Published June 20, 2019 By Adam Lowenstein

Dr. Lowenstein: Hi. Welcome back to the Headache 360 Podcast. I’m your host, Dr. Adam Lowenstein, and I’ve got a amazing guest today. As I think many of you know, I’m a migraine surgeon. I do peripheral nerve decompression for migraines, and a lot of my patients have spent time in emergency rooms, and so I thought it would be great to have an emergency room physician here as a guest. But, we’ve hit the kind of jackpot because Dr. Prystowsky, who I have here, Dr. Jason Prystowsky, is the consummate physician.

Dr. Lowenstein: He is from the Bay Area, and he went to University of California Santa Barbara undergrad, did his med school and Master’s of Public Health at Northwestern, and then did an emergency room residency at Emory and at Grady Hospital. I don’t know if any of you know Grady hospital, but it’s as close to a war zone as I’ve ever been in. He is a clinical emergency room physician at Cottage Hospital, all three campuses. He’s the medical director of the city fire department, and actually as such, he’s got one eye on his phone for some things going on in the fire department, so we may have to do a little pause here. Please pardon us if that’s the case. He’s the director of Doctors Without Walls. He’s co-chair of the College Ethics Committee. This guy does it all. Welcome Dr. Prystowsky.

Dr. Prystowsky: Thanks. I want to call you Dr. Lowenstein, but I know you as Adam, because when we have our kids at Trader Joe’s together shopping for milk and yogurt it’s “Hey Adam.” “Hey Jason.”

Dr. Lowenstein: It’s a small community here, but, very fortunately we have some of the finest doctors that we could hope for. Actually, one of the stories that I tell about Jason, and I think Jason tell us about me is the most intriguing plastic surgery consult I ever got. As many of you know that, I’m originally a plastic surgeon. Did a lot of reconstruction because we’re the people who do the microvascular surgery on nerves, but Jason once… I guess, did you text me or email me from Sudan-

Dr. Prystowsky: I emailed you. Yeah.

Dr. Lowenstein: Jason’s done a lot of work overseas. You tell that story real quick.

Dr. Prystowsky: Oh yeah. No. In 2008, I was in the civil war in South Sudan with Doctors Without Borders, and a lot of interesting medicine. We actually had a couple of interesting cases where I was in the position to do some very, sort of, basic reconstructive surgery and I needed a bit of guidance. Fortunately, in today’s day and age we’re an email away, and I could send you a couple of photographs, and you gave me some good tips.

Dr. Lowenstein: Yeah, man. AK-47 and bayonet wounds, certainly… Let’s just say, Dr. Prystowsky has done some of the most impressive work of any physician that I know, and I know a lot of doctors.

Dr. Prystowsky: AK-47s are no bueno.

Dr. Lowenstein: Yes, in general. This is true. All right. Well, let’s move towards what I think a lot of our listeners are interested in hearing as far as what happens in the emergency room from a migrainer standpoint. You’re going to the emergency room when you have nowhere else to turn. I think when you’re seeing stuff from a patient’s perspective, it can be very different than what the perspective is from the caregivers there. I guess, what are you thinking when somebody comes to the emergency room with a migraine, and kind of what is your initial workup and why, and things like that?

Dr. Prystowsky: No. Yeah. That’s a great question. One of the most common complaints that brings people to the emergency department are headaches. When someone comes, they check in, they’re triaged with a headache, then our wheels immediately start turning. It’s interesting, with my patients in the emergency department, I always like to get right out in front of what are the goals and expectations of the visit. In the emergency department here in Santa Barbara and throughout the United States… I believe that the emergency care in the United States is some of the best in the world. We have really well trained physicians and nurses that are there to see people and help people, and resuscitate.

Dr. Prystowsky: When someone comes in with a headache, we’re thinking about two things. The first thing we’re thinking about is, what is causing this headache, and is it something potentially bad and life-threatening? Then the second question is, how can we get this person feeling more comfortable? A lot of times we treat as we diagnose, that’s a philosophy of emergency medicine. When someone who has migraine headaches comes in, there’s a lot of useful information that they can give us right out of the gate when someone checks in. I work nights in the emergency department. If you come into my shop at two o’clock in the morning, I already have some presumptions, but it’s helpful for you as the listener to come in and say, “I have a history of migraine headaches. I get them every three months, every month, and these are the abortive remedies that I’ve already tried.” We know that if you’re in the emergency department, whatever it is you’ve tried at home has already failed. We’re going to get you back as quick as we can and start to get you feeling better as quick as we can.

Dr. Prystowsky: Friends of mine that have migraine headaches, I always kind of… My heart goes out to them, because when someone has a migraine headache… I’m assuming that the listeners to your program already know a lot about the symptoms, probably more about the symptoms and what it’s like to have migraine headaches, than I do. People are very sensitive to sound, they’re sensitive to light. When I think about one of the worst possible places to be, if I had a migraine headache, would be in a really busy, noisy emergency department where there’s crying babies and maybe there’s people-

Dr. Lowenstein: There’s drunk people-

Dr. Prystowsky: There’s drunk people yelling and maybe there’s… Someone gets brought into a room, and they immediately have to be taken out of that room because someone else who’s really sick needs that room more. It’s like, when you think about the non-medical interventions for migraine headaches, just being in a quiet, calm environment where you can just mindfully start to work on your symptoms, the emergency department is the opposite of that.

Dr. Lowenstein: Years ago when we started seeing migraine patients here, I changed the lighting in the rooms. We have, either normal bright lights or we have half-on lights for that kind of thing. We do try to make this serene environment. I have been, unfortunately, in the ER with both of my kids at night with croup, and in each instance there was a car accident, rollover. Clearly, yeah. I mean, my kid sounds like he’s dying, but I know that he’s not, it’s the air hunger, but there’s a guy who comes in, and he’s bleeding all over the place. Clearly, yeah, he needs the room more than we do, so we get moved out, because they put us in the trauma room.

Dr. Lowenstein: Yeah, if you have a really, really bad migraine, you can feel like you’re dying, right? Triage is one of the hardest things that you guys do. I think that, from a migraine standpoint, that person may say, “They think that that person is sicker than me, but that person’s not sicker than me. I just look normal because you can’t see the wounds that I have, representing the pain that I have.” Its a [crosstalk 00:09:16]-

Dr. Prystowsky: I think it’s important to note, the whole triage process is designed… Again, I’m building a humanities program, so I can talk about the history of triage from the Napoleonic wars, but I’m not going to bore you with those stories. But the whole triage process is designed so that the people who need the help the most and the fastest, get it. The people that have a bit of the luxury of time are not as close to the front of the queue. It’s a system that works. It’s frustrating, because when people are in pain…

Dr. Prystowsky: Believe me, I speak on behalf of all of our doctors and nurses. When someone’s coming in, and they’re suffering, they’re in pain. We want to get them pain free as fast as possible. But sometimes there’s someone who, a life and limb requires the services first. I always tell my patients, “I am so sorry you had to wait. In a perfect world you wouldn’t have to.” If you’re ever in a situation where you show up to the emergency department, and you are immediately greeted by four physicians and six nurses, that’s a bad sign. There’s something really, really wrong.

Dr. Prystowsky: But yeah, it’s tough because… I think it’s important also, when someone has a migraine headache, they’re in a lot of pain, they’re very sensitive to sound, they’re very sensitive to light. The emergency department is built to resuscitate people. It’s not a calm, serene, spa environment. That’s not… We’ll do our best. We’ll turn the lights off, we’ll close the door, but there are some things that are going to be out of our control.

Dr. Prystowsky: Then the next question is, when someone comes in with a headache… A good friend of mine is an internist, and we always laugh and joke. I say that in internal medicine they play to win, and for us in emergency medicine we play not to lose.

Dr. Lowenstein: Yeah.

Dr. Prystowsky: When someone comes in with a headache, I’m thinking about all the worst case scenarios. I’m thinking, “Okay, this patient has a history of migraine headaches, but I need to make sure that this is not one of these other horrible diagnoses-“

Dr. Lowenstein: Aneurysm or something like that-

Dr. Prystowsky: Is it a bleeding aneurysm? Is it meningitis or encephalitis? Is this carbon monoxide toxicity? Right? I mean there’s all of these potentially really dangerous diagnoses that… A lot of times patients with migraines, I’ll ask them a lot of questions, and I can see their frustration like, “I’m having a migraine, I just need the treatment.” I’m like, “I understand, but I want to make sure that this is not something more dangerous. This is not a brain tumor-“

Dr. Lowenstein: A mistake can be fatal and so that’s-

Dr. Prystowsky: Correct. Correct. “I know it’s uncomfortable, and I know it hurts to talk, and I know it hurts to open your eyes, but I still need to take a look at your pupils. I know it’s going to be uncomfortable, and I apologize it’s going to be uncomfortable,” but that gives me some data that helps me to determine whether or not this is life-threatening or not. It’s a process that we have to go through, because at the end of the day our goal is to make sure that everyone that comes through our emergency department gets an accurate diagnosis. If there is something life-threatening, then we address it, and we get them the care that they need.

Dr. Prystowsky: When someone has a migraine headache where the goal… When that person comes through the door, their goal is to get their symptoms under control, right? You come to the ER with a migraine headache, you tell me, “I have migraine headaches, this is the name of my neurologist. I already tried Excedrin Migraine. I already tried Imitrex. I already tried taking a bath and meditating, and it’s now bad. I need help.” Your goal is for those symptoms become relieved. My goal is, I want your symptoms to be relieved, but I also want to make sure that it’s not something life-threatening, which is oftentimes a big miscommunication, and can sometimes cause an adversarial relationship, which I…

Dr. Prystowsky: If anything your listeners can take away from is that, we in the emergency department, we’re not asking you these questions because we want to annoy you. We want to make sure that it’s not something life-threatening, so we can move on to getting you feeling better.

Dr. Lowenstein: Right. I think that people… Classically, I hear a lot, and I see a lot on Facebook and whatnot about people feeling that the people in the emergency room are just not interested in helping. That can’t be further from the truth. Frankly, okay, I’m sure that there are some bad ER docs, and there are some… I couldn’t say that’s always furthest from the truth, but in my experience it’s the same. But the understanding from a patient’s standpoint and a doctor’s standpoint in general, you just go to the doctor. The experience that the doctor is having when they’re seeing the patient is different than the patient is having when they’re seeing the doctor. Nowhere, I think, is that more so than the emergency room. That mutual understanding is, what is it? Patients are from Mars and doctors are from Venus or whatever. The whole thing with, men are from one planet and women from the other. Everybody’s trying to do the same thing. It’s just you got to go about it the way that works best, which may not be the way that the patient wants.

Dr. Prystowsky: I think, in preparing patients when they come to the emergency department with a migraine exacerbation, to be ready for a lot of repetitive questions. A lot of people are going to ask, what is your pain scale yet, right now, on a scale of one to 10? We’re not doing that because we want to be annoying. We want to do that because we want to know how effective our interventions are treating the pain. We’re going to want to know about some of the patterns of headaches. We’re going to want to know about some of the other associated symptoms. Sometimes we’re going to ask about other people in the household. Who else has symptoms?

Dr. Prystowsky: If this is a pattern headache, if someone has migraine headaches or cluster headaches, then our goal is going to be to try to get them feeling better. If this is the first time someone’s had a headache, we’re probably going to do some diagnostic tests, or if this is a headache in a patient that gets a pattern of headaches, but this one’s different, this one has a different characteristic or a different quality, or different severity, we might want to do some imaging or some blood tests, to kind of distinguish, “Is this a migraine headache or is this something worse?” Because you were out mountain-biking three days ago and hit your head really hard. Is that what caused a migraine exacerbation, or is there something else going on? We might investigate into that.

Dr. Lowenstein: What kind of interventions do you typically offer somebody who… Once you’ve established… Okay, this person comes in, it’s a migraine patient, they have migraine headaches 17 days a month, and they usually can have them under control. This one is really, really bad. You’re comfortable that they’re not having anything worse. What can you offer them?

Dr. Prystowsky: Sure. I think you know, and I’m sure if you had a host on your show, or you had a guest on your show who is a neurologist, they’d probably talk a lot about some of the-

Dr. Lowenstein: Coming in two weeks, but yeah.

Dr. Prystowsky: Perfect. A little teaser for your listeners. They’ll talk about different interventions that can help prevent migraine headaches or different interventions that can help, once that aura comes on, and the patient knows that, “Okay, the migraine’s coming,” there are certain medications that can help stop that process [crosstalk 00:17:08]-

Dr. Lowenstein: We call them abortive medication-

Dr. Prystowsky: Abortive medications, right? When someone comes to the emergency department, and they’re already in the full-on, they’re already at the peak level of pain for their migraine, then a lot of those early interventions, we’re not going to go to fast, because we’ve already missed the window to really implement some of those. We’re going to go with some of our non-steroidal anti-inflammatories, which is a class of medications that include naproxen, Ibuprofen, sometimes we’ll use ketorolac because it can be given in intravenous form or intramuscular form, because a lot of people with migraine headaches, they know what medications they need to abort the migraine, but one of the symptoms they have is vomiting, so they can’t keep those medications down.

Dr. Prystowsky: A lot of times we’ll give IV fluids because it’s been shown that dehydration is going to exacerbate the migraine, and if we can address the hydration standpoint, they’re going to feel better. We’re going to get a nonsteroidal antiinflammatory on board, we’re going to get an antiemetic or a nausea medication. There’s been a handful of nausea medications that have been shown in randomized controlled trials that they’re more effective than others. We in the emergency department, like all physicians you have on your show, are going to always use the evidence and use the literature that this medication in the most recent research has been shown to be much better at aborting migraine headaches than this one.

Dr. Prystowsky: We’re going to use an antinausea medication. We’re going to use a nonsteroidal anti-inflammatory. Depending on how recurrent the headache is, we may reach for a steroid because there’s an evolving body of evidence that shows that, that can help prevent a recurrence of headache. Then we’re going to, ideally, give the patient a quiet space to let those medications begin to take effect. One of the questions that I always come in and ask my patients is, 20 minutes later, 30 minutes later, “How are you feeling? Does it feel like the medication is helping?” Then I always also ask, “If you know that this is a migraine headache, if we’re certain that this is a migraine headache and not something else, do you feel well enough to go home and sleep off the headache?”

Dr. Prystowsky: Because we all kind of realized that if someone has a really bad migraine, and it’s already moving in the direction of recovery, would they be more comfortable in the quiet of their own home rather than the busy hustle bustle of the emergency department? Patients, usually, are very good at articulating, “No, no, no. I want to stay here a little longer because I might need a second dose of medication,” or, “No, I feel like this is my fourth or fifth time being through this rodeo, and I’m on the road to recovery. It’ll go smoother at home listening to light jazz than listening to this guy next door who did too many methamphetamines tonight.”

Dr. Lowenstein: Yeah, right. That’s always the problem. But, I think that also, because of the nature of the pain, I think, sometimes you also get patients who interpret that as, “Yeah. They tried to get rid of me. They kept on coming in and saying, ‘Are you feeling like you can go home?'” Again, it can be a very difficult misunderstanding, I think [crosstalk 00:20:30]-

Dr. Prystowsky: Yeah. Because ideally, yeah, we want you to feel better, and we want to get rid of you. We want you to go home and feel better. But sometimes the diplomacy of delivering the message can be misinterpreted.

Dr. Lowenstein: Well. Let me ask you, when do you think somebody… Most of the people who are listening have chronic headaches, either occipital neuralgia or migraines, or chronic daily headaches and there’s a myriad of diagnoses. Somebody who has one of these conditions, when is it appropriate for them to come to the emergency room?

Dr. Prystowsky: That’s a great question. When someone has… We’re talking about chronic headaches, but any type of chronic illness. Whether we’re talking about diabetes or high blood pressure, when is it appropriate to come to the emergency department? The patient is in the best position to know that. We will always take the patient seriously. If you think you’re having an emergency, then you should come to the emergency department and get checked out. We’re always happy to see you. Sometimes we’re not going to be able to see you as quickly as you might like, and ER overcrowding.

Dr. Prystowsky: I mean, we’re not going to get into the healthcare in the United States debate that’s happening right now. Access to healthcare is a big hot topic. Emergency departments are a available resource, they will not turn anyone away. But because of that, sometimes there’s overcrowding, and sometimes there is a bit of a wait. But if you come to an emergency department anywhere in the United States, you will be seen, and we will ask you questions. We’ll do a history, we’ll do an exam, we’ll do appropriate diagnostic testing, and we’ll try to get you feeling better. The important thing for someone who has chronic pain though… Chronic pain is a really… It’s tough. It’s hard for everyone involved.

Dr. Lowenstein: It’s very tough.

Dr. Prystowsky: It is very tough. The reality is, when someone has chronic pain, they really need an interdisciplinary approach. They need a whole diversity of specialists sitting around the table to be involved in their care. If someone has chronic headaches and chronic pain, and their daily life is living with pain at a really high level, then they probably already have a neurologist and a primary care physician, and a pain specialist. Maybe they have a psychotherapist. Maybe they have a surgeon who’s doing nerve decompression. I mean, there’s so many different components of it.

Dr. Prystowsky: One of the things that we don’t do well in the emergency department is, we don’t manage chronic pain. We are in the business of emergency resuscitation, but managing chronic pain is something that we’re not equipped to do, because it requires that interdisciplinary long-term approach. When someone has chronic pain, and they show up to the emergency department, and they’re suffering from their chronic condition, I mean, my heart goes out to those patients. I will always look for an emergency, and I will always address an emergency. But when someone lives at a chronic pain level of eight out of 10 in severity, and that’s every day they live at that chronic pain level, which is a really tough way to live.

Dr. Prystowsky: They’re coming into my emergency department with a pain level of nine out of 10, then I’m going to say, “What are our goals and expectations? Are we worried that this is something else or do we know that this is the recurrent headache? What can we do as part of the interdisciplinary team to address this chronic condition?” A lot of patients will come to the emergency department on weekends, in the middle of the night, and they’ll say, “I live at a level of eight out of 10 in severity. I can’t take it anymore. I want the pain gone.” I will look at them, and I will feel for them, and I’ll say, “That’s an expectation that I probably will not be able to meet tonight in the emergency department.” Which is-

Dr. Lowenstein: Do you actually refer, do you ever tell patients, say, “Hey, do you have a neurologist? You should go see X, Y, or Z,” or do you…. I mean, do most of these patients actually have the proper doctors plugged in, or do-

Dr. Prystowsky: Yeah. This is going to be very specific to the geography of your listeners. I mean, access to primary care, access to specialty care, is such a big… You were just saying, “Hey, this is a 40-minute podcast. Let’s try to keep the conversation under three hours.” You want to start talking about, someone comes to the emergency department because they don’t have any other options, and we’re the only place that they have left. Then they’re saying, “Okay, I need a neurologist, a pain specialist, a primary care physician, a psychotherapist, a plastic surgeon. It’s two o’clock in the morning on Father’s Day weekend. What can you do for me?” I can say, “Well, we can treat your symptoms. We can make sure that there’s not something life-threatening and not emergent, and we can work on referrals.

Dr. Prystowsky: Our ability to get people access to care is going to be very dependent on where they live geographically, what their insurance status is, what some of the resources they have available in their local community.

Dr. Lowenstein: Well. If somebody comes in… This is when we used to come in to sew up things in the emergency room as young plastic surgeons, and you would have [crosstalk 00:25:56]-

Dr. Prystowsky: You’re always invited to come into our emergency department.

Dr. Lowenstein: Thank you so much, sir.

Dr. Prystowsky: Open invitation.

Dr. Lowenstein: But, I have been in situations where we have had celebrities call, and they want Dr. Lowenstein to come in, just because of where we are. They have certain expectations. Somebody comes in with a headache and expects you to give an MRI. They say, “I need an MRI.” What do you do? You can’t get everybody MRIs. I mean, can you?

Dr. Prystowsky: Addressing expectations is one of the tougher parts of the job. For me personally, and I think I speak on behalf of most emergency physicians, we always try to do our due diligence to give the appropriate medication and to mitigate any of the expectations that are there. I mean, MRI, magnetic resonance imaging, is a really useful tool, and in the right setting it’s important. When someone comes in with a migraine headache, and they have neurologic deficits, and we have a question, “Is this a migraine headache with neurologic manifestations, or is this a stroke?” We’re going to get that MRI, because a stroke is something that we want to make sure that there’s interventions, that we can get those neurologic deficits back to baseline. When someone is having a headache, an MRI is not necessarily the first go-to test that we’re going to use.

Dr. Prystowsky: Sometimes, a lot of our patients are going to look things up on Google. They’re going to call a friend who has some medical expertise. Maybe they saw a television show, and they’re going to come in with certain expectations and certain requests. We’ll always listen to them, but in reality, at the end of the day, our goal is to provide the best evidence-supported standard of care. If an MRI is part of that, we will certainly move in the direction of getting that test for them. If an MRI is not part of that, ideally we’re going to communicate, “I hear you, but this is not the test that we need for you-

Dr. Lowenstein: At this time.

Dr. Prystowsky: … at this time.”

Dr. Lowenstein: I can speak to that as well, especially on Facebook and things like that. A lot of the questions that I see are, “Somebody just put me on beta blocker. Who’s been on this, and has it worked for you?” Well, just because another person has had experience X, Y, or Z with this beta blocker, it really has nothing to do with how this beta blocker is going to affect you. I try to work this into every podcast, the things you hear here as well, we are not giving specific medical advice to any individuals. If you hear things on our podcast, they’re things to run by your personal physician, your medical doctor, but do not take any of what we say as a directed advice, because we speak in generalities. Migraine disease is a very specific disease. People experience pain differently, people experience symptoms differently, and people experience remedies very differently. I do think that can be another difficult aspect of chronic pain.

Dr. Lowenstein: Which leads me to, let’s see, we are half an hour into this. I’m going to do… Let’s try and cover, let’s say, a four-day debate in 10 minutes. The big thing that I hear a lot is, “I went to the doctor, they thought I was drug-seeking, they wouldn’t give me any narcotics because they thought I was trying to get narcotics, and they can’t tell how severe my pain is because they can’t see anything.” Migraine and chronic headache and severe pain do not manifest as things that you can actually see on a test. You want to address the-

Dr. Prystowsky: Opiates, yeah.

Dr. Lowenstein: … the opiate issue in ten minutes?

Dr. Prystowsky: I think it’s always tough with pain, because when we think about pain… What is pain? It’s a subjective perception of a noxious stimulus. The only way I know how much pain you’re in is to ask you, “Hey Adam, how much pain are you in right now?” Because it’s not like a broken bone where we can get an x-ray and say, “Oh, this is clearly a nine out of 10 pain,” because it’s very personal, and it’s very subjective. I don’t like using the word narcotics, I’m a public health person. Because narcotics has a criminal justice connotation, and we’re talking about health. Opiates is a class of medications that acts on opiate receptors, and it includes morphine, heroin, fentanyl, Dilaudid or hydromorphone, codeine. Some of the newer synthetics carfentanil and sufentanil.

Dr. Lowenstein: Percocet.

Dr. Prystowsky: Yeah, oxycodone, which is Percocet-

Dr. Lowenstein: The more common… Yeah.

Dr. Prystowsky: Yeah. Opiates are valuable in addressing acute pain. The United States has experienced a drop in its life expectancy for the third year in a row, and most of that is attributed to the current opiate epidemic. I don’t know if you have listeners who are in Ohio, in the Midwest, in the south, the opiod epidemic has really had an extraordinarily tragic impact on communities. If we wanted to make this a four-day debate, we could talk about the history of it, and the role that we in healthcare had to play in getting people addicted to pain medication. Opiates are really valuable in acute pain. When you break your arm, and I need to treat that pain before we set it, and get that pain under control for two days, opiates are a really valuable tool for us to have. When the chronic pain is the problem in and of itself, and it’s not because of an acute injury, then opiates can become part of the problem, and can create more problems downstream.

Dr. Prystowsky: Ideally, we in medicine, as much as we want to make the person in front of us feel pain-free, we don’t want to increase their risk of addiction. We don’t want to increase their risk of overdose. We don’t want to cause many of the other long-term complications that using opiates for chronic pain can contribute to. There’s always these risks benefits that go on. When someone has a migraine headache, and you’re going to have a neurologist on your program in a couple of weeks. It’s a great question to ask him or her. When someone comes in with an exacerbation of migraine headache, we’re going to reach for some of these nonsteroidal anti-inflammatories like ketorolac, or some of these anti-emetics like Compazine or Reglan to really get the symptoms under control.

Dr. Prystowsky: Opiates, as good as they are at getting the pain under control in the short-term, they don’t necessarily improve health. Though a lot of people on these blogs that you’re talking about may leave our emergency departments unsatisfied, they may be irritated, they may feel like they weren’t listened to, and for that I really apologize. Because we do listen to all of our patients. We want to be sure, and we want to be safe, and we want to be conscientious that we’re not temporarily solving one problem, which is the problem of pain right there at that moment, and create a potential problem, or add to a potential problem that’s more lethal downstream. I’ll tell you, when I take off my ER doc hat, and put on my medical director for the fire department hat-

Dr. Lowenstein: Dr. Prystowsky is literally grabbing a imaginary hat, and that was awesome. Okay.

Dr. Prystowsky: We’re using public health harm reduction strategies now in our community, because more and more people are overdosing. A lot of times it’s accidental, because they have chronic pain, and they’re trying to get their pain under control and they’re accidentally overdosing. If your listeners are living in the United States, then statistically speaking, most of them have had a family member, a friend or a colleague from work who has been very impacted by the current opiate epidemic.

Dr. Prystowsky: It’s something that we talk about, as a public health person I talk about, quite openly and quite transparently, that when someone comes into the emergency room department and says, “I know what I’m having. It’s my menstrual period. I usually get migraine headaches around the time of my menstrual period. I was up late last night studying, and now I have a migraine. It feels like my previous migraines, but this one’s really severe. The only thing that works for me is opiates.” I’m going to say, “Let’s try some other things first, because I care about you and I care about your health. I know that these other interventions, according to the science, have been shown to be quite effective. Let’s see if these work first before go to some of these more dangerous remedies, which may do a great job at getting you feeling better right now, but they all in all might increase your risk of dying of an overdose in the long-term. I care about you and I don’t want you to be put at risk.”

Dr. Lowenstein: It’s tough because, I mean, a lot of people say that, “It’s not going to happen to me,” and you’d be surprised. I had a patient here the other day, and I was talking to a mother and her little daughter was in the room. We were talking about narcotics, and I give narcotics for a very short period of time after surgery. I explained, “I do that on purpose, and I rather you in a little bit or a moderate amount of pain than have to deal with the bad stuff, the narcotics.” The little girl looked up at her mom and the mom said to the daughter, “You remember kind of how daddy ended up having to go away for a while in the hospital?” What had happened, he had back surgery… Again, this guy is a standup guy, and he ended up needing to be in rehab.

Dr. Lowenstein: I have another migraine surgery patient that was… he was one of the most remarkable guys. He was on fentanyl patches that would kill, I swear, an elephant. I operated on him, and he went from a pain of nine out of 10 on a daily basis to zero. He had no pain. I called him three weeks later just to check up on him, “How you doing?” He didn’t answer the phone. I was a little worried. He got back to me like three days later and said, “I’m sorry I didn’t answer the phone. I have been in bed with the shakes trying to get off of my narcotics.” When you have nine out of 10 pain, and that’s not your biggest problem [inaudible 00:37:33], it’s a disaster.

Dr. Prystowsky: I think, the opiate epidemic that we’re experiencing is still ratcheting up, and it has… I mean, statistically speaking, all of your listeners have been impacted by this very close to home in some way, shape, or form. That’s the reality-

Dr. Lowenstein: Isn’t opiates the number something very high cause of death in a certain… From 20 to 40 it’s like-

Dr. Prystowsky: We’re starting to get a better idea at measuring it, because it used to be… 20, 30 years ago, if I told you as a public health person, “What does an opiate addict look like?” You’d talk about someone who is behind a dumpster, shooting up heroin. But now, the average person who’s grappling with an addiction to opiates is probably someone who’s working, who’s high functioning, who started out with some kind of pain, started taking these medications, needed to continue to take the medications, developed a dependency. The whole rewiring of the brain, and the way we perceive pain is altered by these opiates. Once you start taking them away, people are super hypersensitive to pain. They go through really horrible withdrawal symptoms. The reality is that, this is out there, I always tell you, good medicine is knowing the right tool for the right job. There is no one tool that fixes everything. If anyone ever tries to sell you that, they’re a snake oil salesman.

Dr. Prystowsky: Good medicine is saying, “You have chronic headaches, what’s going to work for you?” Maybe it will be, your nerve decompression surgery. Maybe it’ll be cognitive behavioral stimulation. Maybe it will be, fill in the blanks. Opiates are very good at treating short-term pain. That’s what we use them for in the emergency department, but when someone has chronic pain, they create more problems than they solve. It always puts us, in the emergency department, in a really tough position when a patient comes in with a chronic pain condition, with the expectation of wanting opiates to treat their pain, because me as a physician, I’m very conflicted because I want you to feel better, but I also want you to be healthy. Me giving you opiates, that kind of contradicts. That kind of conflicts.

Dr. Prystowsky: It’s tough. When your listeners come to the emergency department with a headache, and we’ve determined that this is an exacerbation of their migraine headache, we will certainly treat them compassionately, with the best practice in mind. Know that nowhere in the scientific research and literature, opiates included in that best practice for a variety of reasons, is because we see a lot of opiate overdoses, as well. That is so tragic, and it happens like you said, to young, healthy people who a lot of times they’re trying to treat their pain, but they try a little too hard, and it ends up with a really tragic outcome.

Dr. Lowenstein: Yeah, I know. But unfortunately when your head is exploding you can lose perspective.

Dr. Prystowsky: Absolutely.

Dr. Lowenstein: I can understand both sides of this. Actually, one of my goals in having you on and talking abut this is that our listeners, I hope, can start to understand both sides of it, because there’s perspective from both sides. I think everybody’s trying to do the right thing. It can be hard to see [crosstalk 00:41:18]-

Dr. Prystowsky: We need more dialogues like this. I mean, that’s… I think one of the frustrating things for patients who are coming into the emergency department where all of their abortive remedies have already failed. I mean, if they’re in the emergency department, then whatever it is they tried didn’t work, because they are in our ER. It’s not the ideal time to have a philosophical conversation about goals when they’re like, “My head is about to explode. I want it to stop.” But hopefully, if your listeners are listening to this podcast while their migraine headaches are reasonably well-controlled, and know that this is a lot of the dialogue that’s going on.

Dr. Lowenstein: Well, let’s use that as a segue to, please listen to our podcast. I really, really, really appreciate your involvement, Jason. You’re a gem of a doctor to have in our community. I wish everybody had had access to people. One of the truly most altruistic physicians I’ve ever known. Thank you. To our listeners, please do subscribe. There’s a button somewhere that says subscribe, and please do leave feedback and give us a rating and a review. We certainly appreciate, and I will continue to listen. We’ve got our email at If you have comments or questions that you want to directly have addressed on further episodes I would love to hear from you all. We will look forward to talking to you again soon. Again, Jason, thank you very much.

Dr. Prystowsky: Hey, thanks Adam.

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