Jason Pope is the president and CEO of Evolve Restorative Center in Santa Rosa, USA, and serves as president of the Californian Society of Interventional Pain Physicians. Here, he talks to NeuroNews about how he has seen the field evolve over the past decade, his hopes for the future, and why neuromodulation is “the best kept secret in medicine”.
How have you seen the field of neuromodulation develop over your years practising?
Neuromodulation has been around since 1967. First there was the influence of hardware, but over the last three to eight years, there has been more influence and innovation in software, such as the application of electricity to the spinal cord. Now, not only are people empowered by randomised prospective controlled studies, they are also empowered by collecting their own data, and seeing how well the device performs in their hands and their practices.
How have you seen these technological advances shape research and treatment?
When I was first exposed to neuromodulation, there were only three companies, and it was more of a one-size-fits-all strategy. I think we will begin to see medical devices created for certain indications, so we will have specialists within the world of neuromodulation that will reach for certain therapies based on what they are trying to treat.
If we empower those physicians by marrying the results from the clinical trials with how they are actually performing practice, it will elevate the standard of medical practice while ultimately enabling patients to do better. A lot of the innovation in our space has come from physicians trying to find gaps in their practice and end up reaching for the bench side and industry to help fill those gaps.
What has been the most practice-changing advance thus far?
I think there are two. One that has significantly changed my practice is the advent of dorsal root ganglion (DRG) stimulation. Chronic regional pain syndrome (CRPS) was one of those syndromes that was really difficult to manage, and the prognosis was somewhat poor.
Now, the advent of DRG stimulation has allowed for a treatment that will significantly change someone’s prognosis. Being involved in the ACCURATE study, and seeing it in clinical practice now, is probably one of the most gratifying things.
I also think that the concept of looking inward within practice, to see how well your patients are performing, is important. In the USA and elsewhere, it is sometimes very difficult to gauge from a longitudinal perspective how well patients are performing with a particular medical device. And, if you wait for the patient to tell you the device is not performing, sometimes it is too late, and it is difficult to assimilate such data. Having the ability to track data inwardly within the practice, and doing so in a way where there is validated measures and endpoints, I think is really critical.
On the contrary, what has been the biggest disappointment you have seen?
When you look at the opioid epidemic in the USA that we are currently battling, some of the regulatory strategies surrounding the placement of neuromodulation in the pain care algorithm still seems to be fairly late. Even with the labelling that we have with a lot of devices, it remains a last resort therapy, and it is certainly not that.
It is surrounded by some of the best data that we have; it should not be salvage pain care, but pain care for refractory cases. Unfortunately, we do not see that acceptance with some of the labelling we have here in the USA. Some of our payers are slow to appreciate the clinical data.
To combat this, we need to develop a data sharing strategy to further demonstrate that neuromodulation works away from an industry sponsored study. Having the ability to share those outcomes in a validated manner is important, and doing so requires being able to speak a common language, so all the data that is being acquired is done so in the same manner. Then you can compare patient populations around the world. This is critical for the survival of our space.
Is there anything else on your wish list for the future development of neuromodulation therapy?
I think cost-effectiveness is always important. We have made strides in the neuromodulation world looking at the periphery, not only central neural axial stimulation, but also peripheral nerve stimulation. Having companies that have created technology specifically for the periphery was a huge win for us too.
I also think we need to appreciate that all ships rise with the tide. The language between one therapy and another detracts from the overall success of our space. We need to focus on having a common voice within the neuromodulation world, because it still remains the best kept secret in medicine. There are many who do not know about the field of neuromodulation, so to always talk about it kindly, is very critical.
Outside of your research, what has been the most interesting paper or presentation you have seen in the last year?
I like the work that Saluda Medical has done with the Evoke study. They have created a strategy where you can give the spinal cord the exact amplitude of stimulation that is required to elicit a response. I think the feedback strategy is really innovative.
Also, we tend to publish in our own journals. To see that they have an acceptance in other journals, such as Lancet Neurology, is really important. Expanding the readership may expand the footprint of neuromodulation. This credits them for the exhaustive science they have done and the robustness of their data.
The work by Stimgenics is also very exciting. Purposeful stimulation of the supporting glial cells to institute a change in neuronal activity is very space-altering.
What research are you working on at the moment?
We are doing a study looking at intrathecal therapy. We are trying to compare conservative medicine management to targeted drug delivery in the non-cancer, chronic pain population.
In total, 15 practices are participating in a prospective randomised comparative of intrathecal therapy versus conservative medical management in the USA. We are in the middle of enrolment and we are activating sites currently. I am hopeful that we will have a preliminary slice of data to share with the space next year.
You have been on mission trips to Liberia, Kenya and Mexico. What motivated you to go, and what have you learnt from these experiences?
My motivation was to see how medicine is practised in different environments. Myself and my wife went through World Medical Mission to Kijabe (Kenya) and we spent about three months there. I practised as an anaesthesiologist and my wife taught at the nursing school. One of the takeaways was how wasteful medicine can be (in first-world countries), and I think is it important to be efficient in where we place our resources when we take care of patients.
I think that there is a huge opportunity to improve on the waste of medicine. When we were in Kijabe, we would wash anaesthesia circuits and reuse laryngeal mask airways and endotracheal tubes, and we did so in a sterile way, because the resource was very limited. Yet, when you look at infection rates in those hospitals versus other hospitals, they are very much the same. I think there is an opportunity to create more economic ways to engage in medicine in the USA.
The piece of the medicine pie within most governments is only so big, if we become more efficient in how we disperse those funds, we may be able to take care of more people.
Do you have a fantasy experiment, regardless of cost or ethics?
I think it would be interesting to carry out a clinical study looking at targeted drug delivery and sampling the concentration of medication along the neuraxis. In order to do that you would have to place ports or catheters to sample the cerebrospinal fluid at the various levels of the spinal cord. I think it would be able to give us more granular data and insight into the pharmacokinetics of the cerebrospinal fluid space, outside of the computer model or translational medicine from animal data.
However, this would be a difficult study to perform because I do not know any person who would sign up to get five, six or eight sampling catheters within their intrathecal space. But it would be very interesting to do.
What are the major questions in the field of neuromodulation that remain unanswered?
In terms of the mechanism of action, there is a lot of debate surrounding how spinal cord stimulation works based on of the strategy that is employed. I still think we have a lot of basic science to do regarding that.
I think looking at the influence of temperature on peripheral nerve and spinal cord stimulation would also be interesting; I am sure there will be an opportunity to see some advances in thermal treatment of neural tissue. Also, everyone is looking at the influence of electrical energy on neural tissue, but looking at the supportive structures around the neural tissue is also innovative.
2018–Present: President and CEO, Evolve Restorative Center, Santa Rosa, USA
2007–Present: Regulatory and Marketing Vice President, Anaesthetic Gas Reclamation, LLC, Nashville, USA
2018–Present: President and Co-Founder, Celeri Health, Inc
2016–Present: Co-Founder, Neural Integrative Solutions, LLC
2017–Present: President, California Society of Interventional Pain Physicians
2019–Present: President Elect, American Society of Pain and Neuroscience
2017-Present: Board of Directors, International Neuromodulation Society
2015–Present: Board of Directors, North American Neuromodulation Society
• PROSPER: Post-Market, Randomized, Controlled, Prospective Study Evaluating Intrathecal Morphine (IT) versus Conventional Medical Management (CMM) in the Non-cancer, Refractory, Chronic Pain Population
Device: Intrathecal Pump
• PROLONG: Prospective, Multicentre, Open-label, Post-market Study
Device: Spinal Cord Stimulation
• PRESS: Postmarket Registry for Evaluation of the Superion Spacer
Device: Interspinous Spacer
• REALITY: Long-Term Real-World Outcomes Study on Patients Implanted With a Neurostimulator
Device: Spinal Cord Stimulation
October 2012: Lead Anaesthesiologist, Children Surgery International, Hermosillo, Mexico
January 2010: Lead Anaesthesiologist, Children Surgery International, Liberia, Africa
March 2009: Lead Anaesthesiologist, World Medical Mission, Kijabe, Kenya
2009–2010: Pain Management Fellowship, Department of Pain Management, Anesthesiology Institute, Cleaveland Clinic, USA
2005–2008: Aesthesiology Residency, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
2000–2004: Doctor of Medicine, Indiana University of Medicine, Indianapolis, USA