Abstract
Robert L Barkin talks to Roshaine Gunawardana, Commissioning Editor: Dr Barkin has authored over 150 publications including journals, book chapters and CD-Roms. He is a reviewer for over 30 journals, on the editorial board of nine journals and is an Associate Editor of the American Journal of Therapeutics. He received his BSc. Pharmacy degree from St Louis College of Pharmacy and Allied Science St Louis, MO, USA in 1963, an MBA in Healthcare Administration at DePaul University Chicago, IL, USA in 1976 and a doctorate in Clinical Pharmacy at Purdue University, IN, USA in 1985. Dr Barkin is engaged in a very active in-patient and out-patient practice with a collaborative arrangement with five anesthesiologist and consults with physical medicine and rehabilitation, rheumatology, oncology, neurology, neurosurgery, obstetrics and gynecology, psychiatry and chemical dependency/addiction specialists. He has presented over 500 formal lectures in the USA, Poland, India, China, Taiwan, Philippines, Puerto Rico, Australia and Canada. Dr Barkin‘s interest lies in pain, psychiatry, geriatrics, clinical pharmacology, clinical testing for medication and pain pharmacology. He has been the first to be granted scientific status with the American Academy of Pain Medicine.
Q What led to your specific interest in pain medicine, after obtaining your BSc in Pharmacy & your Doctor of Pharmacy degree?
Among the major areas of concern is the need for patient-specific, patient-focused, patient-centered personalized care, and there appears to be a utilization (by many) of routinized interventions without regard for the complete etiology of the individual‘s pain. There is a need to customize a treatment plan to pain etiologies, the need to engage clinical pharmacology by utilizing polymodal therapeutic interventions in the process and the engagement of other disciplines for the treatment of each patient. It is easy to say we have a world of generic drugs, but we have no generic patients. Listening to the patient, as opposed to hearing the patient, will assure more accountability and responsibility for outcomes that are patient-centered and patient-involved. Gaps in these particular areas of medicine led me to focus my interest and career in this direction. This encouragement was supported by my wife Diana and my two daughters, Stephanie and Dr Stacie Barkin.
Q How have you seen the field of pain medicine evolve since you began as a professor & researcher?
I believe the areas of perception and recognition of pain have changed since I began my career in this field. I have also seen the managment of polymodal treatment plans, engaging in transduction, conduction and transmission modulation and perception of pain also evolve. There have been advances in the perception of pain both on ascending and descending pathways, along with the modulation of the intracellular and extracellular mediator for the molecules involved in pain mediation. In conjunction with that, organizations such as the American Academy of Pain Medicine (which is for physicians only) and the American Academy of Pain Management now have multiple clinical specialists involved in pain, along with the American College of Physicians, American Pain Society and The American Society of Interventional Pain Physicians, form guidance and progression of an evolving treatment plan to modulate pain.
Q Your clinical interests include psychopharmacology. How important is it in your opinion/experience to take factors such as depression, schizophrenia & other similar conditions into account when assessing the pain state of an individual?
In pain patients who have significant psychiatric diagnosis (and associated comorbidities), it may be appropriate to use evaluation tools that may be specific to an individual‘s diagnosis. For patients who may or may not be in remission, it is necessary to proceed with a a high degree of caution since issues with substance abuse, misuse, alcoholism or suicidal ideation may be manifested. We have to predict and control these issues while protecting the patient from self-injury and injury to others. This is most important in those patients who are unable to provide adequate self-control for themselves. Overall, when faced with a pain patient displaying psychiatric tendencies, the clinician is required to facilitate safe and adequate treatment plans both for the patients themselves and for their caregivers.
Q How is your approach to pain management different when dealing with the geriatric patient?
In the geriatric patient, we titrate the specific pain etiology needs of a patient starting at a low dose and augmenting slowly to meet their patient-specific needs while allowing periods to assess titration outcomes. All of the pharmacotherapies are focused upon the drug disease, drug dose and drug–nutrient drug–laboratory interaction. In addition to that, dosing is based on the renal events of the patient along with a complete metabolic profile and the comorbid disease states. It is appropriate to treat and evaluate the patients on an ongoing planned periodic basis and with planned clinical appointments to address side effects, adverse effects, and degree of iatrogenic effects, and to maintain an open, bilateral accessible dialogue.
Q What are the developments you would like to see within your areas of interest in the field of pain management & why?
We need more research to identify and modify multisynaptic-specific binary opioids to provide alternatives to the semisynthetic 6-keto opioids (i.e., hydrocodone, hydromorphone and oxycodone), which provide considerable amounts of abuse due to their transport through the nucleus accumbens to the ventral tegmental area by the dopamine route precipitating euphoria. We are looking forward to agents being created that will mimic more of the oxymorphone/tapentadol, where such euphoria is not a major consequence, and a paucity of CYP450 drug interactions. We are looking at agent-specific applications similar to that of duloxetine and milnacipran. Furthermore, what I would like to see is accountability and responsibility on the part of the prescriber and the dispenser of controlled substances, exceeding minimal standards of care and maintaining a duty to learn and warn, and utilize professional wisdom and judgment when pursuing pharmacotherapy for the patient, having an awareness of the healthcare provider‘s limitations, and the opportunity for a referral to a multidisciplinary, comprehensive pain center where all in disciplines are involved helping to decrease the quality and quantity of pain experienced by the patient, and increasing the patient‘s functionality and overall quality of life. Furthermore, there should be a higher degree of education, on an ongoing basis, for all healthcare practitioners who are involved in the management of pain. There should not merely be one to two lectures in professional schools; Continuing Medical Education should be increased to focus on pain treatment and management as well as implementation, follow-up and the opportunities that are available beyond pharmacotherapeutics.
I would also like to see the utilization of clinical urine drug testing (UPLC/MS/MS) for initial visit baseline testing, periodic follow-up testing, testing based on patient risks and testing precipitated by alterations in patients‘ characteristics and involvements. Furthermore, the use of a pain psychologist and complimentary modalities such as acupuncture, physical therapy, massage and transcutaneous electrical nerve stimulation would be beneficial in progress in the field of pain management in my opinion. And above all, there should be the engagement of the individual‘s cultural needs and competency when assessing the patient‘s pain and family consequences within an environment of a multidisciplinary comphresensive personalized pain management treatment plan.
Financial & competing interests disclosure
RL Barkin has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.