Dr. Kirsh, assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky, is a licensed clinical psychologist. His particular areas of interest include chronic pain management, pain and its interface with abuse and addiction, and palliative care issues in cancer populations. He was recently kind enough to sit down with SDN and give some perspective into clinical psychology as a career choice.
1.Tell us about your educational background.
I attended a rather unique doctoral program at Indiana University – Purdue University in Indianapolis. The program was entitled ‘Clinical Rehabilitation Psychology’ and I was drawn to it as it was basically one of the few dedicated, medical psychology programs in the country. It was a small program but very thorough and challenging. Out of 6 people who entered in my year, 3 of us would eventually graduate. I picked up an M.S. degree along the way and eventually earned the Ph.D.
2. How long have you been with the Pain Treatment Center? What were you doing before?
My current position is an interesting blend. As a psychologist, it is strange that I split my time as an Assistant Professor in Pharmacy at the University of Kentucky (UK) as well as serving as a pain psychologist at The Pain Treatment Center of the Bluegrass (PTC). I have been with the PTC for about 18 months. Before that, I was an assistant director for a Symptom Management and Palliative Care initiative at the Markey Cancer Center at UK.
3. Did you plan to enter this specialty when you were in school?
My training was in medical psychology, so I somewhat could have envisioned my current love of pain management. However, my training was really leading me towards broad-based symptom management and assessment for people with head injury and stroke. Moving to cancer patients, and later pain patients (both malignant and non-malignant) was an ongoing and evolving process.
4. Describe a typical day at work.
The fun part of my job is that there is no ‘typical’ day. I am able to spend some time teaching in the College of Pharmacy, a day or so per week clinically seeing pain patients, and then a lot of time doing research activities. The pain management world is still relatively young and there are a lot of research needs that need to be filled.
5. For what types of problems are patients referred to the Pain Treatment Center?
As a specialty clinic, the PTC only accepts patients by referral. We will accept people with any sort of chronic pain concern, but the bulk of patients have non-malignant pain of some variety (i.e., low back pain, knee pain, arthritis, peripheral neuropathy, etc.). That said, we do have a sub-population of cancer patients with pain issues as well as just about any other type of pain you can imagine. We have over 8,000 patients and serve them with a mixture of medication therapy, physical therapy, behavioral medicine, surgical procedures and interventions, etc. It is a truly multidisciplinary clinic, which is becoming more rare these days.
6. What is the biggest challenge you face in serving your patient population?
The biggest challenge is also the thing that is the most interesting for me. My specialty is really pain management in the face of abuse, addiction, and diversion. Living in central Kentucky, we are an epicenter of sorts for prescription drug abuse. This creates a huge challenge with regards to trying to sort out genuine pain patients, doctor shoppers, addicts, and those patients who might have genuine pain but also some of these other problems.
7. There is significant social stigma attached to pain treatment and prescribing opioids specifically. How does that affect patient care?
There is a growing sense of opiophobia in the country. Some patients are afraid to take opioids for fear of being turned into addicts, while some doctors refuse to write for any controlled substances out of fear from regulatory sanction or being duped by a patient.
8. How do legal and law enforcement issues affect the practice of pain treatment and management?
As above, there is a great deal of fear on the part of prescribing physicians. We have seen many small pain practices shut down after receiving pressure and threats from law enforcement. It is true we have seen some bad doctors who, in my book, were no longer practicing medicine (e.g., seeing 50-60 patients per hour, giving each the same prescription, accepting cash only for the service, etc.). However, there has been a tendency to try to limit all prescribing of opioids by putting pressure on doctors. That said, I think we are starting to see a new trend of law enforcement working with pain management professionals in a collaborative way. The National Association of Drug Diversion Investigators (NADDI) is a great example. I recently joined NADDI and have been really impressed by how that subgroup folks want to work with us and learn about pain management as opposed to assuming all healthcare professionals are misguided and contributing to prescription drug abuse.
9. What is the difference between chronic and acute pain, and how does that affect patient treatment and management of pain?
Acute pain is temporary by definition and is a response to some trauma or insult to a person (i.e., accident, surgery, new disease process, etc.). Acute pain is usually accompanied by physical manifestations such as tears and sweating that let us know there is a real problem. It does serve a survival purpose, such as telling us to quickly remove our hand from an open flame. Chronic pain is a maladaptive, lingering process that no longer serves a survival purpose. Some argue today that all chronic pain eventually becomes neuropathic pain due to a rewiring of the nervous system. Patients with chronic pain can state they have 9/10 pain while sitting in an office looking otherwise pleasant and comfortable. Not seeing the overt signs of acute pain often leads people to think chronic pain patients are faking it or exaggerating their pain levels, which is not necessarily the case.
10. What types of modalities, besides pharmacotherapy, are available to help manage chronic pain?
As I alluded to above, our clinic offers multimodal approaches to pain. Part of the reason for this is that no one thing usually works alone. Indeed, much of chronic pain treatment is trying to take away as much pain as possible while getting the patient to be more functional in their daily lives. We rarely get people “pain free” and try to communicate to patients that drugs alone will not be adequate. Other options include physical therapy, TENS units, injections, behavioral medicine, hypnosis, dry needling, intra-thecal pumps and stimulators, pacing, deep breathing, and various relaxation techniques to name a few.
11. What is the number one thing you wish the general public understood about the problem of chronic pain?
I would like to teach people that opioids do not create addicts simply by exposure. Simply put, there is no iatrogenic addiction associated with exposure to opioids. Patients need to have a unique constellation of genetic, familial, social, psychological, and spiritual components to be vulnerable to addiction. I spend a great deal of time explaining to patients (who have no risk factors) why it is highly unlikely they will become addicts.
12. What aspects of your practice have most challenged or surprised you?
The biggest surprise has been the complexity of patients in this region of the country. I have a few colleagues who were here for a while and then went back to other parts of the country who all had the same thought. We might associate difficult patients with bigger cities, but the truth is the more rural areas have been hit hardest by prescription drug abuse and the tendency to self-medicate to escape their daily existence.
13. Your practice combines clinical and academic work. Do you find that these areas complement each other or is it hard to strike a balance?
They do complement each other, but it is still a challenge. Time management is always an issue and I do feel scattered at times. The nice thing is that psychology affords the training to let me be involved in research, teaching, and clinical work. While I’ll never be rich, I’ll also never be bored or looking for something to do!
14. What is your favorite aspect of teaching? Least favorite?
I love performing and being in front of crowds. I’m a somewhat shy person in other ways, but have always liked being in front of groups. Being able to tell some jokes, make an impression that students might take with them, and connect with a group is definitely a highlight. The least favorite is definitely grading papers and test. Yuck, enough said.
15. Tell us about your research and publishing activities.
I have published nearly 60 refereed articles and 20+ book chapters along with other types of publications. Most of my work focuses on cancer pain, non-malignant pain, addiction, abuse, diversion, and symptom management broadly defined. This takes up a lot of my time.
16. Do you have a family? If so, do you find that your career leaves adequate time to spend with them?
I am married to a wonderful woman named Kristy. We do not have children, but were crazy enough to adopt 4 full sized collies. My career keeps life busy, but I do try to maintain some balance in my life. It is hard to do with constant deadlines buzzing about, but I feel it is important to keep balance so I don’t look back with regret. That said, I do have to confess I have not been on a vacation since I went to Disney World with my family when I was about 6 years old! Guess I still have a ways to go.
17. What do you like to do in your spare time? Do you have any hobbies or volunteer activities you’d like to tell us about?
I am an avid musician and play in a local acoustic-based, roots and Americana band. I play upright bass, electric bass, guitar, ukulele (yes, ukulele), drums, and mandolin. I am primarily a bass player, but have been really taken with the ukulele. Outside of music, my wife and I do volunteer with a Collie Rescue organization. While our house is too small to take any more dogs, we do act as “runners,” picking up dogs in a tri-state area and delivering them to the host organization shelter.
18. In what professional organizations are you involved?
I have to admit that I have never been much of a “joiner” in my life. I am trying to get better in that regard, and am now part of the National Association of Drug Diversion Investigators (NADDI), Kentucky Pain Society, and the Kentucky Psychological Association.
19. Where do you see yourself in 10 years?
That’s a good question. I’ll let you know in a couple of years if I get tenure or not! I have a vision of paying off my student loans and going to a Hawaiian beach to play ukulele, but I think my wife likes Kentucky too much to leave. I try not to think too far ahead, but want to keep my options open. Maybe car sales….
20. What advice do you have for students considering a career like yours?
Don’t. Just kidding! I wish I could say my career worked along some predetermined and focused path, but a lot of things fell into place in bizarre ways for me. So, I’d say develop some interests and broad-based skills, but always keep your eyes open for new and different possibilities. As a medical psychologist, I always need to be a chameleon and mesh with other health professionals such as nurses, physicians, physical therapists, pharmacists, etc. Thus, exposing yourself to a lot of different areas of education is of vital importance so you can fit in and “talk the talk.”