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Video Podcast on Integrated Pain Management at Walter Reed

TRANSCRIPT

Dan: Well, hello. I’m Dan Lukaczer. I’m director of medical education at The Institute for Functional Medicine. And I’m sitting here with Mylene Huynh, who is a medical doctor, and we’re going to talk about a few things related to her practice and her assessment and interventions around pain. So Mylene, welcome.

Mylene: Thank you.

Dan: Can you tell us a little bit about your practice? Where do you practice—and give the audience a little understanding of that?

Mylene: I currently work at the Walter Reed National Military Medical Center. It’s located in Bethesda, Maryland. It is the largest military medical center in the world. It’s a 350 teaching hospital—350 bed teaching hospital, and we serve over a million active duty retiree and family members. I work in the pain clinic there. My patients are usually referred to me for chronic pain, and I provide integrated pain management.

Dan: How do you start when a patient comes in? What do you start with? What is your kind of way that you start talking to them about pain, and about helping them with pain in an integrative way?

Mylene:

The first thing I do is try to empower my patients.

A lot of military patients are used to taking orders, right? There’s usually a rank hierarchy, with the doctor usually being outranked by the patient.

I talk to my patients about, you know, that health, it’s for health, that is their mission.

And in this mission, they are the commander of their mission. They get to select who gets to be on their team so they could be successful on this mission.

I use the Functional Medicine model looking at the ATMs.

[Antecedents] A lot of research shows for a lot of our military members, they experienced higher adverse childhood experiences than civilian counterparts. But I don’t actually touch on that at their first visit.

Triggers are usually deployment, stress; a lot of members are on multiple courses of antibiotics throughout their career. Each deployment, to protect all members against malaria, we place them on

doxycycline, and they’re on doxycycline for months at a time and multiple courses throughout their career.

And then the mediators are a huge part for military members and retirees. Bringing that to their attention—like sleep may perhaps be an issue, stress and nutrition. Most of the family members of military members do exercise. I don’t have to talk a lot about exercise, but stress and nutrition and sleep are the big topics that I start with.

Dan: Good.

You’re obviously talking about, in that model, you’re talking about the base of the matrix, the modifiable lifestyle factors that we talked about. We’ll talk about stress and sleep and nutrition in a minute. How about the other part of that bottom of that matrix in terms of the community and connection to you. You also have conversations about that?

Mylene: Absolutely.

In terms of my recommendation, I put the modifiable lifestyle in terms of eat, pray, love, and play. I start with eating because all of us eat. I know you’re gonna eat.

So let’s start there, and increasing fiber, talking about phytonutrients. A lot of our members may not be exposed to a lot of different vegetables and fruits. I happen to be one that I just love fruits and vegetables. I have not met a vegetable I have not liked. I encourage them to try different types of fruits and vegetables, adding water and fiber, making sure they pay attention to their diet. That’s to eat.

Also, in the military, we’re the Department of Defense. I ask them, “Do you know where the Department of Defense is in your body?” And it’s the gut.

I have a conversation about, “You gotta protect the gut because that’s like the Pentagon, and all the major headquarters are in your gut.” So they get that, you know, starting with the nutrition, the gut as the foundation for health.

The next part: pray. Pray is rest and sleep. It’s about bringing mindfulness and awareness into their day.

And then love.

I usually ask them: what do you love?”

Who makes you smile? Bring back joy into their life.

Then play, it’s asking, what do you want to get better? What would you do differently once your pain is better? Having them focus on the goals, what in the military we call those end states. What is the end state? What does the end of this mission look like? Having them then visualize that and putting that right up front.

Dan: That’s great. It sounds like when a military person, somebody comes in, before you’re even necessarily talking about their pain, you’re talking about that base. And you’re trying to get all of those things set and make sure that they understand that those are the most important places to start with and they’re integrated. That all, of course, makes sense.

The way you’re talking about making it specific for them, that’s always a good thing to do.

In terms of what you do with nutrition, two questions. Just curious, you talked about phytonutrients and food.

Do you use some of the IFM Toolkit items? Or have you created your own, or what do you do?

Mylene: Yes, I do use the toolkit. That’s one of, I think, the greatest benefits of being a part of The Institute for Functional Medicine is having those resources so that I don’t have to recreate those.

Dan: What particular ones?

Mylene: Phytonutrients is huge, [IFM’s] Elimination Diet for those who present with pain and IBS. I usually encourage them to try to eliminate some of the common triggers.

For military members, they follow orders very well. Nobody wants to change diet, right? Diet is so difficult to change. But with military members, I would say, you know, you can do anything for three weeks or six weeks. You know, being in the military, three to six weeks is nothing. People are deployed for six to nine months. So putting that frame of time, it doesn’t seem to be a hindrance for them to try.

Chow hall. So military enlisted members are required to eat in the dining facility, usually on [specific] days. And as a physician, I can write a prescription for them that if I feel that they need to be gluten free, they need to be dairy free, they can take that prescription to the chow hall and get a substitute. That’s part of the
empowerment—I think a lot of members have not thought to ask.

When they go and ask, “We need, you know, more vegetables,” there’s this demand thing. So as a member, if they ask and there’s more people asking, and creating that demand, they’re able to get healthier options.

Dan: The other question is, do you prescribe nutritional supplements? Are they able to get those? Can they afford those? What is the kind of baseline that you work on, if any kind of supplementation?

Mylene: On all formularies, omega-3 is available. Certainly vitamin D. We only have magnesium oxide in the formulary, but we can do a non-formulary request, basically just justifying why we’re asking for a different type of magnesium, and have been successful in that. B complex is available. The only thing that’s not available that I use often, recommend often, is curcumin. But to save cost, people can get it as a powder form, as a food rather than the pill, if they could tolerate that.

Certainly, sleep is an issue, so melatonin they also have to get over the counter. Most of my patients have not pushed back despite the cost. If they’re motivated to heal and feel better, they’ll prioritize the resource.

Dan: That’s great.

All of many of those things are part of the formulary that you could just prescribe them, and there’s no cost issue. What about general labs that you get and use? Do you do a serum vitamin D, or do you just prescribe it?

Mylene: Absolutely, I always test first. Most of the labs are actually available in AHLTA, [those] that we use in Functional Medicine. The only thing that I can’t do is a comprehensive stool analysis. If they present with IBS and a history of multiple antibiotic use, I would treat as if they have dysbiosis. I do go through the 5R steps.

I haven’t had any trouble with the labs. And also maybe because I’m at Walter Reed, where we are a referral center, a major medical center. If I can’t get a lab, we, the military, work with LabCorp. You can always get the lab outside the system if necessary.

Dan: And are you able to get laboratories so you can do a full celiac panel, for instance?

Mylene: Yes.

Dan: Do you do any genetic testing like [HLA] DQ2 or DQ8 for celiac?

Mylene: Absolutely, those are available.

Dan: That’s wonderful.

Mylene: I believe any military physician could order that. Yes.

Dan: Is there a standard panel that you would use across the board, or do you mix and match?

Mylene: Do you mean pain patients in general? I usually check vitamin D.

I have not had a pain patient referred to me at Walter Reed that did not have vitamin D deficiency.”

100% of my patients are deficient. I’ve had patients as low as level of seven or eight vitamin D, and they’re light skinned and active duty in their twenties. Unbelievable, right?

I check magnesium. I check B-12, folate, B-6, and homocysteine to get assessed of their nutritional level. I usually place them on omega-3.

Then, based on the vitamin D level, I supplement magnesium as well.

Dan: You mentioned melatonin that you use for some with sleep issues. What other things are you doing for—obviously again looking at the bottom of the matrix—what other things are you regularly prescribing for those pain patients who obviously, they would have pain if they’re not sleeping. If they’re sleeping great, you probably wouldn’t prescribe anything.

What are some of the general ways that you handle that modifiable lifestyle factor?

Mylene: Sleep is a huge issue for pain patients. When a pain patient comes to our clinic, we ask not only what their pain level is, we ask about emotions, you know? What are they feeling? Anger, shame, you know, getting the sense of their emotion, their energy. Then we always ask about sleep.

And nearly all of my patients with pain have sleep issues.”

So, besides nutrition, I emphasize a good sleep. Studies show, I don’t know if you’re aware of this, Dan, studies show that 85% of military members have sleep issues. Did you know that?

And over 50% have obstructive sleep apnea. And 25% that just have difficulty sleeping. Average military members sleep less than the average American. We sleep less than about five hours or so. 40% or more sleep less than five hours.

That’s because of the operational tempo with the work demand, the fitness they have to continue to do while they are working long days.

First thing I do is try to figure out why they’re not sleeping. If there’s indication for a referral to a sleep clinic for sleep study, if I suspect obstructive sleep apnea, I would do that.

I would try to figure out, is this a delayed onset insomnia, or they’re just getting up frequently? If it’s delayed onset, what I’m finding with a lot of my patients is they’re still working at home. They don’t really stop working. They go home, they exercise, have dinner, and then get back on the computer. I encourage them to have a break between their computer or their iPhone or other electronic devices before they go to sleep. Have a good what we call sleep hygiene, sleep routine, to kind of wind down for the day. Certainly magnesium, melatonin, things like that may help.

If they’re getting up during the nights, it’s usually because of pain, so we would try to maximize, optimize pain control so that they could sleep better. And my patients always joke with me because I always say,

Sleep is good, sleep is good.”

They want to get me a T-shirt that says “Sleep is Good.” Sleep needs to be emphasized. We’ve not done that well in the military in terms of emphasizing sleep as a key part of optimal performance and health.

Dan: I think there are sleep issues across the board with the civilian population, and that’s what I mainly deal with. And sometimes I find it amazing, surprising that you can do very simple things. You mentioned magnesium and melatonin and sleep hygiene and turn that off an hour before you go to sleep or sleep in a dark room. And it’s amazing. The help that just those simple things…they just don’t pay attention, or we don’t pay attention to those kinds of things.

Mylene: Not watching the news late at night.

Dan: That’s a bad thing.

Mylene: I have several patients who worked at the intelligence community, and after they retired, they could not stop watching the news. They feel as if they’re responsible to know what’s going on in the world as part of their work. Disassociating that now that they’re retired, they still feel that they have to know every moment so they don’t get to bed til two or three in the morning.

So that’s a huge behavior change, getting them to maybe watch the seven o’clock news, but not the 11 o’clock news.

Dan: We talked about that bottom of that matrix. Let’s go on…just curious as to some of the therapeutic modalities you use in your clinic in terms of, I know you’re an acupuncturist.

What other things do you use? Microcurrent? Talk a little bit about how you use those, when you use those.

Mylene: Lifestyle is the foundation. Then most patients are referred to me because usually they have failed other modalities. Acupuncture, sometimes it’s the last resort rather than the first resort. I think word’s getting out when people are asking for acupuncture first.

About three years ago, my colleague at Walter Reed and I, my colleague who’s the neurologist, Dr. Steve Sharp, and I were looking for another modality to add to acupuncture because our wait list, Dan, is so high. I would see a patient, a new patient for pain, for chronic pain, would do acupuncture, but they wouldn’t be able to get in for another six weeks, two months. It’s very delayed, and that’s not how we do acupuncture. It requires frequent treatment.

So what we’re looking for is a tool that would prolong the effect of acupuncture. Came to discover frequency-specific microcurrent, and we actually use frequency-specific microcurrent with pretty much every acupuncture encounter. We use both together and find that it does prolong the effect. Both together prolong the effect. We’re able to see a patient once and not again, perhaps, for three or four weeks, or a little longer, and they’re still getting the relief.

Dan: That’s wonderful. You use microcurrent, you use acupuncture, and you use… You were just an instructor on battlefield acupuncture. Do you use that specifically, or do you use general acupuncture for these kinds of pain patients? Because, as you taught us, battlefield acupuncture has a specific protocol for pain. Do you use that regularly with pain patients, with any kind of pain?

Mylene: By the time the patient comes to see me, they’ve had battlefield acupuncture, because we train over 7,000 DOD VA [Department of Defense Veterans Administration] clinicians. They either like it or they don’t. They will tell me often that, no, I don’t want it. Because it’s a big needle, and it’s not always very comfortable. So I’m trained to do full body acupuncture, and that’s what I do. And if they experience that battlefield provides lasting treatment, I will add that. Battlefield acupuncture protocol is an adjunct; I’ll add that if it’s something they find beneficial and they don’t mind the size of the needle and wearing the gold studs.

Although we have lots of military members, including general officers wearing these gold studs at the Pentagon, not everybody’s comfortable doing that. So it’s one of the tools we include. But it’s part of the whole-spectrum acupuncture treatment.

Dan: What other modalities do you use that we haven’t talked about?

Mylene: Yeah, so we are very fortunate at the pain clinic. We have a clinical psychologist who especially trained in pain psychology who works with us. We have a clinical pharmacist. We have a yoga and meditation instructor on staff. We have a nurse who does Reiki, and we have several nurses trained to do various energy modalities such as Alpha-Stim. Our clinical psychologist does biofeedback, in addition to CBT: cognitive behavioral therapy. Then we can refer to an integrative nutritionist.

We do have incredible resources. Occupational therapy provides heart rate variability [feedback training]. If

I feel like that’s where my patient needs more of that parasympathetic activation, they get the OT referral.

It’s very fortunate.

Dan: You have a lot of resources. Is that all within Walter Reed?

Or do you refer out to satellite clinics or how do you do that?

Mylene: It’s all within Walter Reed.

Dan: It’s just all within the same healthcare setting.

Mylene: That’s right.

Dan: That’s wonderful. Do you find that you use group visits with any of those modalities or with any particular kinds of pain patients?

Mylene: We had a physical therapy [group that] actually led a “Living Well With Pain” class that I was a part of. I did the nutrition piece for them. The thing with Walter Reed, it’s a major medical center located actually right across from the NIH. It’s not an easy place to get to. We are finding that it’s hard for a patient to commit to a six- to eight-week visit.

So we have kind of redesigned the group visits. Starting next month, we’re doing one at the pain clinic for new pain patients to introduce them to understanding chronic pain, what it does to the brain, empowering them to select their treatment program. If they want to do cognitive behavioral therapy first or acupuncture first, we can help them design their treatment program, laying the foundation of lifestyle change up front. That’s something we’re starting next month.

And making it shorter, four weeks instead of eight weeks, to see if we can get better compliance.

Dan: That’s great. I grew up actually around—probably a couple of miles from the NIH. That whole complex there, Walter Reed. There’s now a metro station, right? Right there.

Mylene: Oh yeah, the Major Medical Center, yeah. And lots of traffic that comes with it.

Dan: So it’s changed a bit in the 40 years since I lived there.

Anything else, Mylene, that you’d like to share with us that you’re doing, in this—what sounds like a wonderfully comprehensive clinic for chronic pain?

Mylene:

I find Functional Medicine is a very beautiful framework.”

When I retired from the Air Force, I wanted to go back into a direct clinical practice. One thing in the military is, as you stay in longer, you get more administrative responsibilities, and I really missed the clinical care.

I find Functional Medicine really brings back the joy, because you get people better. I don’t have to see my patients as often, and they’re healthier. I think that’s like the purpose of life. It’s not to be with us doctors, it’s for them to be out living.

I have to say that Functional Medicine really helped me restore that joy in clinical practice.

Dan: That’s great. Well, I want to thank you for spending a little time and telling us about your practice and the models that you use.

Mylene: Thank you.

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