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Interview with Dr. George Pasvankas: Managing Pain from Shingles

Shingles, a viral infection of the nerve roots caused by the chickenpox virus, can sometimes lead to a painful complication called post-herpetic neuralgia. The burning pain of this condition can be severe, even interfering with appetite and sleep.

Hear pain management specialist Dr. George Pasvankas at UCSF Medical Center explain the latest treatment options for shingles, including a new skin patch that contains capsaicin, a hot-pepper compound that's found in jalapenos.

Interview Transcript

Introduction

Andrew Schorr:

Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr.

Pain can be debilitating, and it can be caused by all sorts of things. One cause that many people are not familiar with is a reactivation of chickenpox you may have had as a child. You don't have chickenpox again, but you have another condition called shingles, known as postherpetic neuralgia pain. I understand it affects about 1 million people in America a year.

I suffered it, briefly, fortunately, because it can be very severe, when I was going through cancer therapy in my late 40s. This can happen to people with weakened immune systems. It also happens as people get older, so we're going to learn all about that and what treatments are available that can help.

Our guest is Dr. George Pasvankas. He's an anesthesiologist who specializes in pain management at the UCSF Pain Management Center. Doctor, am I right, about a million people a year have this reactivation?

Dr. George Pasvankas:

That's correct. The estimate is an incidence of about a million for reactivation of the chickenpox virus in terms of causing cases of shingles, and the estimate is that about 10 to 20 percent of those people will have to some degree the complication of postherpetic neuralgia, which is the maintenance of that pain problem into a chronic state rather than it just resolving and working its way out as an acute problem.

Andrew Schorr:

First of all, what's the connection with chickenpox? So, many of us have had it as children, and then we thought that that's the end of it. What's happened?

Dr. George Pasvankas:

It can be quite dismaying to patients to all of a sudden have a pain problem and have it traced back when they have their conversation with their doctor to an episode of childhood chickenpox which may have happened 50 or 60 years before. But essentially while the clinical problems from chickenpox clear up at that time the virus itself never really completely leaves the body. It sort of lies in a dormant state in the nervous system, sitting around, waiting.

In some people it never becomes an issue again, but, as you point out, whether it is age or debility or other medical problems or treatments for those medical problems, some people have the unfortunate circumstance where that virus sort of rears its ugly head again and causes an outbreak of shingles.

Andrew Schorr:

So is it an inflammation of like a nerve root? Is that what it is?

Dr. George Pasvankas:

Essentially, it's a reactivation of the virus along one of the nerve roots, and inflammation is certainly one of the processes that's going on at that point in time that causes pain in that distribution.

Andrew Schorr:

What are the symptoms of shingles?

Dr. George Pasvankas:

It can depend on the individual person. Some people will — before it progresses to a frank painful problem — just start to notice something a little bit off in a sort of single pattern area of the body, and often that's just a clue for people that they're seeing it in such a kind of a cutout or geographic distribution of an area. It can start just with noticing that you don't quite feel things right in that area. The area can just feel a little bit more sensitive if you're brushing over it or putting your clothes on or maybe sensitivity to temperature or something along those lines.

For some people, the first thing they notice is the rash that tends to come up in that area. For other people, it will really be a frankly painful sensation in that area as the first thing they notice.

Andrew Schorr:

When you say "rash," what does it look like? We've all had poison ivy as a kid.

Dr. George Pasvankas:

Like many rashes, the first thing somebody may just notice is a color change and a reddening in that area, but typically it will progress to what we call a vesicular rash, which is small eruptions that if it progresses, can become sort of weeping and crusted over and can even leave some permanent discoloration or marking.

Andrew Schorr:

Now, would this be in straight line, almost like there's a nerve highway underneath, and it's just like a straight line typically?

Dr. George Pasvankas:

That's exactly how it will appear for people. That highway, as you put it, could be going in many different directions, depending on where that particular nerve root happens to be in the body. For some people, it can be on the face and affect one particular distribution of the face. Often, it will run across a shoulder or down an arm. In the chest area, it will usually run a pattern that circles along the chest wall horizontally, or could run in a pattern for example down towards the groin or down towards the leg.

Andrew Schorr:

Now, as I was in some cancer treatment years ago receiving some pretty heavy-duty medicines and certainly my immune system was weakened both from the cancer or even from the drugs trying to fight the cancer, I noticed one day sitting at lunch with a friend that I had a sensitivity in a straight line down the left side of my chest. And in mentioning it to this friend, who happened to be a physician, he said sounds like shingles to me, and I was put on an antiviral. We'll talk about that in a minute. Is that sensitivity what you're talking about? It could be just as subtle as that? Because I'd never experienced anything like that before.

Dr. George Pasvankas:

It can absolutely be as subtle as that. Again, for some people it will depend on the order of things. Some people will have the symptoms before the rash, some people will have the rash before the symptoms. I would say in your particular circumstance, you'd call it lucky that you had a vague sense and a sensitivity there before you ended up with a full-blown rash eruption or what sounds like a full-blown really neurologic pain going on.

Early Treatment With Antivirals

Andrew Schorr:

Now, that physician, a primary care doctor, prescribed an antiviral medicine. A lot of us are used to the fact that when you're told you have a virus like a cold or something like that, they say, "It's a virus, there's nothing we can do." But you do have some antivirals that can help with this, right?

Dr. George Pasvankas:

That's correct. Most of these patients are presenting to their primary care physicians or to urgent care centers or emergency rooms perhaps more than they're presenting to a pain management doctor, but the tendency for certain, since this is a circumstance where we know that this can progress to cause a chronic problem like this, and since it is a circumstance where we do have a medication that's effective against this particular virus, that most patients will be treated from the outset with an antiviral medication if it's caught early.

Andrew Schorr:

Let's talk about early. So for somebody like me who got this early warning sign or somebody who started to see a rash, getting medical attention quickly is important. Otherwise, how severe the pain can be?

Dr. George Pasvankas:

I think it's very important to get started on treating the discomfort and treating the underlying problem as early as possible.

Andrew Schorr:

So antivirals, do they always work?

Dr. George Pasvankas:

I think like any treatment, it's variable, and I think in particular what we have to think about is we don't know for certain that you can catch the process at this exact point in time and prevent it from becoming X amount of pain or reduce the chances that it's going to become a chronic pain problem by Y amount or something along those lines.

I would put it more broadly into the picture of it's important to start treating it early, and anything that we can point to would tell us that the earlier is better and whatever effect you are able to get from it by treating it early is better. Unfortunately, we can't say that there's a particular cutoff or a particular level of efficacy that's going to prevent this particular pain problem.

Andrew Schorr:

A couple of things before we go on to other treatments. I know pain — perception of pain — varies by people. Pain doctors often say, "On a scale of one to 10, 10 being the worst pain you've ever had. What kind of numbers do people give you related to shingles pain?

Dr. George Pasvankas:

We do a lot of after-the-fact talking with people about what was going on during their initial phase of things since we're mostly seeing people with the chronic problem, and we'll have people tell us that it is among the most difficult and painful things that they've gone through. There's something about the neurologic character of this pain that's so burning, so intense and so electric shooting that it tends to get high pain scores.

I think there's that hypersensitivity. As opposed to a pain that's maybe severe but going on somewhere where there's not a lot external that's making it worse, this is something where simple things like showers or socks or clothes or just somebody bumping into them by accident can really cause things to go off the charts. So it's absolutely possible to see numbers up at the top of the pain scale for the acute events, and even for the worst cases of chronic ones.

Andrew Schorr:

Let's talk about chronic shingles. People may have seen their primary care doctor but now you say there is a percentage of the time when it becomes chronic, and I imagine they get referred to a center such as yours, the UCSF Pain Management Center, and a specialist such as you. What's going on when it becomes chronic? What does that mean?

Dr. George Pasvankas:

Well, that's a great question. Just the simple definition of when does a pain problem become a chronic pain problem has its own large debate and its own investigation. Certainly, as we talked about, the expectation is that the disease process should run its course. After the reactivation of the virus runs its course and goes away, the pain problem should typically wind its way down as well, and in a span of weeks to a month or a month and change, similarly disappear.

When do we have a chronic pain problem that hasn't resolved appropriately? Certainly when you're looking at, I'd say, six months to a year, everybody is in agreement you're really looking at a problem that's probably unlikely to fully resolve on its own and stay a chronic pain problem. And then somewhere in between, there is a bit of a gray area, and I think that's an area where sometimes people are maybe under-treated or under-referred in terms of trying to get on top of whether or not this is becoming a chronic pain problem at that point.

Capsaicin Pain Patch

Andrew Schorr:

So they come see you. Obviously, you have a range of approaches, but I understand there's one particular approach, and I mentioned it at the beginning, that's connected with jalapeno peppers. Tell us about that, about how to treat this when it become chronic like this. Why particularly in older people who may be taking a number of other medicines, this is particular helpful.

Dr. George Pasvankas:

Well, there's a storied history, particularly involving UCSF, about the investigation of what this hot substance in chili peppers is and on a chemical level and neurological level, what it is that's going on behind that, which is obviously a little bit out of the scope of today's discussion. But as it turns out, there are receptors on the small nerves, essentially the ones that are most peripheral in the body, there at the skin and just underneath the skin, that are helping to sense pain problems. One particular receptor, one way that these things are activated is by this substance that's naturally found in chili peppers which naturally gives them their heat.

As it turns out, unlike a lot of other circumstances in medicine where we're trying to block a certain pain transmission or block a certain problem, we're using this substance to do the opposite. This substance will turn on that receptor. But the hope is that turning it on in a high fashion and a long fashion as we're doing with this type of treatment, you almost — and the pun is intended-— you almost burn out these nerves from being able to do their job.

There's evidence that by doing that over time, you have a decrease in the number of nerves and receptors that are able to carry these pain problems.

Andrew Schorr:

What is the substance called, by the way?

Dr. Pasvankas:

The substance is called capsaicin. It's something that's been around for some time. We've had topical treatments for capsaicin for quite some time, but the difficulty is that they were sort of nonprescription strength, so they were a much more mild strength. They required repetitive application by patients, and there were lots of things that go along with that.

So the chronic, low level of discomfort from applying it because it does activate it when it's first put on, and the slightly annoying nature of having to chronically put on a cream or a gel, especially in some of the areas where people will have these problems, has really been a limitation in the past.

Andrew Schorr:

What is the medicine called?

Dr. George Pasvankas:

The brand name for this patch is called the Qutenza patch. What it basically is capsaicin 8 percent, and so it's a much stronger concentration of this than any of the topicals that people would have been able to put on for such a problem in the past when it was suggested.

Andrew Schorr:

And why particularly in older people who may be on other oral medicines or cancer therapies, whatever it may be, why is a topical patch desirable?

Dr. George Pasvankas:

It's something of a Holy Grail for physicians. When we find a pain problem that can be treated with a topical medication, we're quite excited because firstly, the medications that we're often using for pain otherwise are not particularly targeted to some of these pain problems. I don't mean to say that's always the case, but a lot of times it's just throwing one after another of somewhat nonspecific medicines, whether they're opioid painkiller medicines or what we would describe as neuropathic pain medicines which can be antidepressants that are being co-opted for other uses or anti-seizure medicines being co-opted for other uses.

You're just adding layer after layer of medications that are being exposed to the body systemically. That has a lot of side effects. They interact with one another, they interact with other medications that patients are on, and they interact with other problems that the patient might be having in general if it's debility or memory impairment, or balance difficulty, all these sorts of things.

Andrew Schorr:

So you don't want to give them a red pill to go with the green pill to go with the blue pill.

Dr. George Pasvankas:

Exactly.

Andrew Schorr:

What''s your experience as far as helping people now with these tools you have, this included, where shingles pain has become chronic? Is there hope for relief?

Dr. George Pasvankas:

There certainly is. One of the things patients are always most interested in when they come in and they have a problem at this point that somebody has said, "Oh, I think you need to see a pain doctor. This is a chronic problem. I'm not sure this is going go away." They may talk about a lot of other things during the visit, but one of the things that's on the forefront of their mind really is "Will this go away?" or, "How will I be able to live with this?"

Sometimes it's a little bit discouraging not to be able to give them a concrete answer from the outset that says I can cure this or I will fix this, but I feel very confident letting people know that, especially at the juncture that we're at right now and the number of tools we have available to us.

We have a lot of things we can work on to potentially bring their pain problem to something that's no longer an issue at all for them, where it's a lot more manageable and their quality of life and their functional status is a lot improved.

Getting the Best Care

Andrew Schorr:

If someone has been suffering and went to their primary care doctor but they're still suffering. heir quality of life is limited or putting on clothes or somebody bumping into them or whatever it is, but this shingles problem is not going away, that's when seeing a pain specialist such as you makes sense.

Dr. George Pasvankas:

That's when patients usually come across our radar. They've been on the acute treatment for the outbreak and pain medications to get them over that hump. Many of them, depending on who it is that they're seeing and what their background is, will have already been started before they come to see us on maybe continued treatment with opioid pain medications. Maybe a long-acting one has been added in, maybe they've been tried on a few of the neuropathic or nerve pain medications we've talked about, but generally at that point we're being asked to get involved to bring in second- and third- line measures, consider other procedures, things along that line.

Andrew Schorr:

So if someone has a shingles outbreak, should they despair that there's another shoe that's going to drop a year or two years, five years down the road, and they're destined to have this again and again? And I don't mean the people in the chronic category. But for me, it happened once, I never want to see it again. Should I worry? Could there be another reactivation?

Dr. George Pasvankas:

There could be another reactivation. But as we move into a better era of treatment with regards to vaccination, a lot of people can look into with their primary doctors to help reduce the likelihood that this will be an issue in the future. I think a lot of those patients will be better educatedr, know what to expect, and if they do have a problem again, they'll be very seeking care for it and getting on top of it early.

Andrew Schorr:

Okay. So really we're at, as you said, a better point now in trying to control shingles pain or what you call postherpetic neuralgia pain, and that's a good thing.

Dr. George Pasvankas:

Absolutely, it's a good thing. Even when drug therapies are failing I think we're becoming more and more advanced with our pain management techniques for the more difficult patients, be that other interventional techniques, implanted devices. There's really a whole world of pain treatment options that I think a lot of patients and a number of their referring physicians don't necessarily know about when they're in the early stages of treating some of these most difficult pain cases.

Andrew Schorr:

There you go. Well, certainly if someone is suffering from pain, connecting with a specialist like Dr. Pasvankas makes sense. Thank you so much for being with us, Dr. George Pasvankas of the UCSF Pain Management Center. We appreciate you being with us.

Dr. George Pasvankas:

It's been a pleasure talking. Thank you.

Recorded July 2011

 

Reviewed by health care specialists at UCSF Medical Center.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

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