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Green Shield Canada

Episode 9: Chronic Pain

Episode 9: And now for something completely indifferent
In Episode 9, hosts Sarah and David welcome friend and colleague Peter Gove back into the studio along with Founder and CEO of ManagingLife, Tahir Janmohamed, to discuss the complex topic of chronic pain.
And now for something completely indifferent

And now for something completely indifferent

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Episode 9 Transcript

[INTRODUCTION]

[0:00:15.4] SM: Hello and welcome to another episode of GSC’s podcast; And Now For Something Completely Indifferent, where we’ll be discussing the hottest topics and trends in Canadian health benefits. I am one of your hosts, Sarah Murphy.

Before we get started with today’s episode, we would like to remind our listeners that the views expressed in this podcast are those of the individual speaking and not necessarily the views of GSC. We will likely talk about sensitive and even possibly controversial subjects and we therefore reserve the right to potentially offend and are apologizing for it upfront.

You can download this podcast from our website at greenshield.ca/podcast or subscribe to it from where you get your podcasts. We also encourage you to read our publications, The Inside Story and Follow The Script, which you can also download from our website, and please be sure to follow the conversation on Twitter and LinkedIn.

[INTRO]

[0:01:07.4] SM: And now let’s get started with today’s episode. Today’s episode is hosted by David Willows, GSC’s chief innovation and marketing officer. Hello, David.

[0:01:15.7] DW: Hi, Sarah. Thank you for that. Before we talk to our friends Peter and Tahir about the complex issue of chronic pain, people who listen to this podcast will know that you’ve had many travel adventures in the last couple of months usually involving poor weather. You’ve gone south a couple of times. It’s been freezing cold.

[0:01:36.8] SM: Lots of rain.

[0:01:37.4] DW: And rain too.

[0:01:38.4] SM: Yup.

[0:01:38.3] DW: Oh! You didn’t say that before, but now you’re just making it worst.

[0:01:41.6] SM: I just want to make it even more dramatic than it was.

[0:01:43.3] DW: Yeah, more dramatic. So this weekend, a number of us from our team had the chance to go down to Windsor and Detroit for big Hacking Health event where with all sorts of young people trying to come up with solutions for the healthcare system which was very cool, and we happen to go on this, now, infamous weekend in the GTA where we had yet another ice storm and our best laid plans to actually come home to our families were put aside and were literally trapped in downtown Detroit.

[0:02:09.9] SM: Stranded, trapped.

[0:02:10.1] DW: For three days. There’s not a lot to do there, but I just want to share with folks that you’ve found something to do.

[0:02:18.6] SM: I think you need to put some — Let’s clarify what you’re about to say.

[0:02:21.8] DW: I’m talking about eating food.

[0:02:23.7] SM: There we go. Something I like to do.

[0:02:24.7] DW: We’ve got this brand out, they’re called Change4Life and we sort of harangue people about making healthy choices and I just need to call out the widespread hypocrisy of the GSC product and marketing team for their behavior, specifically at a Sunday morning brunch in downtown Detroit. I don’t think I’ve ever seen you happier than in the two hours we spent having that brunch from about 10 am till about noon. The bottomless mimosas were one thing, but I think we should share with people, because, I mean, brunch thing, traditional breakfast, we both have the omelet preparation table. That happened for us. But what were your favorite unusual things that are available for brunch in Detroit, Michigan, United States at 10 in the morning.

[0:03:07.4] SM: Yeah. I mean, if you’re stranded. Yeah, like you said, we’re not able to get home to our families. We’re wrapping up this event and we’re hanging out. So when you’re going to brunch — I mean, it’s got to be a good one, and this was a good one. I’m not going to lie. It was — You have an omelet station, which is quite possibly like just the best breakfast option you can have, especially if you’re a mom of two kids and you make breakfast every single weekend and somebody is making you an omelet, it’s great.

The other things you could have, like shrimp creole. You could have fried chicken.

[0:03:36.2] DW: I had fried chicken.

[0:03:37.9] SM: I know you had fried chicken. Peter Gove would be very angry with you right now. They make pink pancakes and serve them at your table fresh.

[0:03:46.4] DW: Actually, you go to the brunch room to pick up all these food, but they bring the pink pancakes to your table and they bring one to every table. How many did you end up with?

[0:03:46.4] SM: We may have taken two orders of freshly made yummy pancakes.

[0:03:58.1] DW: Yeah. This is the anti-change4life weekend in Detroit. Are people going to find out about this? I don’t want anybody to know about this. 

[0:04:07.7] SM: Yeah, I think they’re going to find out.

[0:04:08.4] DW: Okay. That’s the problem with recording. Okay, let’s talk about chronic pain.

[INTERVIEW]

[0:04:16.6] DW: Okay. So in the studio today, an old friend, four-time podcaster, our innovation leader of health management, Peter Gove, and I can promise listeners that we have put the beef with Ned, your colleague, to rest. There will be no speaking of Ned today.

[0:04:33.4] PG: I’m sad, but I have to live with that.

[0:04:34.9] DW: Okay, thank you, and we’re going to get to Peter in a second. Our guest today is a gentleman named Tahir Janmohamed. He is the founder and CEO of ManagingLife. Tahir, welcome to the wellness room/podcast studio. Tell us a bit about what ManagingLife is and how you ended up forming this company.

[0:04:54.6] TJ: Sure. Thanks for having me here today. So we are a Toronto-based company, and we are essentially an app-based platform for people who suffer from chronic pain. So back pain, migraines, arthritis, and at the root of what we’re trying to do is really empower people with chronic pain to feel a little bit more in control of their condition, and we do that by allowing people to better understand what they’re going through, and more importantly allowing them to better communicate what they’re going through with their healthcare providers. What it means is we allow people to record what they’re feeling on a regular basis and we’re trying to bring objectivity to the very difficult and subjective nature of pain.

[0:05:32.9] DW: Okay. Great. So I happen to know that you’re like not a doctor. How did you end up starting this company?

[0:05:41.8] TJ: So I am a computer engineer. I did my MBA at UFT, and I work for either years at IBM in their strategy and analytics practice. What that means is I’m a data guy. I’m not a medical practitioner, but during my time at IBM I saw what IBM was doing for all of the insurance companies, banks, all the big players out there in terms of what they were doing with data and how they were using it to actually make these business decisions. I know it sounds cliché, but I saw that there was a lot of opportunity for applying those concepts to the world of healthcare and hopefully having more of a personal impact on the wellbeing of people’s lives.

So three years ago, actually three and a half years ago now, I left IBM and actually pursued ManagingLife fulltime to apply those concepts of data analytics to help people with chronic pain.

[0:06:29.3] DW: Okay. Terrific. Peter, back to you. Now, listeners will know that you’ve got sort of varied history in this industry.

[0:06:37.1] PG: Yes.

[0:06:38.2] DW: I always struggle for words. It’s long, we know that.

[0:06:40.9] PG: Sometimes too there’s all a big misunderstanding, as we know.

[0:06:42.7] DW: Yes. Okay. But you’ve worked both on the disability management side of our business, probably for the predominant part of your time in our industry, now you’re working for a drug claim manager, but you’ve also had time in private practice, in social work, so you’ve come across many different patient sets. How do you define chronic pain?

[0:07:02.8] PG: It’s a difficult concept, and chronic pain for me kind of falls in a chasm between psychiatry and rheumatology and orthopedics, because these things usually start, or not usually, but quite often start as an injury of some description. You can talk about cracks, since that’s a common one, where somebody has a whiplash-y type injury. There’s a certain expected recovery time for those kinds of injuries. There’re soft tissue injuries that recover within 6 weeks, let’s say.

Chronic pain is a phenomenon whereby people could continue to have pain well beyond the expected recovery time. So there’s no real physiologic explanation anymore for why they’re in pain. Typically, three months of pain post-recovery period is considered to be a chronic pain scenario.

[0:07:47.8] DW: Okay. I got it. Tahir, from the people that are already using your app over the past few years, is there sort of a common diagnostic history that you see there? Are there groups of people with sort of very specific diagnosis in their past?

[0:08:02.5] TJ: Yeah, absolutely. As a bit of background, we have over 30,000 users from over 130 different countries, and the most common types of conditions that people who use our application have, the number one is fibromyalgia. So fibromyalgia is a complex condition where there’s no biological marker for it. It’s kind of a diagnosis done by process of elimination. But closely after that, it’s back pain, neck pain, headaches and migraines of all sorts and then the family of arthritis, rheumatoid and alike. So those are our typical users, and that represents about three-quarters of our users.

[0:08:36.5] DW: Peter, is that consistent with what you saw with all your years in disability claims?

[0:08:40.1] PG: For sure, back pain for sure, fibromyalgia for sure. Those are pretty common condition. Yeah, pretty disability related pain conditions, for sure. 

[0:08:50.0] DW: Okay. To both of you, what has been the traditional history of how to treat these people?

[0:08:57.3] TJ: Based on what we’ve heard from our users, the first path to kind of getting treated for chronic pain is to go to your family doc, and unfortunately there’s no formal training in med school for pain management. So it starts off with a conversation, “Tell me how you feel?” “Rate your pain from zero to 10?” “How has it changed since the last time I saw you?” They provide some answers based on memory, and I always say I don’t remember what I wore last week, so no one is able to articulate what they’re going through.

Fast forward three months later when they see their doctor again, same sets of questions. By that time the condition is probably devolved. It eventually reaches a point where the family doc is probably going to prescribe something or refer them out to a specialist, and then when they go to that specialist, they have to retail their story, they’re asked the same set of questions. Maybe if it’s a specialized clinic, they’re given a paper-based questionnaire with — Drawn a little body where it hurts and answer more questions about how you describe your pain, what adjectives do you use.

[0:09:52.3] DW: So we’re still using paper.

[0:09:54.0] TJ: Absolutely. Every clinic that I’ve been to, it is a paper-based questionnaire, and that’s if there is a questionnaire. At the Toronto General Hospital that uses our platform, they have something called the fun pack. It’s over 40 pages of questionnaires that has to be filled out every visit. That just gives you a sense of what the status quo is when it comes to trying to be able to measure pain. 

[0:10:14.1] DW: Yeah. Peter, what did you see in your large volume of disability claims that you’ve managed on behalf of sponsors? What were some of the common themes in terms of treatment of these folks?

[0:10:23.3] PG: I think there’s a few themes there. When you look at the literature on what’s considered to be sort of gold standard in terms of things like managing back pain, the gold standard is to encourage the patient to continue regular activities and continue regular work as much as possible.

What’s interesting about that though is that the literature strongly suggests that’s not what the treaters recommend. They typically recommend bed rest and those kinds of things, and indeed overtime that simply makes the problem worse because I’m sure, as you know, if you spend 10 days in bed, almost anything after that is painful. In fact, it’s probably the worst thing that you can do.

We would see that fairly commonly, and then of course the patients get into a whole kind of cognitive framework where they’re afraid to move, they’re afraid to have re-injury. They develop this sense of inaudible 0:11:13.5] anxiety. In addition to that, there’re kind of social learning kinds of ideas too, which these people gradually get reinforced inadvertently, really, for portraying these kinds of behaviors. You don’t have to go to work anymore. [inaudible 0:11:27.2] paid to be off work and all these kinds of things. It becomes this huge sort of bio cycle social problem that’s very, very difficult to manage.

So we’ve heard about the challenges for family physicians who don’t have perhaps specific training in this. Is there a field out there that is now expert in chronic pain, or is that still under development? I think that chronic pain falls in a chasm between a bunch of professions. There are people with advanced training in managing pain, but — And they run clinics, they run pain clinics and pain [inaudible 0:12:00.8], which in some case are very good. They’re very good, but there’s very few of them. They’re very hard to access. Really, I would suggest that pain management in Canada is poorly understood and poorly delivered by enlarge.

[0:12:14.0] DW: Okay.

[0:12:14.9] PG: Yeah. Actually, some statistic, I’ve read a report where I think there’s just over 70 specialized pain clinics in all of Canada relative to the states. There’s over 1,100. That just speaks to the lack of adequate pain management done here. I’ve seen the pain management done from a number of different angles. There’s the anesthesiologists, there’s the physiatrists, there’s the psychologists, there’s the chiropractors. There’s a whole host of different disciplines that would suggest that they are pain physicians or clinicians.   

[0:12:46.1] DW: Okay. Peter, back to sort of your life in managing disability claims. So obviously you had a lot of claims that probably had the words chronic pain attached to the diagnosis.

[0:12:59.2] PG: Or fibromyalgia, that’s a very common kind of thing as well for sure.

[0:13:01.8] DW: Okay. So what reasonably can ensure its carriers do to manage those cases? What has shown to work, if anything?

[0:13:11.3] PG: Yeah. I think any of these, I’m going to characterize this as a psychological condition to start with, because there’s no sort of physiologic explanation for the pain. So it’s got to be a perception of the pain to begin with.

[0:13:22.2] DW: For the pain to have gone on this long.

[0:13:24.0] PG: Yeah. It’s really — Indeed, I heard a good physician say that when patients say, “Doc, are you telling me it’s all on my head.” He said, “It’s yes. I am telling you it’s on your head,” which I think is quite an interesting way to think about it.

I think with many of these kinds of situations, what you don’t want to do, if you can avoid, is go get themselves embedded into this kind of, at least, call it disability lifestyle of whatever it is. You don’t want them to get embedded into the psychological and behavioral patterns that are associated with chronic pain.

Unfortunately, on the disability side of things, sometimes these people get their claims submitted after a very, very — Like 6 months of a waiting period or something like that. So the time we see them or we would see them in disability, they’d be very much embedded in this space and very hard to budge.

As I suggested, the difficulty with chronic pain folks on the disability side is that case managers are very suspicious of them simply because there are no biological markers to their condition. It’s always sort of malingering and these kinds of things. You’ll get into to sort of a very antagonistic relationship with them.

I think, optimally, if you could get involved to these people very early and basically make sure that the appropriate treatments are being instituted, and that’s basically activity-based treatment, and cognitive treatments.

[0:14:37.5] DW: You have to sort of separate them from a position that’s telling them to lie down.

[0:14:40.6] PG: Exactly. Doing nothing is the worst thing that they could possibly do. Doing nothing and, of course, being medicated with opioids, because once you start medicating folks with opioids and the outcome deteriorates significantly, right? So you really want to try and prevent, first, exposure to opioids and focus on keeping these folks active. Then when we see them in disability, the person is being prescribed an opioid and is very inactive, we know — And complaining about pain with every movement, we know we’ve got a big problem.

[0:15:08.4] DW: Okay. So let’s connect this to the word opioids, because one of the questions I had written down here is what is the connection between a diagnosis, a chronic pain and what we’re not deeming the opioid crisis that’s happening sort of in the western world. Are the two related?

[0:15:25.1] TJ: Yeah. I think what’s important to say right off the bat is that the majority of people who take an opioid aren’t addicts. They do so for a legitimate chronic pain reason, and there are many people who take an opioid to manage their chronic pain and are perfectly functional. I think that tends to get forgotten, and there is a disproportionate amount of emphasis placed on what we are seeing as street level sentinel, which is a very different category of person and a different problem altogether.

So I think that’s an important distinction that we’ve seen —

[0:15:57.1] DW: No. I think we may have moved to a world now where it’s sort of like if you’re prescribing opioid, that’s a bad thing. That’s not good treatment, I think the medical community would say that’s going too far.

[0:16:06.7] TJ: Absolutely. I think the practitioners that I speak to are completely against putting any limitations or laws against prescribing over certain limit because, as I mentioned, there could be someone who’s been an opioid for 5 years, has built up a dependency and needs a certain amount of dosage just to maintain that baseline level of functionality. The moment you cut that person off, they’re going to the streets, because they need it to survive. That’s very dangerous, and the CDC issued guidelines in the U.S. that started putting some limits. Now we’re seeing a lot of doctors in the US refusing to prescribe opioids, and that essentially cuts out a huge portion of people that legitimately need it and are finding their sources elsewhere.

[0:16:45.9] PG: Yeah. I think, really, what we want to do with opioids is as much as possible prevent first exposure. So what you want to do is you want to engage people in more psychological and physical rehabilitation kinds of programs rather than opioids. Certainly, 10 years ago or so, pain doctors felt that opioids were the way to go, and this is a notion that’s promoted by the — pressed by Pharm and others, and they got into prescribing opioids for folks and they’ve learned sort of after the fact that this was not the way to go. I agree, there’s tons of folks who are at high doses of opioids who function quite well and probably we shouldn’t be trying to so-called fix those folks. They’re not really fixable. They do okay. Maybe at higher doses than you would like, but we should probably leave those people alone and look at the folks who are much earlier in this process and try and prevent this from happening in the first place.

[0:17:32.8] DW: Is this similar to — I mean, you’ve been on this podcast before talking about mental health and your famous Medicalization of Unhappiness presentation, where the argument really is we’re using antidepressants as the first line treatment, when there’s this other stuff. Is this sort of the same thing? 

[0:17:43.9] PG: You got it, exactly. You can think about it in this way, is as soon as you medicalize a problem, which probably shouldn’t be medicalized, it’s more bio cycle social. You create all kinds of problems with antidepressants and with pain medications as well. These are social and psychological problems more so than medical problems, and unfortunately when they drift into the medical sphere, we treat them medically and that probably creates more problems than it solves. That’s a very good point.

[0:18:12.2] TJ: I wanted to add. I think I agree 100% with that. I think treating people that are already on an opioid differently than people that are just recently diagnosed and kind of starting their path of chronic pain management, they need to be considered separately. I believe that a multidisciplinary approach to pain management is absolutely required. It’s not just prescribe an opioid and next patient, and unfortunately that’s largely —

[0:18:36.0] PG: That’s kind of where we ended up, because it worked. It seems to work, right? It seemed to work for these folks. It seemed to work.

[0:18:42.8] DW: Okay. Tahir, we don’t like to do commercials, but I want you to talk about your idea and your company and who you’re specifically targeting with your technology and what you hope to accomplish with your app.

[0:18:56.8] TJ: Absolutely. As I mentioned, we have over 30,000 users, and the recent people use an application like ours is because they are either newly diagnosed or they’ve been suffering from a chronic pain condition and they’re trying a new treatment or they’re seeing a new specialist and they have questions. They want to be more involved in their healthcare and I think that is a very difficult thing to do for people who suffer from chronic pain and have been kind of disillusioned with the whole process, is let’s get them engaged and empowered, and that’s the first thing that we try to do with our application. People record about their feeling and then see trends and patterns and they can actually take action.

One example, there was one of our users, a long term opioid user, had been on it for over five years. Started tracking his pain and what he found out is I the morning, that his breakthrough opioid medication was not changing his pain level. It was like a consistent level pain. Now this is a very enlightened person and he actually cut his breakthrough medication in half by stopping taking it in the morning.

Now, no doctor will ever say people should choose their own medication dosages, but in that scenario no doctor could have told him to stop taking it in the morning. So the idea here is let’s provide information back to people because they know their bodies best. It’s very similar to a Fitbit. The second part is when a lot of people with chronic pain go to seek treatment, they really struggle being able to articulate what they’re going through. Describing pain is hard.

So what we do is we try to give them a language in an objective way that allows them to have that conversation and hopefully they are able to get past that point of it’s in your head or you’re depressed, which unfortunately a lot of chronic pain suffers tend to hear. In this way they are able to generate a report that says, “Hey. My pain is real. You can’t just shrug me off. I need some kind of treatment,” and hopefully that treatment is going to be a multidisciplinary treat, not a script for an opioid. I think psychology, pure support, all of these are mindfulness. These are all valid techniques that need to be pursued.

The last part of what we do is we actually have a portal that was consent pain clinics or disability insurers can actually remotely monitor how their patients are doing, and the goal there is to identify people who are at risk and moving down the wrong trajectory, and they look for warning signs, and so that they can intervene proactively and give them alternative treatments, bring them into the clinic, take action and the whole biz is hopefully to change that trajectory so that they can eventually get off their opioid.

[0:21:18.1] PG: That’s really interesting though, because I used to this as an example. You have two people with exactly the same injury, let’s say lower back sprain or something like that. One guy recovers appropriately. It was in what you would expect the other guy with exactly the same situation evolves or devolves into a chronic pain case, right? It’d be lovely if you could figure out which is which. If your data eventually can lead us through sort of picking those folks who need a real intervention, that’d be terrific. That’s be very interesting for sure.

[0:21:46.5] DW: Tahir, how do you find patients and how do patients find you?

[0:21:49.6] TJ: The majority of our users right now search for pain on Google Play Store and they download it. We’re, I think, number two. The first one is a paint app. It’s a spelling mistake. [inaudible 0:21:58.8]. But now we’re starting to have more partnership. The Toronto General Hospital uses it in their transitional pain service. It’s headed by D. Hans Clark, and what they’ve done is they’ve identified what they would call at-risk patients. So patients that are going through a major surgery that are at risk for developing chronic or surgical pain. What they do is in conjunction with psychology peer support and their multidisciplinary approach, they also offer application. The patient is able to self-manage, track what they’re going through, improve the conversation when they do come into the clinic. I think what they’re really going for is to keep these people engaged in their healthcare so they don’t go down that trajectory.

They’re also, as I mentioned, looking for warning signs so that they can pick up the phone and call some of their patients, and their sole goal is to either reduce the amount of opioid consumption after six months or completely eliminate the opioid consumption after six months for that population.

[0:22:51.2] DW: Got it. So what is your long term vision for your company? I mean, right now you’re working in the chronic pain space. You’re trying to get people to know your app. What next?

[0:23:00.5] TJ: What we’re trying to do is essentially trying to reach as many people with chronic pain as possible. We want to be entirely focused on chronic pain. We’re very much just focused on that one condition. We want to evolve the product to add additional value. Things like tracking and generating automatic associations with weather patterns. Is my migraine getting worse when it’s cloudy outside? Getting more sophisticated with medication effectiveness. Is that Gabapentin really making a difference on me? Is that mindfulness therapy having an impact?

So getting more sophisticated about highlighting patterns and meaningful things in our application both for the patient themselves, but as well as those that are responsible for treating them and monitoring them. Our goal is to partner with treatment providers, hospitals, but also insurance companies so that this can be offered to as many people as possible as part of their health benefit plan.

[0:23:49.8] DW: Is it cool to call you a startup?

[0:23:51.2] TJ: Absolutely.

[0:23:52.6] DW: Okay.

[0:23:52.6] TJ: We very much do. It’s very much a startup.

[0:23:54.5] DW: Okay. What are the systemic barriers for a startup trying to do this in the Canadian healthcare system?

[0:24:01.3] TJ: I think one of the challenges is, first of all, something like this has never really been done in the world of pain. Chronic condition management is really difficult in Canada, because our system is set up for acute care. It’s starting to happen in things like mental health and diabetes, but definitely not in the world of pain. I gave that example of the number of pain clinics in all of Canada. I think even though chronic pain affects about 20% of the population, less than 2% of research funding goes into chronic pain research. We have a huge gap to close. That, I think, is a huge systemic barrier.

The second thing is there aren’t the financial incentives at the provider level to adequately deal with chronic conditions, and more specifically chronic pain. There is no financial incentive to prevent someone for not taking an opioid. There isn’t someone to get someone off their opioids, at least for the treatment providers. So I think those are challenges that need to be addressed and are starting to get addressed. I think there was a big chunk of funding that was announced just last month for opioid prevention, and I think that’s going down the right path.

[0:25:02.6] DW: Good. So one of the reasons I asked Tahir that is, because certainly we have been talking to you for probably the last 12 to 18 months about a role that a carrier can plan in this and to try to help sort of spread the word and get more people access to this app. What I’m hoping is a year from now we can come back, talk maybe about some of the systemic things that are happening for this population, but also to see how many more people are using the mobile app and what we’re learning about them. Thanks a lot for coming in toady.

[0:25:29.1] TJ: Absolutely. I appreciate that.

[0:25:29.9] DW: Thank you.

[END OF INTERVIEW]

[0:25:34.6] SM: Thank you to our listeners for tuning in to another episode of And Now For Something Completely Indifferent, a Canadian health benefits industry podcast. To be sure to get future episodes, please subscribe to this podcast wherever you get your podcasts or visit our website at greenshield.ca/podcast to download.

As a reminder, we talk about these issues consistently in our publications which are available on our website. Specifically for today’s episode, you can check out our May 2018 issue of the Inside Story. Thanks for listening, and we’ll talk again soon.

[END]