Becoming Pain-Free: Jennifer Kawi Of UNLV School of Nursing On How to Alleviate Chronic Pain

An interview with Maria Angelova

Which is common for any kind of chronic illness, not just for chronic pain, is nutrition, being able to balance calories in and calories out. Patients with low back pain, for example, who are obese, anything that we carry in front of us puts a strain on the low back.

So many people suffer from chronic pain. Often people believe that they have tried everything, and that there is no real hope for them to live pain-free. What are some things these individuals can do, to help reduce or even eliminate their pain? In this interview series, called “Becoming Pain-Free: How to Alleviate Chronic Pain” we are talking to medical professionals, pain management specialists and authors who can share their insights and strategies about how to alleviate chronic pain. As a part of this series we had the pleasure of interviewing Jennifer Kawi.

Jennifer Kawi, Ph.D., MSN, APRN, FNP-BC, CNE is a board-certified Advanced Practice Registered Nurse and Associate Professor in the UNLV School of Nursing. She has held leadership roles in academia and clinical practice including administrative experience in licensure and accreditation of ambulatory surgery facilities. Dr. Kawi specializes in chronic pain management, for diseases such as fibromyalgia and arthritis. She also researches the biomedical and socioeconomic risk factors related to chronic pain illnesses.

Her program of research focuses on chronic pain, opioids, and biobehavioral factors affecting pain including self-management, self-management support, pain care disparities, and biomarkers. Currently, she has an R56 grant from the National Institute of Nursing Research entitled “Pilot Testing A Theory-Driven Self-Management Intervention for Chronic Musculoskeletal Pain” in collaboration with Johns Hopkins. She has published multiple articles in peer-reviewed journals and presented at regional, national, and international conferences. She received several awards for her nursing contributions.

Thank you so much for joining us in this interview series! Can you share the most interesting story that happened to you since you started your career? What were the main lessons or takeaways?

I think one of the ones that made an impression on me was a patient who brought his family. It was a new patient coming in. I was the one assigned to work him up in that pain center. It was very early on in my pain management practice as an NP specializing in pain management and this patient, because before we even worked patients up, we look up all of the information, prescription monitoring reports that many states do to look at opioid use for our patients. We have access to those. Unfortunately for this new patient that we had, there were so many entries of opioid prescriptions in such a short time with various different providers. It makes it really suspect in terms of what might be potentially going on. Going back into the room at that point and trying to navigate and have this conversation to see what’s going on because there could be a lot of things, right? We don’t want to make judgements and assumptions right away. It could be that the patient’s just not getting the pain relief that they need and they’re having to find different providers and have to take different medications. Maybe it is being sold out there, or diverted, or the patient is having to take all of it. In an opioid disorder type of situation, which requires different management, it’s important to get a full picture so that you can then get a better idea in terms of how to manage patients very well. But just like with any of those kinds of situations, you do get pushback, right? I’m a chronic pain patient myself, so I know that when questions are asked, it’s easy for us to get a little bit defensive and say, “Why are you asking these kinds of questions?”

Long story short, it didn’t turn out very well in the end. The patient was really upset, and was screaming and yelling. It was a young male with his wife and child. What really made me remember this is this child, and it was somebody who was not even seven years old at that time, was just really trying, was the one who was really working on appeasing the situation and kept saying, “Daddy, it’s okay, Daddy, it’s okay. Ma’am, can you please help us?” That kind of thing. And you feel that, and it’s hard to remember those because it makes you realize the impact of chronic pain. It’s not just on that patient, it’s the family, and it’s those individuals who don’t necessarily know the whole situation, but they feel it. It also makes it clear the impact of chronic pain and opioid use and abuse in the community and just trying to navigate those situations to figure out how you can best help, not just the patient, but those who are affected around that individual. I think that’s one of the main things. It’s something that, it’s hard to forget those kinds of situations.

Did he eventually calm down?

Unfortunately, the patient escalated. It was to a point where, this was a time also where there was a lot of talk or hype in terms of, maybe I wouldn’t call it hype. There were so many things in the media about opioid abuse and misuse, and it got to a point where the communication was just really tough already. As a provider looking back at that point, I think reinforcing that being able to communicate better in terms of, “There are things that we might be able to do. There’s no judgment here, but we have to know what’s going on so that we can help address it.” Like I said, is it because the patient is not being effectively managed for their pain and that’s why the family sees it and they’re there to help support that patient? We have different modalities that we can use for it. “Is it other areas that also then need navigation and further treatment?” Those kinds of things. So yeah, it wasn’t a situation that was resolved within the clinic and that’s why it was hard to forget it.

And as you see the impact on a child, the child’s old enough to understand that something’s wrong and she’s the one who’s trying to maintain it.

Exactly. It was one of those things to where it just breaks your heart because you know that this child is probably or has been living with that kind of a situation or may have been in or seeing those kinds of situations and have had to really work on trying to calm it down a little bit so that there could be some sort of resolution, but there wasn’t. It makes it real in terms of the public impact of chronic pain and how we need to do better.

Can you share a story about a mistake you made when you were first starting and what lesson you learned from that?

I think I would look into my interventional pain practice. As a pain specialist, I do pain injections as well. Early on, I was doing a trigger point injection. Trigger point is where there are tight muscle bands in areas of the body, and the most common one, for example, is in the trapezius muscles, very tight. And so we do trigger point injections in those regions. I had a female patient, she’s not even a sports person and is quite petite. I was very cautious in terms of doing the injection because you put some numbing medications in there and steroids. Patient did very well. Everything went well. She felt relief, it’s loose, because it was giving her not just pain in the back, but neck pain and migraines. You can kind of relate to those kinds of situations.

Fortunately, the patient came back about an hour later and then said she couldn’t breathe, and I was very concerned. We did a chest x-ray because I was concerned that maybe I went really, really deep and may have gotten the pneumothorax in the upper area, and that could cause the difficulty in breathing. Everything looked okay in the chest X-ray. It ended up being that, with the patient’s size, with her being petite, the numbing medicine that I had used may have been a little bit stronger than necessary for this patient, and that resulted with numbing the areas, the intercostal muscles, with the feeling like you can’t breathe. Although there’s air coming in and out, because it’s numb, you don’t necessarily get that sensation. It’s just like when you have a dental procedure where you feel that they’re there, everything’s okay, but it’s numb. It’s the same idea when we put those types of injections anywhere in the body. The takeaway there is, although as much as I did the proper assessments and things like that, just being able to be aware that there are differences in every individual, whether it’s a huge bodybuilder, for example, versus somebody who’s really small and petite, even if it’s the same issues that they might be having.

When it comes to health and wellness, how is the work that you’re doing helping to make a bigger impact in the world?

Because of my pain experiences, as a nurse practitioner, it causes a lot of frustration in terms of, “Okay, why are these patients, why do they keep coming back?” We give them these treatments, advanced technology, advanced medications and even injections up to the wazoo and all these ablations that we do and even surgery, and yet, it seems like we’re not doing anything. The prevalence is still high in those kinds of things. That’s how I got into self-management, which seems simple, but it boils down to the basics and the foundation of what needs to happen for maintaining that health and wellness.

In my area, I’ve started this work, well I started as an NP in 2004 and I really dug deep into this scholarly and research work in 2007, and that’s where all of my studies have come from in terms of the pain and self-management area and really being able to understand how, although here are the advanced technology and the treatments that we do and the therapies that we can do for pain, there are also other things in the area of health and wellness that we as patients can do, so that we can take charge and take control of our own chronic illness. It’s anything, if it’s hypertension or diabetes, there’s things we can do at home that allows us to really make some difference.

With that, I think what really pushed me forward is being able to make a difference in this area, the publications, dissemination, and most recently, in the past several years with the pandemic, working with an acupuncturist. I think you’ve seen this work a little bit where I spearheaded a theory-based self-administered auricular point acupressure. I’ve always been interested in integrative healthcare services because this has been going on in eastern medicine for so long. Acupuncture, for example, just finally went into our guidelines here in the United States, and acupressure is based on the principles of acupuncture, but acupressure doesn’t use needles. What I worked on is to make it self-administered to see if it’s something that our patients can learn because pain is not something we can predict; it’s something that happens anytime when you’re at home or whatever it is that you might be doing. It takes a while to get those appointments in, so it’s really important that if we do have that chronic pain, aggravated at that moment, that we have some sort of intervention that we can do already at that point to help address the pain.

That’s how this came about in the air of self-management, then merging it with integrative care through Auricular Point acupressure to make it self-administered. With that, we’ve been able to make it an evidence-based modality and to hopefully even bigger and better is to influence national policy guidelines and make it also included in terms of our pain guidelines, like acupuncture, for example. But it takes forever for these things to happen. Acupuncture just came into our guidelines about 2020, even after being around for decades, so I anticipate that this work is going to be something that, hopefully, people will also listen to eventually and will get there. It just takes a while.

Can you tell the readers why you are an authority on chronic pain?

I think it takes a lot of learning and experiences. Like I said, my work started on this in 2004. It’s being able to stay updated with guidelines and being open to any kind of learning, being able to work with patients with that kind of a disorder, and do the research and the scholar’s work that’s needed, and then being able to disseminate this and if it doesn’t work, then look at other possible venues that could be better modalities for these patients. I’ve luckily been fortunate in my areas that it’s grown and magnified to a point where a difference is being made, but it does take time. It’s learning from the very beginning.

So with 2004, and it’s 2023 now, it’s about three decades of work, which started with me being a nurse practitioner in pain management. Prior to that, I’ve been a nurse for 15 years even, and as you know, we deal with patients a lot in chronic pain. But my key work in this area, it’s really since 2004, and then the scholarly and the research work started in 2007, brought on by the gaps in terms of practices. The frustrations that we feel as providers in the field that things are not working really allows us to investigate what are the things that we can do better. Through time, I’ve had the opportunity to do that for almost three decades.

What are some of the most common causes of chronic pain?

I think that the most important way to describe it is to discuss it based on mechanisms. That’s important because based on the mechanistic causes of chronic pain, it makes a difference how we manage them and treat them versus just talking about them in, “What are the locations?” or “What kinds of pain are those?” For example, in terms of the common causes, nociceptive pain is one of the terminology that is used as a classification or as a cause, meaning any kind of pain that impacts tissue function or any kind of damage or injury to, let’s say, the skin or the bone or even soft tissues. Those are the somatic type of nociceptive. For example, if you have a tear in your tendon, that’s a common example. Visceral pain is also a type of nociceptive pain where the cause is a pain related to internal injuries. So, for example, pain from gallstones, those are very uncomfortable for patients as well. So those are the visceral types of nociceptive pain.

Then you have what we call the non-inflammatory or the inflammatory pain, which are also under the classification of nociceptive pain. The non-inflammatory causes would be things like anything that causes intense noxious stimuli to a body area, for example, patients with osteoarthritis, degenerative disc disease, those who have low back pain that’s caused by arthritis, particularly osteoarthritis. That’s a really good example of a non-inflammatory nociceptive pain. And then we also have the inflammatory types or causes, which is from the body’s inflammatory responses, for example, any kind of mechanical injury, like post-surgical pain or if the immune system is largely involved, like patients with rheumatoid arthritis, which is an autoimmune disorder. These are inflammatory causes of pain that results to nociceptive pain. That big classification is really important because there’s specific treatments that we do for those.

Then we also have those neuropathic pains, and these are caused by dysfunction in either the peripheral nervous system or the central nervous system. Peripheral nervous system would be specific areas, usually more localized like complex regional pain syndrome, which usually affects just the hands or the feet. Then, we have the central nervous system types of neuropathic pain, which are more spinal cord or brain injuries that result in pain, like multiple sclerosis or stroke, for example. These are the neuropathic pains, they’re more when patients complain about sharp, numbness, and tingling pains versus in nociceptive pains, it’s usually more dull, achy. Those are how we can usually try to differentiate those.

And then there’s also the functional pain. In terms of functional pain, or I guess this is the designation where some people might call it psychosomatic, meaning they can’t really find a good cause for it, and so it then gets lumped into this category. Things like maybe IBS, irritable bowel syndrome, or maybe fibromyalgia. So those are the functional types of pain. We also have the overlapping ones. Some patients may have a mix of a nociceptive, neuropathic, or even a functional pain. It gets a little bit complicated, but I think it’s important to be able to see it in this larger framework because it impacts decision making and allows us to really help explain to our patients what might be going on because it affects treatment and hopefully recovery.

Is there one, out of all those categories, that is more prevalent or perhaps the least known that you would want people to know more about?

One of the, I would say even the most common because it’s one of the ones that affects most people and impacts most people, is what we call non-specific chronic low back pain. It’s just the most frustrating for many patients and many providers because this is the type of chronic pain that I guess some people might classify it under functional or psychosomatic perhaps, but these types of patients have pain where there’s no clear pathology. For example, you would do an X-ray or an MRI on them, and you don’t necessarily see a nerve impingement, you don’t see a degenerative disc issue where you can explain where the pain is coming from, so it’s very non-specific. These are the ones that many providers and patients struggle with. This is also where, again, self-management and education comes in. I read it somewhere before, somebody said, “Education is the best analgesia,” because there’s a lot of our patients who try to figure out, “Why am I having this kind of pain?” because that’s the natural tendency. We want to understand, we want to know what’s going on, but there are situations where we just couldn’t figure it out.

We do so many diagnostic tests, whether it’s blood work or diagnostic tests and x-rays and MRIs or whatever, and we can’t really find it, but we understand that the patient has that pain because pain is always subjective. It is what the patient says it is, as we’ve always been told. Because of that, we have to really be able to manage it, and I think that’s probably one of the main important things that we need to do better as well in terms of managing these patients. I think, again, it starts with the basics and foundational treatment in a sense that, we educate, we inform them, we empower them to let them know that, “This is what’s going on, this is all that’s been done. We didn’t necessarily find it, but we understand that you have this pain, and so here are the things that we can do moving forward for it,” so that patients don’t get frustrated and keep looking for other providers, taking on more medications, doing further tests, and then the cycle continues and it just becomes that pain epidemic that we have right now.

Can you share your top five lifestyle tweaks that you think would help support people to becoming pain-free?

It boils down to basic things again, and I personally, because I also suffer from chronic pain, with our work, we’re constantly on a computer. I do have cervical degenerative disc disease, for example, which then causes migraines. The herniation causes pressure and then results in neck pain and migraines. The one thing that I always do is to move, and that doesn’t always necessarily mean having to exercise, but at least being more aware and being more present. No prolonged sitting, standing, and walking is always usually what we say. Meaning if your work entails one where you’re sitting in a computer the whole time, you know that maintaining that situation is just not helpful. So for patients with cervical degenerative disc disease, things like doing flexibility, stretching exercises with the neck, moving it around a little bit to loosen the muscles up and hopefully prevent straining and headaches and those kinds of things. Patients who have low back pain, for example, standing up after an hour sitting down and working, or if you’re doing prolonged walking, at least being able to rest a little bit to give your back a break. Those are really, really important things. It’s not necessarily talking about exercise, it’s about moving and being aware of what needs to be done to loosen those up. So that’s one.

The second one, which is usually something that a lot of patients also have, this pain is something that is affecting not just physically. You have to look at the holistic picture of a patient. Patients with chronic pain will come back and have an aggravation of that pain. Sometimes, the one important question to ask is, “When did it happen? When did it recur? When did it get aggravated? And what was going on at that time?” Because a lot of times increased stress aggravates chronic pain in many patients. So, a lifestyle tweak would be to be able to de-stress, to be able to figure out some relaxation things that help. For some patients, maybe yoga is something that helps them, some breathing exercises in between, focusing on other things, spending time with the family, those kinds of things that give you some fun and some enjoyment so that you can try to focus on other things beyond the pain. Because for patients who live with chronic pain, they wake up and that’s the first thing that they feel. First thing in the morning all the way towards the end. So being able to really try to see how you manage your day so that you can de-stress and allow your body to think about, “What is it that gives you joy?” so that, hopefully, that’s not all that’s the focus. So that’s the second one.

The third one, which is common for any kind of chronic illness, not just for chronic pain, is nutrition, being able to balance calories in and calories out. Patients with low back pain, for example, who are obese, anything that we carry in front of us puts a strain on the low back. That’s a very sensitive topic a lot of times to talk with patients because you don’t want to be, you don’t wanna bias it to say for a patient, “Well, you do have low back pain because you’re obese.” The patient will not really listen very well and will not be able to help themselves when that’s the conversation that happens. But being able to talk about how we can kind of balance nutrition so that there’s not so much so that there is some sort of, if you’re losing weight, that there’s some sort of calorie deficit and working with nutritionists and things like that because any kind of weight gain can put a lot of pressure in the back and the joints. And a lot of the pain prevalence that we have are patients with knee osteoarthritis, hip arthritis, low back pain from degenerative disease, those kinds of things. So I think that’s the third one.

The fourth one I would say is to take control, take charge of your pain, which again, is really hard when you wake up and that’s already what you see in your life or that’s what you’re facing. I think this goes back to the self-management strategies that are really, really honing in on, in terms of goal setting, problem solving, decision making, and action planning. So what are your goals for the day? Give yourself a break and take it a little bit at a time. What are your goals for the day to help you get comfortable? How are you going to manage that, problem solve to make sure that you make the right decisions? So for example, “How do I manage my pain medications? My provider only gave me two hydrocodones to address my pain for this day, and I know that I’m going to be physically active, so how am I going to manage it so that I won’t have to take a third and a fourth and a fifth medication and then end up running out?” Those are really, really important things to consider. “How do I communicate with my provider about my needs?” because those are the other things that our patients always talk to us about, “My provider is not listening to me. I don’t feel like I’m being heard. So how do I communicate my needs to my provider so that they understand what my situation is in terms of my chronic pain?”

So those are really important, being able to take accountability and taking control, I think is probably one of the most important things. It doesn’t define you, your pain doesn’t define you. It’s understandable, it’s something that you live with every day, and our providers need to be able to understand that and then support us in that process. I think that’s really where it boils back down to because we can treat patients with whatever kind of medications or injections or surgery, but if we don’t empower them to take control it makes it very, very hard. I think that’s really the key I would say to pain management, at least to be able to make sure that our patients are fully aware and fully informed.

Where is the best way for people to follow your work online?

I think just Googling it, so just typing my name out and then just seeing the publications and the studies which, if they look at it chronologically, has kind of expanded from pain and self-management from educating not just patients, but also providers so that we can do better, all the way to advancing integrative care to make it more accessible to our patients, especially leveraging technology, which is really huge nowadays. Everybody’s using apps and those kinds of things, so how do we leverage technology, especially for our minorities, our health disparate populations, populations who have no access to it? It boils back to, “How can we really help patients with the ability to self-administer modalities of pain that will be effective for them so that they are able to access that, it’s not costly and it actually works?” That’s the main key of it all. But yeah, just simply Googling it, my name. online.

Thank you for these really excellent insights, and we greatly appreciate the time you spent with this. We wish you continued success.

About The Interviewer: Maria Angelova, MBA is a disruptor, author, motivational speaker, body-mind expert, Pilates teacher and founder and CEO of Rebellious Intl. As a disruptor, Maria is on a mission to change the face of the wellness industry by shifting the self-care mindset for consumers and providers alike. As a mind-body coach, Maria’s superpower is alignment which helps clients create a strong body and a calm mind so they can live a life of freedom, happiness and fulfillment. Prior to founding Rebellious Intl, Maria was a Finance Director and a professional with 17+ years of progressive corporate experience in the Telecommunications, Finance, and Insurance industries. Born in Bulgaria, Maria moved to the United States in 1992. She graduated summa cum laude from both Georgia State University (MBA, Finance) and the University of Georgia (BBA, Finance). Maria’s favorite job is being a mom. Maria enjoys learning, coaching, creating authentic connections, working out, Latin dancing, traveling, and spending time with her tribe. To contact Maria, email her at angelova@rebellious-intl.com. To schedule a free consultation, click here.