A New Model for Chronic Pain Treatment is Needed: Dr. Jacob Hascalovici, Co-Founder and Medical Director of Bliss Health

Lindsey Smith

Hi, I'm Lindsey Smith, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare.

We're going to take a look at the field of chronic pain today in the context of trend lines that could be setting up the U.S. healthcare system for a major problem with access to treatment. On the one hand, the most recent report from the Centers for Disease Control showed a sharp jump in the number of Americans suffering from chronic pain, going from about one in five Americans in 2020 to one in four in 2023. At the same time, the University of California released a study earlier this year showing a forty-five percent drop in the number of residents applying to pain medicine fellowship programs.

Our guest today, Dr. Jacob Hascalovici, is watching all of this closely as the co-founder and chief medical officer of Bliss Healthcare, a U.S.-based telehealth platform specializing in the treatment of chronic pain that is fully covered by insurance. He's also the division director of pain in the Department of Neurology at Hackensack Meridian Health Neuroscience Institute in New Jersey and an associate professor at the Albert Einstein College of Medicine and the Hackensack Meridian School of Medicine.

There's a lot going on in the pain medicine space — including a recent FDA approval of a non-opioid medication for acute pain — and I'm looking forward to discussing the current and the future state of this field with him today.

Thanks so much for joining us.

Dr. Jacob Hascalovici

Thank you for having me, it's a pleasure.

Lindsey Smith

So I'd like to start by learning more about you and what first got you interested in medicine.

Dr. Jacob Hascalovici

Yeah, so thanks. A little bit about my background. I'm originally from Canada, from Montreal. I did my undergraduate studies at Yeshiva University in New York, actually. I then studied neuroscience at the graduate level back in Canada at McGill University, and that's where I kind of really got my interest in neurology and neuroscience.

And after studying neuroscience at the graduate level, I pursued a career in medicine at the Technion University in Israel, where I studied medicine there for four years and then returned back to New York to Montefiore to do any residency in neurology, sort of following my history of studying neuroscience.

Lindsey Smith

That's a really cool story. I always like to hear what got people started to get into the field. And now I'd like to kind of turn our attention to what drew you into the specialty of pain medicine and what you enjoy about it.

Dr. Jacob Hascalovici

Yeah, so it's actually interesting. I didn’t enter the field of neurology thinking that I would become a specialist in pain medicine. With my history of studying neuroscience, actually at the graduate level, I studied dementia and Alzheimer’s. So in my mind, in my thoughts, going into a neurology residency would take me into a cognitive neurology fellowship. One of the things that I realized sort of mid-through my residency is that cognitive neuroscience, the study of memory, is far more exciting and interesting than cognitive neurology, at least to me.

And so midway through my residency, I started to search for different career paths that I could take. I used lots of different motivators and drivers to choose pain medicine. I think first and foremost in neurology, we do a lot of diagnosis, and over the last couple of years — in the last ten, twenty years — there's been an explosion of new therapies and treatments for people with some of the neurological diseases, but there are still many neurological diseases where you don't have the ability to really cure a person.

When it comes to pain, I found that in pain medicine and treating people with headache and different types of painful neurological and musculoskeletal disorders, we really had that satisfaction of being able to take the person's symptoms away or heal sort of their pain. And I also think that, you know, medical students might be listening to this...there’s sort of this idea of thinking about your financial future as a medical student — for some reason, it’s shunned upon. When I was in medical school, I didn’t take any courses in personal finance. I had to teach it to myself actually by reading a bunch of books, including Personal Finance for Dummies and Unshakeable by Tony Robbins, a couple of the other classical books on personal finance.

You know, when I was thinking about what career to choose, I did some research and I said to myself, as a neurologist, what are some of the higher-paying subspecialties? And, you know, I’m not embarrassed to admit that because I actually think it’s really important to think about your financial future in any career that you enter. And that doesn’t take away from the altruistic motivators of going into medicine. 

And so I found that pain medicine is a specialty that is very procedure-based. We do a lot of interventions, and so both being able to heal people in the field of neurology or help them or treat their symptoms significantly and set myself up for a comfortable financial future, I thought pain medicine really spoke to me at that point.

Lindsey Smith

Yeah, I think that makes a lot of sense and a really good call-out for our listeners for sure. Let's talk about the typical problems you see in your day-to-day and your go-to approach for helping your patients manage their chronic pain.

Dr. Jacob Hascalovici

Absolutely. You know, when you think about a neurologist — so first of all, if you go back, if you think about pain medicine, neurology is a precursor to entering the field of pain medicine. Pain medicine is not its own residency. Pain medicine is a fellowship that you can enter through different avenues. The most common is anesthesia. The second most common is physical medicine and rehabilitation. I’d say the third most common is neurology, and then followed by psychiatry and sometimes emergency medicine — those are less common.

So you don’t typically find neurologists that complete an interventional pain medicine specialty. As a matter of fact, there’s a little over 400 neurologists in the United States, actually in North America, that are double-board certified like me in neurology and pain medicine. So it’s a relatively rare bird and breed.

And so when you think about the diseases that I treat, I think from the outside, somebody might think, well, since he’s a neurologist, he probably only focuses on painful neurological diseases like post-herpetic neuralgia or diabetic neuropathy or radiculopathy. But the truth is, our practice really extends to any kind of pain — pain anywhere in the body, really head to toe.

I always say if it hurts, we manage it. So that could be arthritis in the knees, the hips, the shoulders, the hands, chronic generalized pain like fibromyalgia, of course, any type of pain along the spinal axis — cervical, lumbar, thoracic, sacroiliac — or really pain anywhere on the body which is chronic.

And I think it’s important for us to define chronic pain, which is any type of pain that doesn’t seem to be getting better or going away after a time period within which we would expect the body to have already healed itself.

Lindsey Smith

I think that's really insightful. We're going to get to Bliss Healthcare here in just a second, but before we get there, I want to talk about the growing amount of information out there about the use of psychedelics in treatment. What would you like our audience to know about those approaches?

Dr. Jacob Hascalovici

Yeah, I think there's a lot of unknowns. I'm particularly excited. I actually have been using medical cannabinoids in the treatment of chronic pain for years. When I was a young faculty member at Montefiore in the multidisciplinary pain program, I was probably one of the largest medical cannabis prescribers in the Bronx, possibly even in New York.

And so I definitely saw patients who found significant benefit from medical cannabinoids specifically for the treatment of chronic pain. I think about new and novel treatments like psychedelics and cannabinoids, I think it's important to base this in science, not just hearsay. That’s number one. And then number two, I think any type of new treatment in my mind has to suffice three specific criteria.

Number one, it needs to be safe. Number two, it needs to be effective. And number three, it needs to be affordable for the patient. And if it doesn't have all three of these characteristics, then it's just simply not an option in my mind.

Medical cannabinoids are considered safe. They are effective in treating some conditions, but to many people they're simply not affordable, and that’s because the insurance companies have not developed a reimbursement structure even for medical cannabis. And I think it's going to get more difficult now with states — you know, there are many states across the United States where cannabinoids are legalized for recreational use.

And so I think that that will actually move us further away from insurance companies reimbursing for this, whereas if it was specifically held for medical use, we probably would have had a higher chance of having cannabinoids as an approved treatment for different diseases.

With regards to psychedelics, I'm actually particularly interested in ketamine for the treatment of chronic pain and also for some behavioral health conditions like depression and anxiety. I actually was recently looking at a company called Big Leap Health, which I'm an early investor in, and what they're doing is actually empowering clinics — psychiatry clinics and pain clinics across the U.S. — to be able to provide Spravato, which is intranasal ketamine treatments for patients who suffer from psychiatric diseases like depression and anxiety, which are highly linked to chronic pain, and also other types of interventional treatments for psychiatry like deep TMS or TMS, transcranial magnetic stimulation.

Again, I think there's a lot of potential here, but I will only bless things that are safe, effective, and affordable and that occurs on an individual basis. Something that could be safe and effective, or effective and affordable to one person might be effective and not affordable to another, etc., and all the iterations there.

Lindsey Smith

There's definitely a lot of curiosity around those treatments right now, and I think it's really great to hear your take on it. You kind of talked about that personalized approach, which I think leads us really nicely into Bliss Healthcare. The mission at Bliss Healthcare is to improve the health of our community by providing high-quality, comprehensive medical care in a welcoming and compassionate environment. I want to know what the backstory is there and what need you were trying to meet.

Dr. Jacob Hascalovici

Yeah, absolutely. So Bliss Healthcare — that’s BlissHealth.care — is a telemedicine platform that serves people living with chronic pain across the United States. It's available in ten states across the U.S., covering approximately eighty percent of the U.S. population that’s kind of serviceable.It's also fully covered by health insurance — so all the major payers and individual states, including Medicare and Medicaid and all the big, you know, Aetna, Cigna, Humana, etc., Blue Cross Blue Shield. 

And the idea there is, you know, for some reason, chronic pain is not treated like a chronic illness. Let me explain what that means. Diabetes, for example — when you diagnose somebody with diabetes, the conversation moves away from “let’s cure your symptoms” to “let’s figure out how to help you manage your diabetes so that you can live a normal life and feel like yourself again.”

When it comes to chronic pain, though, we don’t view a person with chronic pain as someone who has a chronic illness. The expectation is that a doctor will cure the disease or take the symptoms away and then they'll go back to their normal life. And so I think there needs to be — and we're not really sure why that is — it probably happens for several reasons, mainly just because there aren't that many specialists in the United States that treat chronic pain.

Unlike primary care physicians, where there are many more in the United States, there are far fewer specialists that devote their time to treating chronic pain. The effect of that is we can't follow patients continuously over prolonged periods of time. And if you have a chronic disease, it really requires a continuous care model approach. You would never give a person with diabetes some insulin and tell them, “If you don’t get better, come back to my office.” Never. What you would do is tell them, “Here’s some insulin, check your sugar every single day for the next month. You’ll meet with a diabetic nurse in a month from now. If there’s an issue, we’ll call you. If there isn’t, we’ll schedule another follow-up in three months so we can titrate your medications.”

And this patient is under your care and purview for the longevity of the person’s condition and life and so that’s how you manage a chronic illness successfully. That’s how you control sugar, that’s how you control blood pressure, that’s how you control hyperlipidemia or high cholesterol. And so the same principle must be applied to other chronic illnesses like chronic pain and that’s one of the needs that Bliss Healthcare is trying to meet.

What we try to do is bring chronic pain sufferers — people who live with chronic pain — to doctors who will work with them on a continuous basis, doctors and nurses, I should say, where they will meet with the doctor, establish a care plan for the management of their pain, and then check in on a monthly basis with a nurse.We use remote monitoring for this — remote therapeutic monitoring — where patients will send us data on their pain, their mood, their sleep using an app called FitCam, which we use in our clinic.

And then at the end of the month, the patient will meet with a nurse. They can review the data with the patient, ask them how they’re doing. If they see that their pain scores are high, they escalate that and flag it to a doctor. The doctor makes changes to the patient’s medication. If it works, wonderful. If not, the patient will meet with the doctor again for a follow-up, etc.

And the beauty of this is this all happens on the internet using video calls, so the patient can do this from the comfort of their own home. There are no more long commutes to the doctor’s office or long office waits.

And I should also add that if you’re in pain, sometimes it’s hard to get out of bed in the morning. Imagine having to get out of bed, get dressed, get into a car, drive to an office, wait in an office for an hour or two just to meet with the doctor for a few minutes, order more tests, go back home.

It’s a lot for a person without chronic pain. And so we’re trying to make access to care easier. We’re trying to deliver chronic pain care in a continuous fashion, really treating it like a chronic disease.

And then finally — and I think this is the most important part of our mission — is to treat people with pain who are suffering from chronic pain with respect and dignity and the empathy that they deserve. And unfortunately, because pain is not something that can be seen or measured, oftentimes patients feel marginalized. They feel dismissed. They feel disempowered when they meet with their physicians. They feel like their symptoms are trivialized.

And, you know, without getting into the reasons why that is, it doesn’t foster a strong doctor–patient relationship. And that’s the key here, which is through respect, through empathy, through listening, we foster strong relationships between the doctor, the nurse, and the patient so that we can deliver this continuous care in the most effective way to our patients.

Lindsey Smith

That sounds like a really thoughtful model that you set there. And I liked the approach of that comprehensive model, that continuous plan personalized to that individual and really treating all patients with respect and empathy. 

You touched a little bit on telehealth, and I want to kind of come back to that. It is convenient, no doubt — I’m a big fan of it personally. But I want to understand to what extent do you think telehealth can fill the access gaps that seem likely to develop in the U.S. based on the rise in demand and potential drop in the number of providers?

Dr. Jacob Hascalovici

Yeah, I mean, I think there’s a huge need for telehealth and I think it fills an incredible access gap. You know, I live in New York, and so there’s no shortage of doctors in New York City and, you know, this is true in most of the major metropolitan cities across the United States. There are concentrations of doctors in places that are, you know, more metropolitan, let’s call it.

But that is approximately twenty percent of the country. The other eighty percent of the country exists across more rural areas. And so those areas have very, very significant access gaps because there just simply aren’t providers. I would say out of the seven thousand board-certified pain medicine physicians, probably less than ten percent of them are located in rural areas across the United States — and densely populated rural areas, I should say.

And so the ability to see a specialist who’s sitting in his office in New York through telemedicine, if you live in rural Alabama, that is highly, highly impactful to a person who’s suffering from chronic pain. If you live in a rural area and you suffer from chronic pain, the probability is that your symptoms are going to be managed by a primary care physician. And they may not necessarily have all the tools to manage a person’s pain. So they won’t be doing any interventional therapy for that patient, and they may not necessarily know about all the new sort of cutting-edge non-opioid-based medications that we have available to be able to prescribe to patients.

And so, yeah, I think there’s a lot of potential in the continuation of telemedicine and telecare, including remote monitoring. And I just hope that there is more legislation that’s passed to really solidify this as a part of healthcare for the future.

I’ve referred to this in several papers that I’ve written over the last couple of years, but I really think that what we’re seeing is this digital healthcare revolution. Actually, we’ve already seen it — it’s already happening. So everything that we can do to continue to keep telemedicine as a practice that’s reimbursed by insurance and by CMS, I think we need to really lobby for that and continue to lobby for that.

Lindsey Smith

Yeah, I think that’s a really good point. It definitely does fill that gap and helps lots of patients in rural areas. And if you’re living in a lot of pain, to your point earlier, you might not want to drive into a doctor’s office when you’re in so much pain. So I think that’s a great point. We’re excited to see the continued progress made in telehealth.

I want to talk a little bit about those patients that are suffering from chronic pain. Are there any support groups or resources available that you would recommend to them?

Dr. Jacob Hascalovici

Yeah, there’s a lot of resources. You know, there’s a lot of good books out there on cognitive behavioral therapy and on managing chronic pain. I just finished a book called *The Way Out*, which talks about pain reprocessing therapy.

I’m a big fan of a book called Feeling Good by Dr. David Burns, which is sort of the basis of cognitive behavioral therapy — which was designed for mental health conditions like depression and anxiety but can be fully applied to the treatment of chronic pain as well.

There are a couple of apps for migraine sufferers, Migraine Buddy, and there are other apps out there for chronic pain, like Curable. By the way, I don’t work for any of these companies or get anything from them. So yeah, there are some resources and many of these, sort of the more online communities over on Facebook — they definitely have support available there.

On my personal Instagram, that’s @DrJacobPain, I try to post videos and different educational content about different types of chronic pain conditions. I think we know for sure that pain education can actually help people manage their pain better — just understanding what pain is, what some of the conditions are, why people have them, and what there is to do about it. That alone can actually help people manage their symptoms, along with other things like stress management.

So there are things out there, and I encourage people to take a look and try to find them.

Lindsey Smith

That’s awesome and very helpful. Thank you so much for passing along those great resource ideas. We’ll be sure to share them with our audience.

Speaking of education, we are a teaching company and we love to fill knowledge gaps at Osmosis. Is there a topic you think Osmosis should make a video about to fill a gap that is of particular concern or of interest to you?

Dr. Jacob Hascalovici

Yeah, I mean, I think personal finance for medical students and nursing students, I think, is absolutely critical. We just don’t know. Nobody teaches us about our 401(k)s, our 457(b)s, our Roth IRAs, and saving for a rainy day, and disability insurance, and life insurance — these types of things — which I honestly wish I knew about earlier and really understood earlier.

So I think that could be an interesting topic for a future podcast if you don’t have that already.

Lindsey Smith

Thank you so much. Yeah, that’s a great suggestion. We’ll be sure to pass that along to our content team for consideration.

Before we get to my last question, I wanted to ask you what advice you would give our students and early career health professionals in our audience about meeting the challenges of this moment and approaching their career in healthcare.

Dr. Jacob Hascalovici

Yeah, I think something that always comes across my mind is getting comfortable with being a little bit uncomfortable.

As you grow in your career and things move forward, there will be moments where — especially in this sort of new technological age that we’re living in in healthcare, this digital healthcare revolution — there are going to be new tools and new things available to us that may not necessarily feel comfortable.

One good example of that is AI-assisted note writing. I can see this in our current practice where our hospital recently introduced a new AI note-writing software and there’s this sort of great divide. There’s half of the providers who are very excited about it and ready to use it, and the others that are just very afraid of it.

And so I think generally — and this comes up in many different situations in medicine, not just with the use of technology — but there will be times where you feel uncomfortable. And I think approaching that with confidence and trying to figure out a way to get comfortable with being a little bit uncomfortable — which means pushing the boundaries a little bit, responsibly — I think that’s some of the best advice that I’ve received and I continue to utilize and think about on a daily basis.

Lindsey Smith

That’s really great advice. Thank you so much for sharing that with our early medical school and early career health professionals in our audience.

Before we wrap up, is there anything we didn’t cover that maybe we should have today?

Dr. Jacob Hascalovici

Well, two things. Number one, we’re, you know, living in a very exciting time for pain medicine. The FDA recently approved one of the first new non-opioid-based pain medications in over twenty years.

The drug is called Journavax, and it’s a brilliant molecule that blocks sodium channels selectively — those specific sodium channels that are overexpressed on nerves that are responsible for pain signaling. So very similar to lidocaine, which blocks nerves non-selectively, this blocks nerves selectively. And the reason I think it’s particularly exciting and interesting — of course, it’s great to have something new and available for us to offer to our patients — but beyond that, there is a company called Lutroo Imaging, which is actually developing a radiotracer for that specific receptor, the sodium 1.8 channel.

And what that means is not only are we now able to use a new medication to treat pain, but in the near future, through companies like Lutroo — who are developing radiopharmaceuticals that target that molecule, that receptor — we might actually be able to see where pain is coming from in the body and measure its signal intensity. So this is going to be a game changer in the field of pain medicine, and it’s really, really an exciting time to be in this field. That’s number one.

And then I think number two, of course — many people know chronic pain is an extremely common condition, one in three people in the United States, one in five people depending on what statistic you read — and so if you’re out there and you’re suffering from chronic pain and anything I said today really speaks to you, specifically about our mission at Bliss Healthcare, feel free to reach out. You can find us at BlissHealth.care or you can find me @DrJacobPain on Instagram. Feel free to reach out and we can see if the services we offer are right for you. 

Lindsey Smith

Awesome. Very exciting developments with the new medicine you mentioned and the ability to really kind of pinpoint where that pain is coming from. And be sure to check out Bliss Healthcare. Thank you so much, Dr. Jacob, for being with us today.

Dr. Jacob Hascalovici

My pleasure. Thank you again.

Lindsey Smith

That’s a wrap on today’s episode of Raise the Line with Osmosis from Elsevier. A big thank you to Dr. Jacob for sharing his insights on the evolving landscape of chronic pain treatment and the challenges we face in ensuring access to care.

As we’ve heard, the rising prevalence of chronic pain combined with a shrinking pipeline of pain specialists is a trend line we can’t afford to ignore.

I’m Lindsey Smith. Thanks for checking out today’s show. Remember to do your part to raise the line and strengthen the healthcare system. We’re all in this together.