Infant sleep advice; a non-addictive pain reliever: Upstate Medical University's HealthLink on Air for Sunday, April 27, 2025

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pediatric pulmonologist gives advice about infant sleep.

Zafer Soultan, MD: ... They start to have some sort of consolidation, some sort of sleeping for five to six hours during the night, is by 3 months. This process, by 3 months, they start learning how to do that, and hopefully they are going to be successful by 6 months of age. ...

Host Amber Smith: A pain medicine doctor tells about a new non-opioid pain reliever.

Vandana Sharma, MD: ... Where I'm looking at it is, like, patients who have acute postoperative pain, where we do not want to quickly go over to opioids right away. This would be another thing that we could use. ...

Host Amber Smith: And an attention-deficit/hyperactivity disorder expert explains what's important to know about ADHD in adults. All that, and The Healing Muse. But first, the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll hear about a new non-addictive option for pain relief. Then we will learn what's important to know about ADHD in adults. But first, some advice for helping your baby sleep.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Today, we'll learn what you can do to help your infant sleep well, with my guest, Dr. Zafer Soultan. He's the chief of pediatric pulmonary medicine at Upstate and the director of the Upstate Pediatric Sleep Center.

Welcome to "HealthLink on Air," Dr. Soultan.

Zafer Soultan, MD: Thank you, Amber. Thank you for this opportunity.

Host Amber Smith: One piece of advice that new moms often receive is to sleep when the baby sleeps. Is this good advice?

Zafer Soultan, MD: Absolutely. They need to rest in order for them to take care of their baby, so sleep is very important for mothers, as it is for the baby.

Host Amber Smith: Now, how much sleep do newborns need and how does this change over their first year of life?

Zafer Soultan, MD: Newborns need a lot of sleep during the first year of life. They need anywhere between 14 to 18 hours of sleep. So how does it change over the first year? Yes, indeed, there will be a little bit decrease in the hours of sleep toward the last few months of infancy.

Host Amber Smith: But at the beginning they sleep a lot.

Zafer Soultan, MD: They sleep a lot. It's basically, they sleep, and they wake up just because they're hungry, so they wake up to eat.

Host Amber Smith: So that's generally what wakes them up, is that they're hungry?

Zafer Soultan, MD: Yeah. They are hungry. They have a small stomach, and they eat 1 ounce, 1 ounce and a half. So, they wake up to feed. So they sleep, although there are many hours, they are divided in intervals. They are couple of hours or three hours of sleep, then wake up, two to three hours sleep, then wake up to feed.

Host Amber Smith: And does that happen all through the night? Is it normal for them to not sleep through the night?

Zafer Soultan, MD: They don't have the circadian rhythm, the day and night clock, mature yet, so they don't differentiate between day and night.

And yes, that's normal to happen throughout 24 hours a day. We're talking now about the newborn in the first couple of months.

Host Amber Smith: Do newborns dream?

Zafer Soultan, MD: Newborns go into what we call active sleep, or rapid eye movement sleep, which means a time when our muscle tone is kind of relaxed and our eyes kind of moving right and left.

So they do a lot of that comparing to adults or older children. So older children have this stage of sleep approximately 20%-25% of the sleep time. Newborns do that half of the time or maybe even more. So a lot of times, mothers will observe that while they're asleep, they're moving, rapid eye movement, they're moving their eyes right and left.

So that's the time when older children dream. So the question now, since they have a lot of rapid eye movement sleep, this stage of sleep where our eyes move quickly, and during this stage, we dream, so the question, do newborns who have a lot of it dream a lot?

Probably not. Probably, they haven't yet matured that system of dreaming. Probably, that takes a couple of years to develop.

Host Amber Smith: Now, at what age would a baby be expected to start sleeping through the night? Is it unusual? You said the first couple months it would be unusual, right?

Zafer Soultan, MD: It's unusual if they don't wake up to feed, not that they slept. They need to get a certain amount of milk, so we (pediatricians) don't like it if they don't get it, and they sleep a lot, and they are not waking up to feed. How come? They're supposed to wake up every two, three hours to feed.

Now that age when they start the process of not necessarily sleeping through the night, when they start to have some sort of consolidation, some sort of sleeping for five to six hours during the night, is by 3 months. This process, by 3 months, they start learning how to do that, and hopefully they are going to be successful by 6 months of age. So, it is expected, but that doesn't mean it's going to happen at 6 months. It's a learning process for them.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with pediatric sleep specialist Dr. Zafer Soultan about common sleep problems in children.

What are the best strategies for teaching an infant to sleep well? What do you end up talking with patients (parents) about?

Zafer Soultan, MD: As I mentioned, at 3 months, they start learning the day and night.

So at 3 months of age, the parents need to help the baby learning this process, help them distinguish between daytime and nighttime, which means in the daytime, we expose them to light when they wake up. We play with them. We sing for them. We have toys and noises and activities, of course, suitable for age.

And in the nighttime, as we kind of discussed, they're going to still need to wake up to feed. But when they do wake up, we don't play with them, and we don't make noises, and we have the light dimmed in the bedroom, and we get the room a little bit colder. So then we are helping them, we're assisting them distinguishing between daytime and nighttime. And therefore, I'm hoping that by 6 months of age, they will master this.

Host Amber Smith: What are the clues that a baby is getting tired and ready to go to sleep?

Zafer Soultan, MD: When they start to do certain things, they need to sleep.

It's like, they rub their eyes, they reach out to their ears. They're not interested in playing or looking at you.

They look to the other side. You want to play with them. You want to tell them, "Come and play." So the way they do it, by turning to the other side, that means they're telling you that "I'm not interested. I want to sleep."

Host Amber Smith: Now you mentioned the room should be cooler. Why is that?

The way our body's set up, that the colder we are, the more we make that melatonin, which kind of triggers sleep. So we recommend that temperature at, like, 70 degrees or maybe 69. The older (kids), you can go down to 68 and 65 sometimes.

Now, the room needs to be dark, but what about a night-light? Is that good to have on in the room?

Zafer Soultan, MD: It's not, like, good to have. So baby doesn't require night-light. So a night-light maybe for family and safety ... but if it's an older child (who) demands the night-light, that's OK. It's basically dimming the light. The light has to be dimmed in the whole house in the evening, including the bedroom.

Host Amber Smith: Now, I'm thinking about a baby who doesn't ever exhibit signs that it wants to go to sleep. How can you encourage them? Do lullabies help?

Zafer Soultan, MD: We talked about training, or assisting, the baby, the same thing, like, you're teaching your baby how to ride a bike, let's say, or how to walk when you start assisting them and encouraging them and holding their hands and putting objects for them to hold onto.

So the same thing you need to do to assist them with this process, which means doing some sort of a bedtime routine. So our brain loves bedtime routine, so we change the diaper, we feed, we sing a lullaby, we dim the light in the room. We are all quiet. We don't have noises in the house, nobody jumping and making a lot of noises, so the baby will feel the difference.

This is a bedtime routine. So we have a little bathing, lowering their body temperature, hugging, very soft, very calm, and dimming the light and singing the song and maybe rocking maybe a little bit and then putting them in the crib. So the sleep process will be putting the baby in the crib to teach them how to sleep on their own, how to soothe themselves to sleep.

So the process of learning how to sleep in the night, the main, main, main thing, or paramount importance, of that process is when the baby will learn how to sleep on his or her own. So after all these bedtime routines, including the lullabies, the baby should be put in the crib to fall asleep on their own, not while asleep -- they should be still awake, but very, very drowsy.

Host Amber Smith: And the babies are put to sleep on their back only?

Zafer Soultan, MD: Yes, (on the) back to sleep is important to prevent sudden infant death syndrome. There are quite few recommendations, but the main one is to put (them) on a little bit semisolid mattress and on their back only.

Host Amber Smith: Now, how do you feel about those sleep sacks, or bundling the baby rolling like a burrito almost, to keep them bundled in and snuggled? Are those useful? At least in the first couple months?

Zafer Soultan, MD: Perhaps. Perhaps it soothes the baby down, and the baby associates it with sleep, and they go to sleep because of this. Yes.

Host Amber Smith: What about pacifiers? Do you ever recommend the use of pacifiers?

Zafer Soultan, MD: Pacifier is recommended by the American Academy of Pediatrics after the baby is finished with learning the breastfeed. So after the baby masters breastfeeding, a pacifier, provided we follow the rules, the condition of the pacifier to be one piece and to be wide on top, so the baby won't swallow it.

A pacifier has a lot of benefits. It supports the airway, keeps it open, soothes the baby to sleep, so there's no objection.

Host Amber Smith: Well, let's talk about some of the things that could cause a baby to have a tough time sleeping and what parents can do about it.

I'm thinking about teething, and that would be later in the first year?

Zafer Soultan, MD: Yes, whenever the baby is in pain, teething, colic, acid reflux, ear infection, fever, cold, they cannot breathe from their nose because they have a cold and their nose is stuffy.

Acid reflux and vomiting and heartburn for the baby and crying, yes, these are unusual.

Typically, the baby cries when they go to sleep, it's because they are not ready yet. They didn't finish their training. It's not failure of the parents. It's the baby hasn't been able yet to soothe themself to sleep.

In the first three months. The baby soothes themself to sleep by mom rocking them and holding them. Now we are going to start at 3 months teaching the baby how to soothe themself on their own. So they don't know what to do, and they cry. The most common reason is just crying because they haven't been trained yet, more than teething.

But if the baby is trained, and they've been falling asleep on their own, and now they are crying, that means there's something wrong, as I mentioned.

Host Amber Smith: So do you then have to figure out, "Oh, is it an ear infection? Are they teething? Do they have a fever?" You have to figure out what's causing the discomfort then, it sounds like.

Zafer Soultan, MD: Yes. And there are breathing issues. There are breathing issues. There are babies who have a congenital anomaly. The airway, the nose, the mouth, the throat, is not normal and tend to be narrow or tends to close up when they sleep. And then the parents will notice the baby is not crying, but they kind of choke while they're asleep. They make noises when they breathe. They stop breathing, they struggle to breathe. Their chest and abdomen moves in a unusual way. They breathe fast. They have retraction, sunken chest, whenever they breathe. So that's a breathing issue, and that indeed wakes up the baby. They keep waking up to breathe.

Host Amber Smith: That sounds like that could be a serious issue, though, that they would need to bring to the doctor's attention.

Zafer Soultan, MD: Yes. Yes. Absolutely.

Host Amber Smith: Well, want to ask you more about that, but before we get into that, what if you have a baby who cries when you're trying to train them to sleep, but they cry when the caregiver leaves the room?

How do you train them to get used to being alone?

Zafer Soultan, MD: You've got to keep training them, so do not give up, same like your baby keeps falling when they're walking, and then you just say, "OK, don't walk." No. So you don't give up.

There are different techniques, and you're going to choose one of them. The fastest one, if you can do it, is to let them cry out. You put them in the crib, and you leave the room. Within a couple of nights, the baby will learn that they're going to sleep on their own. Of course, leaving the room, but you're going to leave the door open and keep monitoring what's going on with the baby.

A little bit gentler way is that you put them (down), and they cry, and you keep coming back to check on them, but you do not carry them. You keep them in the crib, but you keep coming back.

And there's another way where you put a chair, and you sit next to them, but you don't touch them, and you don't sing for them, and you keep watching them crying. And over time you keep moving your chair away from the crib.

And there's another way, is that you keep carrying them. They cry, you carry them a little bit, and then you put them back. You carry them a little bit, and then you put them back. And they keep crying, and it's a process. It's going to take a few weeks

Eventually, you will notice that when you, for example, if you did the way that "I will let them cry, but I will keep coming back," I will start by coming back in one minute, then in two minutes, then in three minutes, then in four minutes. Then in five minutes, when you come back in six minutes, you notice they fell asleep already, they learned.

If you keep carrying them and putting them back, over time, you learn, OK, after 10 minutes of this process, they slept. But you are enforcing. You are enforcing the baby and forcing them to learn how to sleep by themselves. That's why the training is important. So with the training, try to, in the first three months of the training period, which is between 3 months to 6 months, it's good to start teaching the baby to cry a little bit. Don't jump directly to the baby and carry them whenever they need anything. Start the process. Start testing the system and encouraging the baby to sleep on their own.

Host Amber Smith: So that's got to be harder to do if you're sharing a bedroom with the baby, if you have the crib in the corner of your room.

Zafer Soultan, MD: Yeah, a little bit, but you could. Some people opt to put the crib in their room. Some parents do that. So then they leave the bedroom. They don't stay in the room until the baby falls asleep. I mean, it's a process.

Now, the norm is that they learn. I mean, how many times do we see a baby unable to walk, unless of course, if there are underlying issues?

So all babies learn, and they do it, but when it took the baby a little while to learn, then it's a process, a little bit difficult time for the parents. And many times parents need to have shifts. The father or the mother who works, maybe they go to sleep in another room because it's a process, and there will be a lot of crying and lifting and putting back.

Don't forget, the same baby will keep waking up in the night asking for the same process until eventually they learn. But it's really worth it, it's really important because the baby learning how to soothe themself to sleep is a clue for eventually having a good set of sleep habits all across childhood until adolescence, but every baby learns. It is going to happen.

They're going to learn.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more about sleep problems in children.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, with Dr. Zafer Soultan. We're talking about common sleep problems in children.

Now, what are some of the common sleep disorders in infants, and how are they treated?

Zafer Soultan, MD: The most common one is the infant who hasn't learned how to sleep on their own. So, parents' expectation from friends that, their baby sleep on their own by 7 months of age, then, here we go, we have a baby who's 8 months or 9 months, crying all night. This is the way the parents present it, that "My baby does not sleep."

And when we ask, "What do you mean?" they mean that they keep waking up crying, and the parents take them, carry them, cuddle them and rock them as they did initially (at) start of the night, and then they fall back to sleep.

Unfortunately, this is at a cost for the parents. They need to work, and they cannot every two hours wake up and do what's needed for 15 minutes, half an hour. And the next day, they're exhausted, and they do call it that this baby doesn't sleep. So basically, this is the issue. So that's the most common problem.

We have a secondary problem. Babies who are in pain for some reason, whether they do have certain anomalies or disorders which make them be in pain. For example, a common problem is acid reflux, where the baby regurgitates, and the acid burns them, hurts them inside, and they cry.

Again, we talked about teething, ear infections and common colds with obstructed nose. And another common problem we see is the sleep apnea, but sleep apnea in infants most of the time occurs in a baby who has anomalies in their airway and in their tongue and in their face, (which) is not friendly for them to breathe well when they sleep.

So those are the common problems we have in infants. Of course, there are seizures, abnormal movements during sleep that can happen. That's rare.

Host Amber Smith: So when you talk about sleep apnea, what does that look like to parents that are watching their baby sleep? Can they tell that the baby has stopped breathing?

Zafer Soultan, MD: Yes. So parents can see the baby stop breathing. They see the baby struggle to breathe. They seem to be working hard to breathe. They have retractions, sunken chests, when they breathe. They make noises like snoring or abnormal noises. Sometimes they turn blue.

So those are the signs of sleep apnea. However, it's common for babies during the rapid eye movement stage of sleep. Babies do a lot of rapid eye movement stage. Half of the night is spent with that. During that time, the baby will be having disorganized breathing. The parent will notice that they breathe fast, and they stop. Then they breathe, and they stop. That's normal. So I think today I confused the parents a little bit. I did mention a similar sign when I said they have sleep apnea. So they best thing's to talk to your pediatrician.

So when the pediatrician sees the baby whose parents say, "When we put them to sleep, and they're moving their eyes ..." -- many times parents see it -- "... then we notice that the abdomen goes up and the chest goes down, and we notice sometimes they stop breathing."

Yet, the pediatrician looks at the baby, and the baby is well nourished, healthy, doesn't have an anomaly which can block his breathing. Then we just assure the parents, we just tell them that's normal. So yes, indeed, if it is pronounced and concerning to the parents, even though I said most likely it is normal, discuss it with your pediatrician.

Host Amber Smith: How common are anomalies that would cause sleep apnea in an infant?

Zafer Soultan, MD: One of the common ones is the babies who are born with a soft voice box, so this is a common problem in babies when they are born and the larynx, the voice box, is soft, and they make that noise (wheezing).

And those babies, when they sleep, sometimes the airway, the voice box, closes, and they have sleep apnea. One of the common congenital anomalies is trisomy 21 (Down syndrome). In trisomy 21, the tongue is bigger, and the baby is a little bit weaker, so also they're prone to have sleep apnea. So those are the two kind of common issues.

There are many, many congenital anomalies which make the airway close, but those are common.

Host Amber Smith: Now some of those would be sort of diagnosed at birth, that there might be a risk for that.

Zafer Soultan, MD: Yes. And some of those, the parents are alerted of the possibility of doing that. And actually many of them, the physician who's taking care of this baby, do anticipatory work to rule out this issue because they anticipate this is going to happen.

So they do sleep studies, they do other studies to observe the baby.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with pediatric sleep specialist Dr. Zafer Soultan about common sleep problems in children.

Now, if parents are struggling with a baby's sleep, how do they reach an expert like yourself?

Do they go through their pediatrician?

Zafer Soultan, MD: Our pediatric sleep center is comprehensive. We do have four pulmonologist providers who are expert in managing sleep disorders in children. And we do have a pediatric psychologist who has expertise in intervening and behavioral therapy for infants and children insomnia.

So it is a comprehensive program, and we do have a sleep lab for sleep study. This is the diagnostic process where we observe the infant asleep to diagnose breathing problems.

So how do we refer to us? We accept self-referral, but it's better if it comes through the pediatrician because one of the common problems I mentioned, that is babies normally stop breathing while asleep, maybe a pediatrician will just assure you, rather than waiting a long time to see the sleep specialist.

Host Amber Smith: When you talk about a sleep study for an infant, how does that work? Does the parent bring the baby into the hospital?

Zafer Soultan, MD: The parents first get evaluated at our center, and the referral for the sleep study, and this is basically like a hotel stay where the baby will be asleep in a crib, and the one of the parents will be sleeping next to them.

However, while the baby is asleep, they're monitored, comprehensive monitoring. Many, many probes and instruments, outside instruments, to monitor everything, from breathing to oxygen, to heart, to brain waves, camera, snoring, noisy breathing, movements.

Host Amber Smith: So you'll get a pretty comprehensive, it seems, list of things that, "Are they working well, or is there something wrong?" You'll be able to tell after that sleep study.

Zafer Soultan, MD: Yes.

Host Amber Smith: Well, what's involved after that? If you detect that there is an anomaly, I mean, how do you fix some of these sleep disorders?

Zafer Soultan, MD: The sleep study is done for two main indications, one of them breathing issues, and the other one, abnormal movement and seizure issues.

So abnormal movement and behavior and seizures, this goes to the neurologist.

The breathing issues while the baby is asleep are either because the airway gets blocked, or they have a problem with the center in the brain which ordered or triggered the breathing.

And each one, we manage it separately. For the blockage, we see where the blockage is, and we try to remove it. Or if it's not removable, it's a matter of weakness or narrowing, then we do CPAP, which is a machine that pushes air on the nose of the baby. And we apply that air by a mask on the nose or little cannulas (tubes) in the nose. Sometimes we treat problems with oxygen supplements.

It's a list of interventions, and on rare, extremely rare, occasions, with certain severe conditions, we kind of open another "nose." We open a "nose" (a breathing hole) in the throat that we call a tracheostomy for the baby to breathe when there is total blockage and the baby cannot breathe.

Host Amber Smith: Do you ever have parents that come in for the sleep study with the baby, and you find out that the baby hasn't been trained to sleep very well and needs help with that? Is it ever that reason?

Zafer Soultan, MD: Yes. Now, many times, our team, because we are experts, we make the diagnosis and avoid doing sleep studies on these babies because we made the diagnosis.

We understand why the baby is not sleeping because that's the common problem, common presentation, that "My baby doesn't sleep." And then we understand that's what we call a behavioral insomnia. That baby needs training, hasn't finished his training yet, needs to be given chance to train and learn.

Host Amber Smith: Well, Dr. Soultan, thank you so much for making time to talk about this.

Zafer Soultan, MD: You're welcome. Thank you for this opportunity.

Host Amber Smith: My guest has been Dr. Zafer Soultan, the chief of pediatric pulmonary medicine and director of the Upstate Pediatric Sleep Center. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "Health link on Air," a new non-opioid pain medication.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Lots of people with short-term pain are concerned about becoming addicted to opioid pain medications. The Food and Drug Administration recently approved a new non-opioid prescription pill, called suzetrigine, that's said to be non-addictive.

Here to tell us about it is Dr. Vandana Sharma. She's an anesthesiologist and the director of pain management services at Upstate.

Welcome back to "HealthLink on Air," Dr. Sharma.

Vandana Sharma, MD: Thank you, Amber. Thank you for having me for this talk show. It's really a pleasure to be here.

Host Amber Smith: Well, if I understand correctly, suzetrigine is the first in a new class of analgesics.

So what type of pain is it designed to treat?

Vandana Sharma, MD: You are very correct. For a very long time, actually, the acute pain world has been missing a new addition to our armory of medications that we use for acute pain, so this comes as a very nice change for us. Long time ago, World Health Organization revealed the WHO "Ladder" (for pain treatement), which most physicians are aware of, and that includes, starting with the least addictive drugs, and then moving up the ladder to treat patients' acute pain.

And for almost decades now, we have been using acetaminophen, in other words, Tylenol, ibuprofen. We have been using weak opioids and adding some adjuvants (secondary treatments) to them, like gabapentin and nortriptyline are antidepressants.

But each one of these comes with its own side effects or sometimes inefficacy or not being able to work alone. So we did need another drug, in this continuum of medications that we have, that could one, give us another option to treat pain, and two, could work along with all other medications and help better to increase the potency of pain control.

As an acute pain specialist and chronic pain specialist, I'm very excited to know that finally we have one more breakthrough in this realm of acute pain management, where we could help our patients with another class of medications.

Host Amber Smith: So it's another tool that you can use?

Vandana Sharma, MD: Absolutely.

Host Amber Smith: Would you use it more for chronic pain or acute pain?

Vandana Sharma, MD: At this point of time, it's only approved for acute pain and for a short period of time. So based on the limited studies that we have available, it's marketed by a pharmaceutical company, and they have studied it on over a thousand-plus patients. And this is studied only for acute pain patients. It has not yet been studied for chronic pain patients. And they have been cleared to use it only for a two-week period maximum. So 14 days would be the maximum time period that we could use it, but it definitely gives us the option when the patients need it the most.

Where I'm looking at it is, like, patients who have acute postoperative pain, where we do not want to quickly go over to opioids right away. This would be another thing that we could use before we put our hands on the big guns.

Host Amber Smith: So after surgery, this might be something they get in the hospital, or they get sent home with?

Vandana Sharma, MD: We don't know yet,

Host Amber Smith: And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Vandana Sharma, MD: but I'm working on it, to put it there. This was very recently cleared by FDA, and typically, in academic institutions like Upstate, we usually do not quickly rush over to something that just comes out. We want to foresee the results, and again, sometimes looking for the results takes a long time as well.

So we did our own research, we did our own studies and talked to the company reps as well. So far it's looking promising, but I wouldn't know for sure till I use it, and that's why we are trying to be as familiar with the drug as possible.

For now, just as you said, I think we could start using it in acute postoperative period. But also there is a limitation that this is an oral drug, so a lot of times people are not ready to take orally as soon as they come out of surgery, so I don't see that I could use it in PACU (post-anesthesia care unit) right away.

But I do see that this is something we could start once the patients are able to take orally at all our outpatient surgery centers, where the patients could be sent home the same day, so they're ready to take orally after a couple hours, after anesthesia wears off.

Host Amber Smith: Well, let me ask you a little bit more about some basic questions. Can you explain for us how pain works in the body? How does the brain receive pain signals?

Vandana Sharma, MD: That's an interesting question. I'll try to simplify it as much as possible.

I know it's a complicated phenomenon, but let's try to make it simple. I'll start with the concept of nociceptors, or in simple words, these are pain receptors. Now, these pain receptors are everywhere in the body. They're present on the skin, in the tissue, in muscle tissue, in joints, in the coverings of the brain, which is called dura.

In other words, they're present everywhere. These pain receptors, they sense pain, and then their job is to, once they have sensed an injury ... so, going back again, pain is like a response of the body to protect itself from the injury. So that's how the pain initially evolved, as a protective response. And typically it starts with an injury or an inflammation, something that the body senses as not a pleasant experience to it. It can be a chemical injury. It can be a mechanical injury, like a surgery, or it can be an inflammatory injury, any kind of injury sensed by these pain receptors.

And then they transmit this pain signal through the specialized nerves to the spinal cord. And in the spinal cord, the conjunction of these nerves are what we call first-order neurons, or first-order nerves. They hand over the signal to the second-order nerves, and then these nerves from spinal cord take the signals over to the brain.

So this is like a pathway that starts in the periphery. And periphery could be anywhere in the body. And from the periphery, they transmit this signal to the center, which is first the spinal cord, and then spinal cord to the brain.

When we talk about the pain pathways, we have targets at all these different sites where the pain pathway can be blocked. And in other words, those are the places that we use as pain physicians to help our patients. The most promising thing that we were using so far to treat acute pain or acute postsurgical pain was nerve blocks, which is to numb up the nerves that are sensing this pain. And they obviously have to be injected near a nerve, so it's a procedure.

Suzetrigine, which is a new drug, is doing this similar thing. It's working on the same receptors that the nerve-blocking agents work on, such as lidocaine works on, but in a different manner. And it's highly specific for the specialized nerve receptors, or the channels that activate these nerves, which are called sodium channels.

Another good thing about suzetrigine is that it works in the periphery, which means right where the pain begins. That's where it dampens the nerve signals as they're carrying the nerve sensation, the pain sensation, from the periphery over to the spinal cord, so it's a novel mechanism of action.

But unlike the nerve-block agents like lidocaine or bupivacaine, the commonly used local anesthetics in practice, which may or may not be feasible to be used in all sorts of patients, suzetrigine, most likely being an oral agent, can be used in the periphery for variety of pain syndromes.

Host Amber Smith: And it's again, an oral medicine that you take, you swallow, as opposed to the injections with the nerve blocks.

Vandana Sharma, MD: That is correct. It's an oral pain medication. By no means I want to sound like this would replace the nerve blocks, because nerve blocks are still, I feel, the most potent way for us to control pain, to stop pain. Regional anesthesia still is, I should say, the best tool that we have available to control acute pain in whatever circumstances we can use it. Like, for example, in orthopedic surgeries or major abdominal surgeries or major thoracic surgeries, regional anesthesia, in whatever form, either in the form of central blocks or peripheral blocks, it helps the best, as the topmost site of controlling pain. And then after that, we use all the other adjuvants, and I see suzetrigine as being an adjuvant, where we could use it in addition to everything else.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Vandana Sharma about a new non-opioid pain medication called suzetrigine.

So if suzetrigine and nerve blocks work on nerves, is that how opioids and acetaminophen and ibuprofen work? Do they also work on the nerves?

Vandana Sharma, MD: They do not work directly on the nerves, but they do work in the whole pathway, as I talked about, from periphery to the spinal cord and from spinal cord to the brain.

So, as I said, there are several areas of pain modulation in this whole pathway where these drugs work at different steps. So let's first talk about Tylenol, for example. Tylenol and NSAIDs (nonsteroidal anti-inflammatory drugs) both. So they are both anti-inflammatory agents, which means they stop the inflammation. The NSAIDs like ibuprofen or meloxicam or Celebrex, they all work in the periphery, where the inflammation is happening.

So as I first alluded to the pain receptors, or nociceptors, they usually get activated by inflammatory markers that rise in our blood as a result of inflammation injury and whatever. So these anti-inflammatory drugs like ibuprofen and other NSAIDs, they stop the inflammation in the periphery, and that's how they stop the pain signals from going forward.

Tylenol, on the other hand, is more of a central inflammatory agent, so it doesn't work as much in periphery as it works in the central nervous system. So that's how it causes a reduction in fever as well as in pain.

Now, talking about the other agents, like opioids, which work on separate kinds of receptors, these are immune receptors that are present, again, everywhere, but they are more concentrated in the spinal cord as well as in the brain. And they can be used as an IV (intravenous) agent or as oral agents or even in the form of an adjuvant to the epidural infusion sometimes, where they can work directly on the spinal cord receptors.

So they are very potent. But then, at the same time, they do carry the risk of dependence and addiction. And that's why, if you would know that we are trying to find ways to minimize the use of opioids in the perioperative period, what we have noticed over last few decades is that the acute perioperative period is the time when the patients could for the first time get exposed to opioids, even though it's for a short period of time. But it can sensitize them to a different pathway in their lives towards pain sensitivity and also is a crucial time when people could develop opioid dependence and, in worse forms, could develop opioid addiction.

And believe it or not, perioperative period is a very critical time when all these things can happen, and especially in "opioid-naive" individuals. So we are always, as I said, trying to find out ways to minimize the use of opioids. To say we can do opioid-free anesthesia or opioid-free analgesia (pain relief) in the perioperative period would be a long shot, at least at this point. It's not impossible, but it's difficult. And that's why we depend upon many medications that work on different mechanisms to stop the progression of pain, in addition to opioids.

So, going back to how these other drugs work, I just briefly talked to you about how opioids work, how NSAIDs work, how Tylenol works, and how nerve blocks work as well, which is like numbing up these nerves from carrying the pain. And then we have several other adjuvants, like gabapentin or pregabalin or Lyrica, that all have shown a little bit of promise. We have gotten some studies that have shown they're wonderful, and then there's some studies that have shown that the side-effect profile is not as good. So they cannot be used on every patient with the same efficacy.

And I think that's true for all other medications, too. You have to be very selective for which patients, what kind of pain that you're treating and what combination can you use, several interactions that they could have with other medications.

And same thing is true for suzetrigine, as well, and even though we don't know a whole lot yet, because of the lack of real world data. All we are getting is from these randomized control trials that the drug company did. But again, the way I look at it is, it's a promising avenue, at least for the first time someone is looking at sodium channels, highly selective sodium channels, blocking them and trying something that is not addictive, that does not work on, these other receptors, does not interact a whole lot with other medications and could help through a different pathway.

Host Amber Smith: Now, you used the phrase "opioid naive." is that someone who hasn't taken opioids before?

Vandana Sharma, MD: Yes. CDC (Centers for Disease Control and Prevention) defines opioid-naive individuals, who have had minimal exposure to opioids, for less than two weeks.

Host Amber Smith: Well, how do we know that suzetrigine is not addictive?

Vandana Sharma, MD: That's a great question actually.

First of all, the best evidence that I can tell you is that it does not work on the receptors that addictive drugs work; for example, it does not work on new receptors.

Secondly, in all of these studies, there was nothing so far to prove that the patients who took it had any withdrawal reactions after it was stopped, or there were any difficulties with stopping the medication after 14 days. So it's probably safe to assume at this point that suzetrigine is not an addictive agent and also based on the available data that includes its mechanism of action, the preclinical data, and the clinical adverse event data. All of these have not so far shown an addictive potential for this drug.

Host Amber Smith: Are there people that would not be candidates for taking the drug? Does it have interactions with other medications, for instance?

Vandana Sharma, MD: The answer is yes. we first have to look at how this drug is metabolized in our body.

This is metabolized by the liver enzymes. These are specialized. Liver has a multitude of enzymes, but what we are talking about is a particular subset, which is called cytochrome P450 system. This enzyme is responsible for the majority of metabolism of this drug, so in patients who have liver dysfunction, and especially advanced liver dysfunction, where we would expect that this enzyme would not be fully functional, we expect that suzetrigine may not get metabolized easily. So the pharmaceutical company recommends that there should be dose reduction in patients who have mild to moderate liver dysfunction and should be altogether avoided in patients who have severe liver dysfunction. So definitely that would be one class of patients where I would be hesitant on using this drug.

Anytime we are taking any medications that could inhibit this enzyme, could potentially increase the amount of drug in the system. The company recommends that patients who are using grapefruit, in any form, shouldn't be using that because with enzyme inhibition, there could be potential interactions or increase in the drug levels.

Some other drugs, like some antibiotics, like clarithromycin or erythromycin, could also inhibit the enzyme and could be problematic. Several other medications could cause interactions as well. So it's very important that patients do reveal their medication list to the physicians if they're interested in using this drug.

What we are looking at at this point is at least start using it in inpatients, and then, seeing whether the patients can be sent home with this for a short period of time, like, as I said, 14 days is the maximum. And in most of these studies it was used for a minimum of seven to 10 days.

And for myself, I would want to see how much dose reduction can, be seen in the opioid use, and whether this is worthwhile being used among other medications or not.

If we see that patients have a meaningful improvement in their pain scores, a meaningful reduction in the use of opioids, then I would certainly consider this as a successful endeavor as an acute pain physician.

Secondly, patients with end-stage kidney diseases, where they have kidney insufficiency to severe degree or to the point of requiring dialysis, we wouldn't be using that. It has not been studied in pregnant patients or in children, so again, that is one population where we are still restricted.

We don't know what's next to come, though. I think those are the common ones. And then anytime we are talking about restricting in which populations, we think about elderly population as well. So as long as the liver function and kidney functions are pretty good, so far it has been proven safe in elderly individuals as well.

Host Amber Smith: Well, let's talk about the side effects, because opioids come with a lot of side effects. What about suzetrigine? Are there side effects to be aware of?

Vandana Sharma, MD: As I was telling, they have studied this in more than a thousand patients at this point, and the amount of side effects that they found were not very serious.

Based on the data that I looked at, I think the common side effects that they found were muscle spasms, incidents of rash, some patients had a mild increase in a certain chemical in our body that's called creatine phosphokinase, or CPK. And we do not know what caused this because less than 1% of patients or close to 1% of patients got these side effects.

What was the mechanism behind these? It's hard to say. They also checked on nausea, vomiting, and there was a very mild increase, I believe, in patients who were taking suzetrigine, but nothing was clinically significant for not being able to prescribe. Like, for example, among a thousand patients, I think there were 10 who developed rash, and itching, and some people developed muscle spasms, but nothing was clinically significant to stop the medication.

But I think overall, maybe less than 1% of patients actually stopped the medication for several reasons, not necessarily because of any life-threatening or bigger adverse events.

Host Amber Smith: You didn't mention constipation, and I know that's a big one with opioids. Is that not seen in suzetrigine?

Vandana Sharma, MD: So far they have not mentioned that constipation was seen, and that's one of the big points that causes patient dissatisfaction in the acute perioperative period, not being able to move their bowels. So nothing that has been noticed so far or has been pointed out yet.

Host Amber Smith: Well, it is exciting to have a new class of analgesic. Do you have patients asking you for this?

Vandana Sharma, MD: Yes. I think it was beginning of March, or maybe February, sometime the same day when the news broke out that FDA has cleared this new drug for use in acute pain. At least a few patients in the clinic in my pain clinic, same day, started asking about that.

I do have some colleagues up in the OR (operating room) asking about this as well. So yes, I see the level of excitement among, the general population as well as among the physicians about being able to use this drug.

And I shared the same enthusiasm as well. And that's why I reached out to the pharmaceutical company to see, like, if they could give us more information, whether we could attend some of their webinars to get more information about the drug and if there were safer ways to start using it among highly selective patient groups in the hospital, for inpatients, to get more familiarity with the medication and seeing the safety profile for ourselves.

But at least based on the preliminary data that we have available from a lot of these studies that have been done, I feel confident that I could start using it without worrying too much about the side effects or safety profile of the drug.

Host Amber Smith: Now, suzetrigine is what it's called, but are there brand names available yet?

What else might people hear it called?

Vandana Sharma, MD: The brand name for the drug is Journavx, and I just came to know about this, that what they meant by this was your "nav." Nav is the voltage-gated sodium channel. So they put NAV in there, so it kind of puts the mechanism of action in there, too. So Journavx is what we are seeing right now.

Host Amber Smith: Well, Dr. Sharma, thank you so much for making time to tell us about this. I appreciate it.

Vandana Sharma, MD: Thank you very much for having me.

Host Amber Smith: My guest has been Dr. Vandana Sharma. She's an anesthesiologist and the director of pain management services at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some advice from professor Stephen Faraone from Upstate Medical University. What's important to know about Attention Deficit Hyperactivity Disorder in adults?

Stephen Faraone, PhD: The first thing that's important to know is that just because you were not diagnosed with ADHD in childhood doesn't mean you don't have ADHD. Many adults with ADHD never had a diagnosis. They may have had problems in childhood that were caused by ADHD that were just never recognized. That's the most important thing.

The second most important thing would be that there are very good treatments for ADHD in adulthood, treatments that have been tested now for decades, that we know work very well and have very few adverse effects, if any.

And when they do have adverse effects, they're usually well managed, so you shouldn't be afraid of the treatments for the disorder either.

There are also adults with ADHD who have had a long life of difficulties because their ADHD has not been managed. And then maybe in their 20s or 30s, they realized, "Oh, these problems seem to be ADHD." They get diagnosed. It also is important to remember that pills don't replace skills, that although the medicines for ADHD will definitely help you in your current life, they won't replace any life skills that you may not have learned because of your ADHD in the past. And for that, sometimes it's useful for adults to enroll in a cognitive behavior therapy program that is especially geared for adults with ADHD.

Host Amber Smith: You've been listening to Stephen Faraone, a professor of psychiatry and behavioral science and neuroscience and physiology at Upstate and president of the World Federation of ADHD.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: There is now awareness and emphasis on mental health. Two of our poets gave us a sense of how a child's struggles with such illness also affects the parent. First is poet W.F. Lantry, who describes what the illness does to his son in his poem "Extreme Ways."

There is an epigram to Ernest Dowson:

"-- Those scentless wisps of straw, that, miserable, line

His straight, caged universe."

He had to discard everything, his songs,

and everyone who tried to hold him close.

It's like he lived inside a Moby riff,

played endlessly, shut down within his mind,

his thought unknowable, a hieroglyph

I cannot read. Did he forget his dose,

or tell himself, again, he didn't need

what others knew? I could not intercede.

In other times, he held the chickens' wings

quite gently while I clipped one half their flights

so they'd be grounded close to earth, confined

within their fence. My reckless heart delights

in memory the images it brings:

once, walking with his mother on a strand,

I fell behind, and saw him take her hand

to help her balance on the title stones.

But where's the balance now? These double doors,

Locking behind us, buzz in turn, designed

to block out everything our sense adores,

reduce his worlds to exclusion zones,

and hold him where no conscious love belongs.

Ann Weil has stark images and searing emotions in her poem "Choices for the Mother of a Son with Mental Illness."

I could ...

Cut a slit and peel back the dewy blanket of grass.

Crawl beneath the sod, pulling its cover over my head.

Let the earth, warm with the spring sun, heal my ache.

Stand on the street corner and rage-scream at the traffic.

Fall to my knees, gutted by panic's sharp knife.

Run fast and far, a rabbit fleeing the rabid dog.

Climb to the jagged peak of understanding.

Know too little and too much.

Cover the wounds with powder and blush.

Bargain with the Devil, make a deal with God.

Open the cupboard of my chest.

Squeeze my heart, bring it back to life.

Knock gently on his door, wait for the invitation.

Ask, How are you today? Prepare his favorite foods.

Tell him he is loved. Hold him as he weeps.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our web site at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

This is your host, Amber Smith, thanking you for listening.