Neurosurgeon at Presbyterian/St. Luke’s Medical Center in Denver, Colorado, Giancarlo Barolat, MD, talks about technology that can replace opioids for pain relief.
Interview conducted by Ivanhoe Broadcast News in 2023.
Let’s start with Malia, tell us about Malia when you met her, what brought her to you?
Barolat: Malia is a delightful lady who unfortunately in 2009, was involved in a terrible car accident. She shattered her body from the waist down, she broke both legs, and the pelvis, and her injuries were so severe that they were considering amputation. In fact, one foot, was almost amputated by the injury, and they were able to put it back together. She had terrible injuries, and many surgeries, was in the hospital for months, and then finally she came out of all that, but had developed this terrible pain in the left leg. The pain was unbelievably excruciating and it had ruined her life. She went down the route of narcotic medications, which is the route that most doctors will put these patients through these days. She became addicted, and that also caused additional issues with her life. Then at some point, her pain was so bad in the left leg that she considered having the leg cut off because she thought she was better off without the leg than having so much pain. She went as she consulted to have the leg cut off and she was told, that if they cut the leg, there was no guarantee that the pain would go away, and so you might end up stuck with not having the leg, and still having the same severe pain, which would be a different pain. It would be what we call phantom limb pain, but still, it’s a pain that can be just as incapacitating and just as severe. She was in a very dark place in her life. She had terrible excruciating pain, she could not function, she was addicted to narcotics, and she had no future. She was then referred to me to see whether I thought that there were other options that could improve her life without having to amputate the leg. I thought that she would be an excellent candidate for what we called spinal cord stimulation. That’s a modality where we actually implant a pacemaker device in the nervous system to try to stop the pain signals from reaching the brain. We discussed that and she was in full agreement with it. She would have tried anything really to get rid of her pain, so we did a test to see whether that would have worked for her, and it worked like magic. In 2012, I implanted an electrode in the spine, and then that was connected to a pacemaker that was placed in her Buttock. She started using the device, and the device gave her almost complete relief from her pain. She was able to avoid the amputation, get rid of all the narcotics, and get back to a productive life. I don’t know if she would be alive today if I hadn’t done that procedure. Now she’s full of life and when I saw her first, she was a derelict.
Do most of your patients come to you with very little hope?
Barolat: Correct.
What is that like? It must be so difficult to see people in this dark place.
Barolat: It is difficult, and it’s inspiring because there’s a lot of good that you can do to people. A lot of people that I see, either have tried or have considered suicide. I have a few patients that come to me, and they say, “if this doesn’t work, I don’t think I want to live, because I don’t want to live with this pain every day, because it’s like being tortured every day.” Unfortunately, for a lot of these patients, it causes a lot of disruption in their families, and it becomes an issue of not just having the pain, but not having a support system. Some of these patients’ additional issue is that people don’t believe them. Not only do they have this terrible pain, but they don’t get any sympathy. That puts them in a very dark place.
And many of them have gone down the path like Malia, using narcotics to curb that pain. Given there’s so much attention on that epidemic, can you talk a little bit about how common that is? How many of your patients also use opioids and how does that contribute to the epidemic?
Barolat: Most of the patients that I see are on opioids. For some patients, the push to come and see me is to get rid of the opioids. Opioids are, for a very small percentage of patients, a good thing, but for most people, they are terrible things. When you have chronic pain, and now you’re addicted to opioids, you start with one problem, pain, and then you have another problem, addiction to opioids. Also, when you are on high doses of opioids for a long time, it can make your pain worse. Some people get terrible migraines from opioids. We know that when we operate on people who are on opioids, it’s almost impossible to control their pain after the surgery. If they go and get another operation, their pain might be out of control because they’re already on high doses of opioids and the doctors will not give them any more opioids, otherwise, they kill them. They suffer a lot more, so opioids cause a lot of problems socially, psychologically, and physically. Whatever we can do to reduce them is very welcome.
Including neurostimulation?
Barolat: And neurostimulation.
Talk to us about what that option is, how it works, what’s implanted.
Barolat: The nervous system is like an electrical system. Pain is like an electrical short in the nervous system. The nervous system sends alarm signals all the time, even when there is no need to. Chronic pain does not serve any purpose, is just there to torture you. With the stimulator, these devices that we implant on the nervous system, we can stop the pain signals. We’re introducing a signal on top of a bad signal. Somehow, we’re able to either interrupt or change that signal so that when it reaches the brain, it is not perceived as pain. The person might feel a tingling, but no pain. There are some pain conditions where even just the slightest touch causes unbelievable pain. In fact, some of these patients come in and the first thing they do is look where the air conditioning vents are because the air from the ceiling will trigger terrible pain. We put the stimulator on, and many patients have no pain. Sometimes we turn it on within a few seconds and they can touch their hand and have no pain.
The effect can be that immediate?
Barolat: Not always, but they can be. There are some conditions where the effects can be that immediate. The patients themselves can’t believe it.
Do you have the neurostimulator for the rest of your life presumably? What is the long-term maintenance like?
Barolat: I had a patient a couple of weeks ago that I replaced the battery of the stimulator who’s had it in for 30 years, and it’s been how he controls his pain for 30 years. I had a patient yesterday, a young woman, that I put a stimulator on when she was 17, and she’s now 30. The stimulator is made of an electrode and a pacemaker and the pacemaker contains a lithium battery, just like your iPhone, and contains the electronics. The lithium batteries will deplete roughly every 12 years. Every 12 years, you have to have a small procedure. It’s an outpatient 20-minute procedure where you replace the unit. You open where it is, you have a little screwdriver, and you unscrew the battery from the thing, and then you plug a new one in and you’re good to go.
Who is a good candidate for this?
Barolat: Anybody who has pain that has lasted for more than six months and has not responded to various treatments could be a candidate for this. It depends and there are many types of pains that respond starting from the top. One could be headaches. I see a lot of young women with terrible headaches. We put on these devices, and many times their headaches are cured.
There are a lot of patients that have had spine surgery. For instance, surgery on their neck, and surgery on their lumbar spine, and they continue to have a lot of pain. Either pain in the back or in the neck, or pain going down the arms or the legs, and there is no more surgery that can be done. Those would be very good candidates for that. People who have nerve injury, pain, or trauma like Malia, or people that have had surgeries. Patients who have diabetes; can have intractable pain in their feet. Diabetic neuropathy, all kinds of pains.
Who is not a good patient or a good candidate?
Barolat: Somebody whose pain can be cured. If somebody has a condition where you can fix the problem and cure the condition, then that’s not a good candidate. That should be treated otherwise. Somebody who has had pain for less than six months, because you want to make sure that the pain is permanent before you do any of this. Then somebody who has a lot of psychological instability might not be a candidate for that. We have everybody that we consider for this modality be screened by a psychologist. That’s no different than many other treatments today, including bariatric surgery, for people who are overweight. There’s a lot of these long-term conditions where you want to make sure that the patient is stable enough to work with you because it’s not a one-time thing, it’s an ongoing thing. If the patient is not going to be able to come back for follow-up, he’s not a candidate because it’s not a one-time thing. You must work with them. If patients cannot guarantee follow-up, they’re not candidates for this. If patients are on blood thinners, they might or might not be candidates for this. Then if people have frequent infections because you’re implanting a device, you’re implanting a foreign body, and if you have a predisposition to get infections, they will probably get infected. The pain has to be severe. If somebody has just a little pain, they’re not a candidate for this. Pain has to be incapacitating.
Why don’t we hear about it more?
Barolat: It is being used more frequently. When I started doing this 40 years ago, really, I was one of the first, and there were not many people. Today there are many more people doing this, but it’s an expensive modality. Insurance companies make you go through several hoops before they approve that. A lot of people don’t like the idea of something being planted in their bodies. Some people don’t want something implanted in their body. But if your pain is bad enough, most people will overcome that limitation and we’ll consider that, and it is becoming more and more popular.
What do you wish the patients knew?
Barolat: I would say one of the most common things that my patients ask is “Why didn’t they refer me to you five years ago, ten years ago? I would have not gone through all the suffering that I have had if I met you five years ago; I would have not had 20 surgeries that didn’t do anything for me.” I think refer patients to at least be evaluated. Not everybody is a candidate for this, but there are a lot of patients out there who would benefit from this but are not being referred for it. That’s just the way it is.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Stephanie Sullivan
Stephanie.sullivan@HealthONEcares.com
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
