate the importance of considering substance use history, current opioid prescriptions, and sleep in universal screening of patients with chronic non-cancer pain for opioid misuse. Future work should target longitudinal studies to verify the causal relationships between these variables and subsequent opioid misuse.
View details for DOI 10.2147/JPR.S131979
View details for Web of Science ID 000400675500001
View details for PubMedID 28496354
Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic.
Anesthesia and analgesia
2017; 125 (5): 1733–40
Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.
View details for DOI 10.1213/ANE.0000000000002458
View details for PubMedID 29049117
Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial.
Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice.To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation.A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings.Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research.clinicaltrials.gov Identifier: NCT01067144.
View details for DOI 10.1001/jamasurg.2017.4915
View details for PubMedID 29238824
Opioid Abuse And Poisoning: Trends In Inpatient And Emergency Department Discharges.
Health affairs (Project Hope)
2017; 36 (10): 1748–53
Addressing the opioid epidemic is a national priority. We analyzed national trends in inpatient and emergency department (ED) discharges for opioid abuse, dependence, and poisoning using Healthcare Cost and Utilization Project data. Inpatient and ED discharge rates increased overall across the study period, but a decline was observed for prescription opioid-related discharges beginning in 2010, while a sharp increase in heroin-related discharges began in 2008.
View details for DOI 10.1377/hlthaff.2017.0260
View details for PubMedID 28971919
- Taking adolescent prescription opioid use in context: risk stratification in early mid-life based on medical and nonmedical use. Pain 2016; 157 (10): 2143-2144
- (139) Risk factors for long-term prescription opioid therapy for chronic non-cancer pain. journal of pain 2016; 17 (4S): S10-S11
- Pain Duration and Resolution following Surgery: An Inception Cohort Study PAIN MEDICINE 2015; 16 (12): 2386-2396
Pain Duration and Resolution following Surgery: An Inception Cohort Study.
2015; 16 (12): 2386-2396
Preoperative determinants of pain duration following surgery are poorly understood. We identified preoperative predictors of prolonged pain after surgery in a mixed surgical cohort.We conducted a prospective longitudinal study of patients undergoing mastectomy, lumpectomy, thoracotomy, total knee replacement, or total hip replacement. We measured preoperative psychological distress and substance use, and then measured pain and opioid use after surgery until patients reported the cessation of both opioid consumption and pain. The primary endpoint was time to opioid cessation, and those results have been previously reported. Here, we report preoperative determinants of time to pain resolution following surgery in Cox proportional hazards regression.Between January 2007 and April 2009, we enrolled 107 of 134 consecutively approached patients undergoing the aforementioned surgical procedures. In the final multivariate model, preoperative self-perceived risk of addiction predicted more prolonged pain. Unexpectedly, anxiety sensitivity predicted more rapid pain resolution after surgery. Each one-point increase (on a four point scale) of self-perceived risk of addiction was associated with a 38% (95% CI 3-61) reduction in the rate of pain resolution (P = 0.04). Furthermore, higher anxiety sensitivity was associated with an 89% (95% CI 23-190) increased rate of pain resolution (P = 0.004).Greater preoperative self-perceived risk of addiction, and lower anxiety sensitivity predicted a slower rate of pain resolution following surgery. Each of these factors was a better predictor of pain duration than preoperative depressive symptoms, post-traumatic stress disorder symptoms, past substance use, fear of pain, gender, age, preoperative pain, or preoperative opioid use.
View details for DOI 10.1111/pme.12842
View details for PubMedID 26179223
Management of a Patient with a Thoracic Epidural After Accidental Clopidogrel Administration.
A & A case reports
2015; 5 (2): 18-20
We report a case of accidental clopidogrel administration in a patient receiving ongoing epidural analgesia postoperatively. The epidural catheter was removed 7 hours after the clopidogrel dose without incident. The onset of inhibition of adenosine diphosphate-induced platelet aggregation in healthy individuals has been reported at 12 to 24 hours after administration of a single 75-mg dose of clopidogrel. This case demonstrates the importance of understanding clopidogrel's pharmacology to avoid ordering unnecessary tests, which may delay catheter removal. Consideration of appropriate testing and limitations in the context of unintentional antiplatelet administration with indwelling neuraxial catheters is discussed.
View details for DOI 10.1213/XAA.0000000000000165
View details for PubMedID 26171737
- A Review of Chronic Non-Cancer Pain: Epidemiology, Assessment, Treatment, and Future Needs FOCUS: Journal of Lifelong Learning in Psychiatry 2015; 13 (3): 267-282
Factors Associated with Opioid Use in a Cohort of Patients Presenting for Surgery.
Pain research and treatment
2015; 2015: 829696-?
Objectives. Patients taking opioids prior to surgery experience prolonged postoperative opioid use, worse clinical outcomes, increased pain, and more postoperative complications. We aimed to compare preoperative opioid users to their opioid naïve counterparts to identify differences in baseline characteristics. Methods. 107 patients presenting for thoracotomy, total knee replacement, total hip replacement, radical mastectomy, and lumpectomy were investigated in a cross-sectional study to characterize the associations between measures of pain, substance use, abuse, addiction, sleep, and psychological measures (depressive symptoms, Posttraumatic Stress Disorder symptoms, somatic fear and anxiety, and fear of pain) with opioid use. Results. Every 9-point increase in the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) score was associated with 2.37 (95% CI 1.29-4.32) increased odds of preoperative opioid use (p = 0.0005). The SOAPP-R score was also associated with 3.02 (95% CI 1.36-6.70) increased odds of illicit preoperative opioid use (p = 0.007). Also, every 4-point increase in baseline pain at the future surgical site was associated with 2.85 (95% CI 1.12-7.27) increased odds of legitimate preoperative opioid use (p = 0.03). Discussion. Patients presenting with preoperative opioid use have higher SOAPP-R scores potentially indicating an increased risk for opioid misuse after surgery. In addition, legitimate preoperative opioid use is associated with preexisting pain.
View details for DOI 10.1155/2015/829696
View details for PubMedID 26881072
- Self-Loathing Aspects of Depression Reduce Postoperative Opioid Cessation Rate PAIN MEDICINE 2014; 15 (6): 954-964
From Catastrophizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing
JOURNAL OF PAIN RESEARCH
2014; 7: 219-226
Pain catastrophizing (PC) - a pattern of negative cognitive-emotional responses to real or anticipated pain - maintains chronic pain and undermines medical treatments. Standard PC treatment involves multiple sessions of cognitive behavioral therapy. To provide efficient treatment, we developed a single-session, 2-hour class that solely treats PC entitled "From Catastrophizing to Recovery" [FCR].To determine 1) feasibility of FCR; 2) participant ratings for acceptability, understandability, satisfaction, and likelihood to use the information learned; and 3) preliminary efficacy of FCR for reducing PC.Uncontrolled prospective pilot trial with a retrospective chart and database review component. Seventy-six patients receiving care at an outpatient pain clinic (the Stanford Pain Management Center) attended the class as free treatment and 70 attendees completed and returned an anonymous survey immediately post-class. The Pain Catastrophizing Scale (PCS) was administered at class check-in (baseline) and at 2, and 4 weeks post-treatment. Within subjects repeated measures analysis of variance (ANOVA) with Student's t-test contrasts were used to compare scores across time points.All attendees who completed a baseline PCS were included as study participants (N=57; F=82%; mean age =50.2 years); PCS was completed by 46 participants at week 2 and 35 participants at week 4. Participants had significantly reduced PC at both time points (P<0001) and large effect sizes were found (Cohen's d=0.85 and d=1.15).Preliminary data suggest that FCR is an acceptable and effective treatment for PC. Larger, controlled studies of longer duration are needed to determine durability of response, factors contributing to response, and the impact on pain, function and quality of life.
View details for DOI 10.2147/JPR.S62329
View details for Web of Science ID 000364587600005
View details for PubMedID 24851056
View details for PubMedCentralID PMC4008292
Pilot study of a compassion meditation intervention in chronic pain.
Journal of compassionate health care
The emergence of anger as an important predictor of chronic pain outcomes suggests that treatments that target anger may be particularly useful within the context of chronic pain. Eastern traditions prescribe compassion cultivation to treat persistent anger. Compassion cultivation has been shown to influence emotional processing and reduce negativity bias in the contexts of emotional and physical discomfort, thus suggesting it may be beneficial as a dual treatment for pain and anger. Our objective was to conduct a pilot study of a 9-week group compassion cultivation intervention in chronic pain to examine its effect on pain severity, anger, pain acceptance and pain-related interference. We also aimed to describe observer ratings provided by patients' significant others and secondary effects of the intervention.Pilot clinical trial with repeated measures design that included a within-subjects wait-list control period. Twelve chronic pain patients completed the intervention (F= 10). Data were collected from patients at enrollment, treatment baseline and post-treatment; participant significant others contributed data at the enrollment and post-treatment time points.In this predominantly female sample, patients had significantly reduced pain severity and anger and increased pain acceptance at post-treatment compared to treatment baseline. Significant other qualitative data corroborated patient reports for reductions in pain severity and anger.Compassion meditation may be a useful adjunctive treatment for reducing pain severity and anger, and for increasing chronic pain acceptance. Patient reported reductions in anger were corroborated by their significant others. The significant other corroborations offer a novel contribution to the literature and highlight the observable emotional and behavioral changes in the patient participants that occurred following the compassion intervention. Future studies may further examine how anger reductions impact relationships with self and others within the context of chronic pain.
View details for PubMedID 27499883
View details for PubMedCentralID PMC4972045
- Pilot Study of a Compassion Meditation Intervention in Chronic Pain Journal of Compassionate Health Care 2014; 1: 4
- Perioperative Interventions to Reduce Chronic Postsurgical Pain JOURNAL OF RECONSTRUCTIVE MICROSURGERY 2013; 29 (4): 213-222
Exploratory factor analysis of the beck depression inventory: predictors of delayed opioid cessation after surgery in a pilot cohort study
CHURCHILL LIVINGSTONE. 2013: S25–S25
View details for Web of Science ID 000317639400100
Analysis of preoperative measures that predict interference with sleep recovery after surgery
CHURCHILL LIVINGSTONE. 2013: S19–S19
View details for Web of Science ID 000317639400076
- Local Anesthetics and Other Interventional Approaches Neuropathic Pain: Causes, Management and Understanding Cambridge University Press. 2013
Factors contributing to pain chronicity
CURRENT PAIN AND HEADACHE REPORTS
2009; 13 (1): 7-11
The chronicity of pain is the feature of pain that is least understood and most directly linked with our inability to effectively manage pain. Acute pain is relatively responsive to our current pharmacologic and interventional armamentarium. However, as pain persists, our ability to treat effectively diminishes and the patient's frustration and resource utilization increases. This article explores our current understanding of the factors linked to pain duration and the transition from acute to chronic pain in both human and animal models, and across a spectrum of human chronic pain conditions.
View details for DOI 10.1007/s11916-009-0003-3
View details for Web of Science ID 000263064900003
View details for PubMedID 19126364
- The dromedary sign - An unusual capnograph tracing ANESTHESIOLOGY 2008; 109 (1): 149-150