Q&A: Top Doctor Praveen Mambalam Is Working Toward a Better Understanding of Chronic Pain

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This article appears in print in the April 2019 issue, as part of the Top Doctors cover story. Click here to subscribe.

Why did you choose this specialty?
Pain medicine was an evolution for me from anesthesia. The OR was too much solitude; I wanted the outpatient setting, where I could talk to patients while helping them. Since pain medicine is a subspecialty of anesthesia, it was a readily available transition to foster my needs.

What is the most common type of pain among the people who seek your expertise?
Mainly we see pain related to the spine, such as disc herniation and spondyloarthropathy (joint diseases). However, we handle a number of chronic pain ailments involving all areas of the body.

What’s the most effective treatment for chronic pain?
There is no one effective treatment. Management is individualized to the patient and his or her presentation. Comprehensive methods that include combined approaches of rehabilitation, medication and injections are most effective and safe.

How has the opioid epidemic affected how you treat pain?
When we started our practice in 2007, we saw many patients from the community on high levels of opioids. With our comprehensive approaches, we were able to slowly reduce daily opioid use for our patients. With state and federal guidelines on opioid prescribing, there has been a steady decline in heavy opioid prescribing for chronic pain in the community. We have maintained our approaches, incorporating advancements in treatments and technology to help our patients move away from opioids and become more functional.

The opioid epidemic has resulted in a prevalence of opioid tolerance and dependency for a patient living with pain. We have incorporated addiction and chemical dependency programs into our clinics. There is also a psychologist on staff to service these programs as well as improve coping mechanisms for people with chronic pain.

What are your special areas of interest?
Lately, I have been focusing more on functional outcome measures for each patient. Since pain is subjective, it is challenging for physicians to address treatment objectively. Functional outcome measures clear the water. Focusing on objective data, such as how many steps each day a patient takes, brings more objectivity to how treatment is working on patients with pain.

What new treatments can we look forward to in your specialty in the next 5–10 years? 
Patient-demand analgesic devices: Data suggests that patients, when given the opportunity, know how to control their pain best, since pain is dynamic throughout the day. Patient-controlled devices for pain are superior for managing pain with reasonable safety. One example would be a patient-controlled morphine device, used in a hospital setting. Intrathecal morphine pumps [which deliver medicine into the spinal canal] and spinal cord stimulation would be examples of pain control devices for patients with chronic day-to-day pain.

What’s the biggest misconception about people with pain?
That the pain patients are feeling is real. Patients in need of treatment are not addicts and they are not crazy, but each situation is different, often difficult, and there is no magic bullet.

Is there a patient behavior that you wish you could change? 
I’d like them to be able to cope and function despite living with pain. Changing this involves heavy rehabilitation of the mind and body while doctors try to figure out the best approach to treat chronic pain diseases.