Pain Specialist Neel Mehta, MD - 2019 Low Dose Naltrexone (LDN)

Linda Elsegood: Today, my guest is Dr Neil Metta from New York. He's a pain specialist. And all the different things he's done are absolutely amazing. Thank you for joining us today. 

Neel Metha, MD: Thank you, Linda, for having me. This is a real pleasure. 

Linda Elsegood: So could you tell our listeners, what experience you've gained so far in the pain field?

Neel Metha, MD: Well,  I think it'd be helpful to have a little bit of background about me and understand why I've chosen this line of work. I am an anesthesiologist by training and  have gone on to do fellowship training in pain management. During my time in medical school, I was fascinated by anesthesiology and orthopaedics and had a real hard time trying to decide how I'd go forward in my career.

I ended up choosing anesthesiology for a number of reasons. During my training in anesthesiology, I had the fortune of working in a great pain management centre here at Weill Cornell. And I  learned a lot about the suffering of patients and of the limited options that we had.  I also had some time in the obstetric ward to treat women in labour and suffering from pain and saw how we had great options for them. So I saw a lot of potential.  I ended up choosing to do pain management because I thought it gave me an aspect of treating a broader range of patients rather than just women in labour. When I came out, I still was amazed that other than some nerve blocks, and some various medications that had been around for years, such as Gabapentin and Lyrica and traditional opioids, there really weren't any other novel ways to treat pain.  I was always sorting out, questing and thirsty for new and better ways that were safer and, and had fewer side effects, and really trying to minimize opioids even before this opioid crisis existed. The opportunity to do that has really been a lifelong goal and continues to drive how I work in research here.

Linda Elsegood: Well. I'm sure the ladies who were in labour really appreciated your help having been there myself. It is called labour for a reason, isn't it? 

Neel Metha, MD: The gratification that you got almost instantaneously was so rewarding. And I do miss that aspect. But now I get to treat both sexes. 

Linda Elsegood: Yes.  A question I'd like to ask. It’s been many years since I had my children and epidurals were the main thing for pain in those days. What options are there now? 

Neel Metha, MD:  So epidurals still remain the mainstay of traditional labour. But the cocktail using those epidurals has evolved. So the idea of being numb from the waist down really has, has been eliminated. And now you have what we call walking epidurals where patients can actually ambulate during their time before they're in active labour and pushing. We are trying to minimize the number of opioids that we use as well by doing things like combined spinal epidurals that allow sort of more instantaneous pain relief if someone has progressed a little bit further in labour and then have an epidural to back it up. And then the most headway's been done in C-sections where the surgical techniques have really sort of stayed the same.

But the anaesthetic techniques have improved. So using fewer opioids, doing things like transverse abdominal pain blocks, nerve blocks of the abdominal area muscles, and also realizing just how much opioid is needed and using multimodal therapy, you can almost eliminate the number of opioids. So some of my colleagues have done tremendous work where they have been able to actually cut down on the number of days that someone has to stay in the hospital just for pain, and that has made real improvement, both for the quality and cost of healthcare-related to having a baby.

Linda Elsegood: Wow. It's amazing. So now you treat both genders. Do you treat children as well, or are you just an adult physician? 

Neel Metha, MD:  I do treat children. I generally start at around age six, although the mainstay of my care is, is adult. Just recently I have had the good fortune of recruiting a great colleague,  who actually did training with me, but then was working elsewhere, and her name is Dr. Veronica Kuru Lo. And she's an anesthesiologist and a specialist in pediatric pain. So she is now our new director of pediatric pain management at Cornell, and a really unique opportunity, the only one of its kind in New York City, to have multimodal pain management therapy for paediatrics, both on an inpatient and outpatient basis.

Linda Elsegood: I myself have MS, and I used to have very bad pins and needles and very painful numbness, and people used to say about pain, I haven't got pain, but I've just got this really bad pins and needles. And then one day somebody said, well, isn't that painful? Well, yes, but I wasn't classed as pain per se, but sort of fake pain, you know, pins and needles,  but anyway, what kind of pain do you treat? Many autoimmune diseases have pain in different forms. You know, it can be a dermatological pain. It can be a fibromyalgia type pain, or an MS pain, or these pins and needles. You know, what do people present to you? What kind of pain?

Neel Metha, MD: Well, working in an academic medical centre, essentially a tertiary care centre, we see the full spectrum of pain. So the majority of my cases are going to be spine and musculoskeletal related conditions. Things like nerve-related pains due to disc herniation or sciatica in lay term or spinal stenosis or osteoarthritis of the joints, whether it be spinal joints or hips and knees and ankles. But also we treat headaches. We treat neuropathic conditions like shingles and trigeminal neuralgia, postherpetic neuralgia, postsurgical pain conditions like post-laminectomy syndrome, you know, failed surgeries for the spine that continued to have neuropathic pain or post breast mastectomy surgeries that lead to chronic pain.

Also, the things you've mentioned, like MS and fibromyalgia, so really a potpourri of conditions and the symptoms range from as simple as an ache as you've mentioned, could be paresthesias or pins and needles. It could be a burning electrical type of pain. And often, we use the description of the pain from the patient to help us focus on what is the underlying dose diagnosis and what's the underlying treatment for this particular condition. It helps us tease out just how much is coming from one condition versus another because as you know, you could have a diagnosis of MS. But also have a disc herniation. And trying to differentiate the two causes and how you would treat them may differ quite significantly. Finally, we do a lot of cancer-related pain as well, whether it is active cancer and things like a tumour, or compression of a nerve or tumour burden.

 

Also, metastatic disease to the bone, end of life care, also the survivors that have had trouble with treatment-related causes of pain such as post-chemotherapy or post-radiation-related neuropathies or postsurgical-related pains. We’re trying to help them regain their life. What's been a new phenomenon is we have always been very aggressive with opioids in the cancer population because we feel they're suffering and may have little time left, but now we've been able to successfully treat so many patients in modern-day medicine that they survive, but now have the potential for opioid addiction. And how do we help those patients come down off of medication and regain their functional lives again? The question is how do we classify pain?

It's often a real story that's developing as the patient is talking to us as we examine them, as we gather information and interpret results, and then make a little bit of systematic trial and error of treatment. Often this is a shared decision, you know, medical process with the patient. Because some may have thoughts on how they want to proceed and just how aggressively or what types of treatment they'd be open to. Some may only want to do things like acupuncture and physical therapy, which we offer, and some may say, I've been living with this for a long time. I want to be as aggressive as possible to treat this as quickly as we can. And that may require things like implantable devices or other types of treatments. 

Linda Elsegood: Do you treat Phantom limb pain?

Neel Metha, MD: Very much so,  Phantom limb pain, obviously in post-trauma, related conditions or even amputations from diabetic neuropathies or poor vascular conditions. Certainly, we have seen our fair share of those patients.

Linda Elsegood: When did you first hear about LDN? Was that during your training? 

Neel Metha, MD: It actually was after my training. I met some colleagues that have presented at the LDN conference, such as Chopra and Dr Samia, Dave Daddo. And they're great colleagues who have been visionaries in pain management. I know that they've been using LDN for a long time in the complex regional pain syndrome. And as I started to research the drug more and more, I realized how little was known in the pain community. And then shortly afterwards, we started to see some good papers coming out, such as the work done by Sean Mackey out in Stanford for fibromyalgia.And then also meeting some doctors, older physicians that knew about combination LDN and an opioid therapy to try to prevent  addiction and increase the strength of the medication—so learning a little bit from history about the drug.  As  I've read more and discovered more about it,my trainees have learned and enthusiastically tried to understand what it is and have really adopted it and use it in their practices, often differentiating themselves from a lot of other physicians and, seeing how it positions themselves to be more comprehensive in their treatment.

Linda Elsegood: So how long have you been prescribing it yourself? 

Neel Metha, MD: I have probably been prescribing about five years now, maybe a little bit over that. And the rate of usage has gone up significantly. What I am most fascinated by now is the wide variety of dosing that is being utilized. I think most recently a lot of people who have adopted the use of LDN have sort of based it on the papers that have come out of Stanford using a range of one milligram to four and a half milligrams. But we realized that's not a one size fits all and ultra-low-dose prescribing in the microgram strength. It's also something I've been increasing usage of. The frequency of usages is also something I'm fascinated by, whether to use once a day or all the way up to four times a day. And so the trouble is trying to understand this and research, this is where we are in this day and age.  

Linda Elsegood: And what would you say the patient's success rates have been with LDN?

Neel Metha, MD: So it's actually one of the drugs that have been a home run. I would say if I had to do a head to head comparison against something like Gabapentin for neuropathic pain, my anecdotal experience has been that it's more successful than those types of drugs for a number of reasons.

Number one, its overall efficacy has been good in terms of reduction of pain, but the biggest thing is compliance. So how easy is it for a patient to follow directions and use it, and also interaction in side effects is almost minimal. Some patients may describe some minimal side effects, but they tolerate it and go on with it.

 

But Gabapentin and Lyrica are more challenging with the side effects such as weight loss, weight gain, and sedation and dizziness are really challenging for them. And often it's frustrating for everybody because we'll try those drugs. And if a patient comes back a week later or two weeks later saying, I took one dose, didn't tolerate it, and I stopped it altogether. So our challenge in those treatments is that we just don't have anything equivalent until we discovered LDN and now we almost offer it to every type of neuropathic condition and the drug is cheap. We are fortunate that the compounding pharmacies that we work with have been able to offer it at a very palatable price compared to some of the other compounding drugs that we may use.

Linda Elsegood: And have you used it in Phantom pain? 

Neel Metha, MD: I've used it broadly in neuropathic pains. Phantom limb is something I have used it in, although I will say that my population of Phantom limb pain is much smaller than say, by trigeminal neuralgia or fibromyalgia or other neuropathic conditions. We've also been using it a lot in patients that have myofascial pain. That has become more of a centralized or hypersensitized type condition. So when they have central sensitization of their muscle pain, I find LDN very effective. 

Linda Elsegood: I was only asking about the Phantom limb pain because we have many members that are military who've lost limbs, and you know, it is worth the try, isn't it? You know, you've got to find someone who will prescribe it, but it's definitely worth a try. 

Neel Metha, MD: Absolutely. I see very little downside to it. I think often the patients, once they hear about it and talk about how we plan to use it, what's the potential for benefit and the minimal side effect, we have a very good success rate of having patients try it and be pleased with it. If you just do research on naltrexone alone on Google, sometimes it's a little scary, the types of things that come up associated with naltrexone.  I take the time to counsel patients on why we are using it and how it does differ from the other purposes of naltrexone itself. And that's very reassuring for patients. Phantom limb pain, I think, is one of those things that it's almost a no brainer to use in these conditions along with other multimodal therapies, including.

Mirror therapy, physical therapy, and then refractory conditions to consider things like ketamine and spinal cord stimulation or peripheral nerve stimulation. So there's a wide variety of treatments, but LDN should be one of the mainstays. 

Linda Elsegood: We've been going 15 years now, but it was mainly.to help autoimmune conditions. Such as rheumatoid arthritis, but we were saying it probably won't do anything for osteoarthritis, but that's not the case. It does work for osteoarthritis as well, which is quite amazing. A lot of our members are in their 70s or 80s and have been having very high doses of steroids throughout their years, since they were like 20, 30, and it's caused, crumbling of the spine. So nerves are getting trapped, and LDN seems to be working really well in those cases as well. But it sounds absolutely horrendous. I would hate that to happen to me. But I'd like to think steroids aren't as widely used now as they were. You know, 40 years ago. Would you say that's the case, that we're doing something different than a high dose of steroids over a long period? 

Neel Metha, MD: We certainly have an appreciation for the risk of high steroid use. So we know now what doses we can use at a time and how often those patients can get it. But unfortunately, the steroid is still a mainstay treatment for various conditions like osteoarthritis, especially in the, in the hands of an interventional specialist. We still believe in the continuum of care, such as things like physical therapy.  But also, the use of acupuncture, turmeric and when appropriate steroids, if you're going to give maybe localized steroid.And now a lot of things like platelet-rich plasma and STEM cell are starting, and it's the emergence of data, but you're right, LDN does work. And while it may not have 100% cure rate you can certainly lessen the burden of osteoarthritis enough for people to be able to do more in their physical therapy and be more active and lose weight and all the other things that come in a positive cycle, to help them overall improve their functional ability in their quality of life.

Linda Elsegood: Have you found a benefit using the ultra-low dose alongside opioids to make them more effective, to help patients withdrawal from their opioids?

Neel Metha, MD: So this is a healthy debate I have with a colleague of mine. He starts at a hundred micrograms and will consider ramping that up over time,  two, four times a day, and then slowly get up into potentially a milligram dose. And I tend to start the opposite. I may start at one milligram and decide whether I need to go up or down based on the symptoms that they're experiencing. The challenge that we have is there are patients that don't respond in the milligram dose but do respond in the microgram dose even with it and have an absence of side effects. And this is where I think to work with. Your organization and working with David on research in this to really pinpoint how we best identify dosing for patients is going to be fascinating. But to answer the question about how I have found it,  it has really helped patients with tolerance and actually prevention of tolerance. We use it quite frequently in traditional opioid receptor type drugs. But I also use it synergistically for neuropathic pain conditions when I use things like Tramadol.  My belief is that it's worth a chance to see. We start extremely low. We are able to get one of our compounding pharmacies to start at a hundred micrograms in a tablet form, which a patient can split in half and take 50 micrograms at a time. We see really interesting clinical data, and now we are just starting to try to put this together and see if we can publish our work on it.

Linda Elsegood: If you are a drug addict through no fault of your own because they are prescription drugs, but it still makes you addicted to these opioids and coming off, you've got to be so careful that you don't go into withdrawal. So if something like ultra-low-dose can be used to help wean people off without those awful withdrawal symptoms, in my book that's got to be amazing. 

Neel Metha, MD: Absolutely. If we can eliminate the usage or even cut down the doses to be in a safer range, I think it helps everyone, including the patients that are taking these medications, the prescribers who are trying to handle risks of these medications, the families that may be in the same households where these medications are being stored and trying to avoid the harm of getting these medications in the wrong hands. These are all potential benefits of downstream effects of LDN  

Linda Elsegood: And what's the long term effect to the body if you take high doses of opioids?

Neel Metha, MD: Well, there's a number of things. So number one to the patient itself that's taking the opioids, there's a very high likelihood of tolerance, and that's a very challenging and frustrating problem for everybody in that the same dose of medication has a diminished effect in terms of pain relief. So the natural thought would be to increase the dose. But eventually, even without the absence of addiction and addiction type behaviours, the same patient taking a higher dose has a much higher likelihood of achieving side effects that could make it unbearable to continue on that therapy. And what side effects am I referring to? Those are things like severe constipation,  not being able to function at work, missing days at work or being unproductive during their time, mood irritation and irritability to the point that they become very, difficult to be around the family, to the point of not being able to drive to work or drive in a car anymore because they're so impaired or that they sleep more, may gain weight, become less active. So overall, their quality of life may go down, even though they have the original intention of trying to improve their pain with a higher dose. And then you have the risk of addiction. And that is a potential for now using medication in inappropriate ways, combining it with things like alcohol and so forth, and then finally what is the risk of all this medication sitting in the home? So could a teenager in the household get into it and use it in a recreational way and cause harm and die?

Could it get in the hands of a young child? Could it get stolen and get into a drug addict's possession? All of these things are harmful. We can eliminate or reduce the amount of medication in circulation. There are so many downstream effects in addition to the ones that the patient would benefit from.

Linda Elsegood: Well, wonderful. We've just about run out of time. Can patients refer themselves to see you? Do they have to be referred by their own doctor, how do patients get to see you? 

Neel Metha, MD: So, for LDN, I think recently you've been kind enough to share some of our practice information. And just recently I've had a few, a couple of patients that actually have no pain, real related things, but wanted to talk about LDN usage.

And I've been happy to see them. So patients are able to make an appointment if they are not coming for a particular pain condition. I asked them to specify with our schedulers they are here to discuss LDN and I'm happy to meet with them. But for painful conditions, I have a team of.

eight other doctors that have experience with LDN. Some of them have been prescribing it for just as long as I have. So, we welcome these patients to see us if they're motivated to want to try to improve their lives without the use of opioids. We really welcome them if they're trying to reduce the amount that they take. LDN is a great drug, but there's a multitude of options that we want to present to them. And that's where we think our multidisciplinary practice will really help.  

Linda Elsegood: And what numbers should they call you on? 

Neel Metha, MD: So our office number is six, four, six, nine, six two seven two, four, six. We are located in Manhattan. We'll also offer video visits for follow-up visits. We're not allowed to do it for the initial ones, but if they are able to make the journey to see us even from far away, one time, then we can potentially continue to care for them virtually. We have had patients come from other countries and also from up to 48 States of the 50.  

Linda Elsegood: Wow. It's been amazing talking to you today, and we'll have you back at another time. 

Neel Metha, MD: Linda, thank you very much for the opportunity. It's really been a great collaboration that we have started on and I hope to continue to help everybody through our work together. Thank you. 

Linda Elsegood: This show is sponsored by Mark Drugs who specialize in the custom compounding of medications, assuring that the client gets the proper prescriptions for their unique needs and conditions. They work with practitioners integrating knowledge and treatment of experts to create comprehensive health plans. Visit markdrugs.com or call Roselle six three zero. Five two nine three four zero or  (847) 419-9898.

Any questions or comments you may have, please email me, Linda, linda@ldnrt.org I look forward to hearing from you. Thank you for joining us today. We really appreciated your company. Until next time, stay safe and keep well.