• 25 Dec, 2024
• Dr. Michael Gofeld

Beyond Painkillers and Epidurals: Dr. Gofeld on Innovative Journey to the Future of Pain Medicine and Osteoarthritis Treatments

Imagine a world where pain relief isn’t just about masking symptoms but addressing the root causes. Dr. Michael Gofeld, a leading pain medicine physician, invites you on a journey beyond conventional practices. Discover the limitations of the 0-to-10 pain scale and explore groundbreaking treatments for osteoarthritis, from lifestyle changes to cutting-edge regenerative therapies. Get ready to rethink pain management and learn how a “curious physician” is shaping the future of this critical field.

Magazica: Welcome, readers and viewers! We are honored to have with us today, Dr. Michael Gofeld. He is a renowned pain medicine physician, clinical scientist, R&D consultant, and healthcare administrator. His extensive research and expertise in neuromodulation, diagnostic and procedural ultrasonography, and innovative treatments for osteoarthritis have significantly impacted the field. Today, we will dive deep into his insights and gather valuable knowledge on improving our well-being. Dr. Michael Gofeld, welcome to Magazica.

Dr. Michael Gofeld: Thank you for inviting me and for the kind introduction.

Magazica: Let’s begin our journey into the world of pain medicine. You have years of experience in this field. Can you share what inspired you to pursue a career in pain medicine and what keeps you passionate about it after all these years?

Dr. Michael Gofeld: That’s a very complex question. The short answer is curiosity. Let me explain. When I was a third-year resident in anesthesia, I participated in a month-long rotation in a chronic pain clinic. This was back in 1998. Every patient who came in was treated with an epidural injection—one after another.

I asked the attending physician, a kind doctor already in her sixties, why this approach was used for all patients. She replied, “Just keep doing it; it’s the standard.” That didn’t make sense to me. I started reading about it, though information back then was limited, especially outside the United States. Despite the scarcity, I found bits of information that piqued my curiosity.

It seemed like an unexplored area—terra incognita, so to speak. I realized it offered many opportunities for me as a young physician to learn, research, and potentially make a difference. That marked my first step into pain medicine.

Magazica: That’s fascinating. It sounds like your curiosity drove you to challenge conventional practices.

Dr. Michael Gofeld: Exactly. That rotation extended to six months because the resident after me couldn’t join due to her pregnancy. During that time, I observed and learned a great deal. Later, I pushed for a neurology rotation, something uncommon in anesthesia programs. My program director initially resisted, but I showed him it was allowed in the curriculum.

Those experiences solidified my interest. Pain medicine bridges various disciplines—basic and medical sciences, surgery, radiology, human behavior. It’s an intersection of so many fields, and I thought, “This is where I can make an impact.”

Magazica: Pain medicine indeed seems multidisciplinary. For readers who might not be familiar, could you explain what pain medicine encompasses and why it’s crucial for overall human health?

Dr. Michael Gofeld: Pain is the second most common reason, after the common cold, for people to seek medical help. When patients say they have arthritis or a slipped disc, what they usually mean is, “I have pain.” Pain is a universal experience that often becomes chronic.

Pain medicine acts as a bridge between various specialties. Modern medical practice is highly specialized—orthopedic surgeons focus on specific joints, for instance—but pain often doesn’t fit neatly into one category. Pain specialists address this gap by combining knowledge from different areas.

Historically, pain medicine dates back thousands of years, but modern pain medicine truly began after World War II, thanks to Dr. John J. Bonica. He was a military physician who noticed that many wounded soldiers suffered from conditions like chronic regional pain syndrome. He discovered that nerve blocks provided temporary relief and realized the potential of combining them with physical therapy, psychological support, and nutrition.

Magazica: That sounds revolutionary.

Dr. Michael Gofeld: It was. Dr. Bonica’s approach laid the foundation for multidisciplinary pain management. He developed an inpatient program where patients stayed for a month, receiving comprehensive care. It was effective but expensive. While such programs exist in places like Germany, they’re rare due to the cost.

In the U.S., multidisciplinary pain management has evolved but doesn’t fully adhere to Bonica’s vision. I was fortunate to serve as the medical director of the Bonica Pain Center in Seattle, where I learned about his groundbreaking methods.

Magazica: Thank you for the historical perspective, particularly how advancements have evolved since post-World War II. I’ve observed similar trends; my father had persistent knee issues. The constant pain was always evaluated by asking, “What’s the grade of the pain?” I can relate to that experience.

Magazica: Such as?

Dr. Michael Gofeld: Years ago, a groundbreaking study in Bone and Joint identified the most effective treatments for generalized osteoarthritis: quitting smoking, losing weight, exercising regularly, and adopting an anti-inflammatory diet. These lifestyle changes were more effective than all surgical interventions combined.

Magazica: That’s remarkable. Why don’t more people pursue these approaches?

Dr. Michael Gofeld: Inertia, mostly. People often prefer passive solutions. For instance, instead of dietary changes, they might take medications like Ozempic. Instead of exercising, they’ll rely on physiotherapy or massages. There’s a societal tendency in Western cultures to consume health care passively rather than actively engage with it.

Magazica: That’s a challenging mindset to shift.

Dr. Michael Gofeld: Indeed. Additionally, we tend to overlook the role of epigenetics. Many people with generalized osteoarthritis have a family history of the condition. But with interventions like a healthy diet, regular exercise, and supplements, we can mitigate genetic predispositions.

Magazica: That’s encouraging.

Dr. Michael Gofeld: It is, but the larger issue lies with societal norms. In many Western countries, being obese, smoking, or eating processed foods is normalized. Conversely, in regions like sub-Saharan Africa, generalized osteoarthritis is rare. People there often maintain leaner physiques, eat simpler diets, and are physically active.

Magazica: So osteoarthritis is essentially a lifestyle-driven condition in many cases?

Dr. Michael Gofeld: Exactly. When Western lifestyles spread—like in parts of China—there’s a corresponding rise in obesity and osteoarthritis. However, it’s important to distinguish between generalized osteoarthritis and mono or oligo-osteoarthritis.

Magazica: What’s the difference?

Dr. Michael Gofeld: Generalized osteoarthritis affects multiple joints due to systemic factors. In contrast, mono or oligo-osteoarthritis typically arises from localized issues, such as a prior sports injury. For instance, a young athlete who injures their knee might develop osteoarthritis in that joint over time, despite maintaining a healthy lifestyle.

Magazica: How is such localized osteoarthritis treated?

Dr. Michael Gofeld: Many patients resort to corticosteroid injections, which are standard and covered by public health systems like OHIP. While corticosteroids can be effective as a bridge to surgery, they’re not ideal for long-term use.

Magazica: Why is that?

Dr. Michael Gofeld: Cortisone injections can accelerate cartilage degradation with repeated use. Studies show that corticosteroid crystals and local anesthetics used in these injections can damage cartilage. Patients often end up needing knee replacements sooner.

Magazica: That’s concerning.

Dr. Michael Gofeld: It is. Plus, cortisone injections can have systemic side effects like immune suppression and water retention. For younger patients or those not ready for surgery, alternative options exist, such as viscosupplementation. This involves injecting a viscous, gel-like substance into the joint to mimic normal joint fluid, reducing inflammation and improving function.

Magazica: What about other innovative treatments?

Dr. Michael Gofeld: Platelet-rich plasma (PRP) is another excellent option, particularly for knee osteoarthritis. PRP has shown superior results in multiple randomized controlled trials. However, it’s crucial to ensure the procedure is done correctly, with the right equipment and expertise. Some clinics use devices designed for cosmetic purposes rather than orthopedic applications, which compromises the concentration of platelets needed for regeneration.

Magazica: That’s a valuable point.

Dr. Michael Gofeld: PRP requires a platelet concentration 8 to 9 times higher than normal blood levels to achieve regenerative effects. Lower concentrations won’t suffice. Other treatments include fat grafts, where adipose tissue is harvested, processed, and injected back into the joint. Fat contains anti-inflammatory factors and growth factors, which promote cartilage repair and provide cushioning.

Magazica: Are there any emerging treatments gaining traction?

Dr. Michael Gofeld: One emerging approach involves injecting PRP into the bone’s growth plate, especially for severe arthritis or sports injuries. This technique aims to improve the end plate’s health and stimulate cartilage regeneration. It’s promising but still requires rigorous study.

Magazica: That sounds innovative. What’s the difference between regenerative treatments in Canada and other countries?

Dr. Michael Gofeld: In Canada, we primarily use PRP and fat grafts. In the U.S. and elsewhere, some clinics market stem cell therapies—a misnomer, as these aren’t true stem cells. Understanding the science and limitations of these therapies is crucial.

Magazica: Okay, it’s a big secret of the industry, right? What’s the name of this process you mentioned—signalling cells?

Dr. Michael Gofeld: Yes, that’s correct. These are mesenchymal signaling cells. They are incredibly robust and work to attract the natural resources of the human body to restore anatomical integrity and function. However, they are not exactly stem cells.

All those treatments people travel to Mexico or the Bahamas for—those are very questionable. There are also other substances pushed by the industry, like Wharton’s jelly, exosomes, cultivated cells, products that have never been properly tested. They’re often marketed as revolutionary, but in reality, their benefits are often negligible and occasionally harmful The National Library of Medicine (PubMed) sited about 150 randomized controlled studies (RCT) on PRP for knee osteoarthritis. However, there was not a singe RCT on exosomes. As I sometimes let my sarcasm out, the only tangible outcome for some of these treatments is income—for the providers.

Magazica: That’s interesting. Could you elaborate on alternative treatments for osteoarthritis?

Dr. Michael Gofeld: Sure. One option now gaining traction is HIFU—High-Intensity Focused Ultrasound. This technique allows us to target deep into the bone, creating focal hyperthermia.

The heat is not enough to destroy or burn tissue but is sufficient to induce robust anti-inflammatory and regenerative effects. This mechanism, which I call “thermo-modulation of pain,” is gaining recognition as a promising approach.

Studies, particularly from Japan, have shown that patients who received HIFU treatment of the knee reported significant improvements. This is an exciting avenue for addressing focal osteoarthritis.

Magazica: Fascinating. Your work in this area is clearly advancing patient care. So, as we near the end of our conversation, I have two final questions. Let’s start with a lighter one. You seem incredibly busy. How do you balance your professional and personal life?

Dr. Michael Gofeld: Ah, balance. It’s always a work in progress. I actually took a physician burnout test offered by the Ontario Medical Association. They have various tests, some free and some requiring a fee. When I took it, I found that I was moderately burned out, which, honestly, is not bad for someone with over 25 years in practice.

When I left my role as a medical director of a large clinic, my stress levels dropped significantly. These days, my professional principle is simple: I focus on treating patients whom I genuinely believe I can help.

Magazica: That’s an interesting approach.

Dr. Michael Gofeld: Some might call it “cherry-picking,” but I think of it as prioritizing care. Every patient deserves medical attention, but if I know that my tools and expertise won’t provide the best outcome for a specific individual, I refer them elsewhere—to hospital-based pain programs, neurology, psychiatry, or physiotherapy. This ensures that my time and resources are focused where they can have the greatest impact.

By doing this, I also keep my wait times remarkably low. Most new patients can see me within two to three weeks, and interventions, if necessary, are scheduled within a week or two. This efficiency is crucial because it allows us to address issues promptly, avoiding delays that might render interventions less relevant.

Magazica: That’s quite an efficient system.

Dr. Michael Gofeld: Yes, and it reflects my curiosity and passion for advancing care. While I don’t consider myself a traditional researcher, I describe myself as a “curious physician.” This curiosity drives me to stay engaged with the latest developments in medicine.

Magazica: That’s a wonderful term—“curious physician.”

Dr. Michael Gofeld: Thank you. It really fits my approach. I’ve been involved in more research since leaving the University of Toronto in 2018 than during my time there. For instance, I recently participated in studies on an obstructive sleep apnea device in the Republic of Georgia. While unrelated to pain management, I was brought on board as an ultrasound expert.

The collaboration was inspiring, involving colleagues from Germany, Johns Hopkins, and Stanford. Experiences like these keep me motivated professionally.

Magazica: And on the personal side?

Dr. Michael Gofeld: Personally, I have a few rituals that keep me grounded. I practice yoga almost daily—my wife is a yoga instructor who trained in Mysore, India, with Sharath Jois. While I don’t always do the full 90-minute practice, I dedicate at least 30 minutes to yoga most days, with longer sessions on weekends.

I maintain a predominantly plant-based diet with occasional indulgences, like a hamburger now and then. I also practice intermittent fasting, which I find beneficial for metabolism and overall health.

Finally, I engage in hypoxic training—controlled breathing exercises that simulate high-altitude conditions. It’s another way I prioritize my physical and mental well-being.

Magazica: That’s an impressive commitment to self-care.

Dr. Michael Gofeld: It’s all about maintaining balance and being intentional in both professional and personal decisions. I always strive to act with care—whether in choosing how to treat patients or how to care for myself.

Magazica: There’s so much to cover, but we must be mindful of time. Today’s focus is pain medication. There are many other topics—neuromodulation, ultrasonography, or the latest research—that we’d love to discuss in the future. For now, how do you see the future of pain medicine, and where do you see yourself within it?

Dr. Michael Gofeld: I approach pain medicine differently from many of my colleagues who view it as longitudinal care. Many pain clinics in Ontario focus on repeated injections—weekly, biweekly, monthly—continuing endlessly. It reminds me of Voltaire’s quote: “The art of medicine consists of amusing the patient while nature cures the disease.”

These injections often aren’t nerve blocks, despite being called that. When I ask patients if they experienced numbness after the injection, the answer is often no. So, they’re not nerve blocks. Instead, they’re largely placebo—providing warmth, muscle relaxation, or temporary comfort.

I advocate strongly against injections without a clear anatomical diagnosis. It’s unethical to subject people to endless injections, even if they believe they help. The brain is powerful; it creates endorphins and dopamine, reinforcing this cycle.

Pain medicine should be a science, not a business. It’s about consultation—offering patients advice, collaborating with family physicians, and performing targeted interventions based on precise anatomical diagnoses.

I review MRI images myself rather than relying solely on radiologists’ reports. While radiologists are excellent, reports can sometimes miss crucial details like disc tears or muscle atrophy.

With that in mind, my approach is to see patients less frequently—every three, six, or even twelve months—focusing on new cases. This way, my practice doesn’t become a revolving door for repeat patients. It’s about maintaining ethical care and keeping the focus on genuinely helping patients.

Magazica: That’s such a paradigm shift. I’ve seen my father struggle with knee pain, treated in three different countries, yet never receiving this kind of in-depth, anatomy-based approach.

Dr. Michael Gofeld: Pain medicine must remain patient-focused—patient-oriented rather than patient-directed. Patient-directed care often results in doctors following patients’ demands to maintain satisfaction scores, which isn’t always best for the patient.

In Canada, I’d like to see pain medicine evolve with universal education principles. Multidisciplinary programs funded by the government should be more efficient and patient-focused, addressing bio-psycho-social issues holistically.

However, I firmly believe we shouldn’t medicalize social problems like poverty, addiction, and unemployment. These are societal challenges that medicine cannot solve.

Magazica: That’s a compelling perspective.

Dr. Michael Gofeld: Thank you. Ostensibly, both American and Canadian public health publications highlighted the economic toll of pain—more significant than cancer or heart disease, costing billions annually. Despite this, pain clinics remain underfunded and tucked away in hospital basements, while gleaming cancer and heart institutes dominate. If pain truly causes such widespread disability, why isn’t more attention and funding directed towards it?

Magazica: A powerful observation.

Dr. Michael Gofeld: Thank you.

Magazica: With that proactive vision, we conclude this conversation. Thank you, Dr. Gofeld, for sharing your insights.

Dr. Michael Gofeld: Thank you for having me.

Magazica: It’s been an enriching conversation! Thank you, Dr. Gofeld.

Dr. Michael Gofeld: Thank you very much for having me.

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Keywords: Pain Management; Osteoarthritis; Regenerative Therapies; Minimally Invasive Treatments; Chronic Pain