Month: July 2014

Painkillers Most Often Prescribed in the South

/ Thomas Cohn, MD

Painkillers in the SouthMany people have heard the term “Minnesota Nice,” but the term “Minnesota Tough” may soon be a new moniker after it was revealed that Minnesota was among the lowest per capita states for pain pill prescriptions.

The report published earlier this month by the Centers for Disease Control and Prevention assessed painkiller prescriptions and analyzed how they varied state to state. The study analyzed prescription totals for common painkillers including Vicodin and OxyContin, and the findings uncovered an alarming trend about painkiller prescriptions, particularly in southeast.

Alabama had the highest rate of prescriptions, followed closely by Tennessee, West Virginia, Kentucky, Oklahoma, Mississippi and Louisiana. Doctors in the south also had higher prescription rates for antibiotics and stimulants for children.

The study wanted to pinpoint the problemed states after some concerning overdose death trends emerged over the last few years. In 2011, 41 percent of the 41,000 overdose deaths were from prescription pain meds.

“Prescriptions go up, deaths go up. Prescriptions go down, deaths go down,” said CDC Director Dr. Tom Frieden.

Frieden added that more drug monitoring programs at the state level and more laws aimed at shutting down “pill mills” are two main ways local and national governments could help curb prescription painkiller overdoses.

Minnesota’s Number Encouraging

Although the exact numbers aren’t known, USA Today published a color-coded map that determined whether a state’s total painkiller prescription per capita total was low, medium, high or very high. Minnesota was one of 13 states to earn the “low” distinction along with Alaska, California, Colorado, Hawaii, Illinois, Maine, Massachusetts, New Jersey, New York, South Dakota, Vermont and Wyoming.

Aside from being tough, it appears that Minnesotans are aware that pain care needs to be a multi-faceted approach. There is no magic pain pill. Prescriptions need to be combined with diet, exercise, physical therapy and help from a trained professional if you want to give yourself the best chance to live a pain free life.

Keep it up, Minnesota.

Related source: Lee County Courier

Acetaminophen May Not Aid Back Pain Woes

/ Thomas Cohn, MD

acetaminophenA new study out of Australia found that Acetaminophen, also known as Tylenol, did little to relieve back pain woes in more than 1,600 patients suffering from back issues.

The study compared Acetaminophen to a placebo pill and found that neither pill proved more effective in:

  • Pain relief
  • Easing discomfort caused by back pain
  • Helping patients fall asleep faster
  • Improving overall quality of life
  • Recovery time

Researchers say their findings may change the way doctors issue prescriptions for back pain.

“[Acetaminophen] might not be of primary importance in the management of acute lower back pain,” said study author Dr. Christopher Williams.

Others were not so quick to consider changing prior practices.

“While this is a fascinating study, it is only one study and should change clinical behavior,” said Dr. Houman Danesh. Another expert, Dr. Michael Mizhiritsky, agreed with Danesh and questioned some of the study’s techniques, saying, “The drawback I see is there was no group that did not receive treatment – meaning there could be a placebo effect” at work.

I agree with Dr. Danesh, and his final thoughts on the study perfectly sum up that pain management needs to be a multi-faceted approach.

“Most back pain patients improve in 6-8 weeks,” Danesh said. “It is important to note that the best treatment of back pain involves not only pain medication, but also physical therapy to address muscle imbalances. Acupuncture for back pain has also been researched by the U.S. National Institute of Health, and after reviewing the literature they state that there is evidence to support the use of acupuncture for back pain.”

Complex Regional Pain Syndrome in Minnesota

/ Thomas Cohn, MD

CRPS in MinnesotaComplex regional pain syndrome (CRPS) is a difficult medical issue to treat. If you think you may have it, you want it gone. Unfortunately, there are few physicians and even less specialists who understand it and are able to manage the problem. Pain specialists, neurologists, and many other experts struggle with the diagnosis and treatment of the condition. In any field of work, 90% of people do a good job, however with CRPS, you need to find the 10% who are superior in their skill level. They are the artists, they put in a phenomenal effort to find a cause and a set of solutions to cover all the complex interrelated issues.

The starting point with complex regional pain syndrome is finding a Pain Specialist certified by the American Board of Physical Medicine and Rehabilitation. These are medical doctors with the extensive qualifications in all aspects of understanding pain. Board subspecialty qualifications insures a higher level of knowledge. The next quality is that the physician sees and treats the problem frequently. If they only see a couple of cases a year, it is unlikely they will have the interest and skill needed to successfully manage the problem. If the doctor walks into the room, immediately knows what is wrong and can talk to you sensibly about the problem, you have found the expert. He will also take a team approach to treating you, guiding you through any additional diagnosis and the variety of treatment options.

Treatment of CRPS

A CRPS expert will also understand this is a not a final diagnosis. CRPS is being caused by some sort of damage to the a particular region of the body. Finding the cause behind CRPS is essential in finding the route to managing and possibly resolving some or most of the pain. Treating symptoms rarely treats the CRPS. An expert will dig deep to find the all the issues that stimulate the sympathetic nervous system maintaining the pain. At times, treating the underlying problems resolves the CRPS. Unfortunately, at times, the damage to structures cannot all be solved and residual issues remain despite the best management.

Complex regional pain syndrome affects both the upper and lower extremities. Finding the diagnosis that is causing the problems is essential in treating CRPS. Treating the symptoms is helpful initially, but treating the underlying problem is essential in improving the outcome. In the lower extremity, orthopedic injuries especially to the foot and ankle cause CRPS in about five percent of individuals. Common causes include injuries to the ligaments and tendons of the ankle and foot that caused instability. Surgical management of the foot and ankle problems, along with aggressive simultaneous lumbar sympathetic injections may resolve the issues. Complex regional pain syndrome is less common in the upper extremities, but is also related to ongoing, unresolved injuries that are continuing to stimulate pain signals.

Find a Minnesota Pain Doctor

Finding a pain specialist who understands the complex issues related to the pain is difficult. Experience and training is essential to achieve a good outcome. Look for the physician who sees many patients with this problem on a regular basis. If the physician has not seen these patients frequently, it is unlikely that you will be satisfied with your treatment results. CRPS is a difficult problem to treat and finding the pain specialist with experience is necessary for a satisfactory outcome.

The Link Between Obesity and Chronic Pain

/ Thomas Cohn, MD

Obesity and PainA large portion of individuals who suffer from chronic pain are also obese. The question is often asked which comes first, and will solving one issue make the other go away? The answer is obviously not a simple one, but both of these subjects are related.

Obesity is a severe problem in developed countries like the USA.  Once obese, people do not move as much, and overloading the body can lead to pain in areas like the back and joints in the legs. Having pain in the low back or joints and being obese does not mean that losing weight will resolve the problem since permanent injury may already be present.

Obesity and Pain

Obesity is a primary problem affecting a large segment of society. Treatment is varied, and one single strategy does not help everyone. Since obesity leads to many health problems that cause pain, like diabetes, vascular disease and early osteoarthritis or degenerative arthritis, treating obesity before these problems occur is important. Once permanent damage to the body is done, reversing the injury is often impossible and treatment can only be aimed at symptom management. If you are obese, work with professionals to bring your weight under control to prevent permanent side effects.

Having low back pain and obesity often makes symptoms worse. If you are overweight by 50 pounds, this is like constantly carrying 5 one-gallon jugs of water with you 24 hours/day without ever having a break. Every time you do anything, there is that 50 pounds you have to lift and move, and it becomes easy to see why you would hurt. However, low back pain is often related to permanent changes in the lumbar region including the joints, discs, and bones. Losing weight will not reverse the permanent changes present but may allow easier pain management.

Joint pain, especially degeneration of the knees and hips, can occur with obesity. Increased weight is a common factor that promotes increased wear and tear on the knees and hips. Once the damage has occurred, the changes are usually permanent. Weight loss will make the symptoms more manageable, but will reverse the degeneration that has occurred.

Obesity is a major health issue. If it were easy to solve, then we would not be facing such challenges in society today. Treating obesity early helps reduce the secondary problems it causes. Solving obesity will often not solve a pain problem. Keeping healthy, strong, and mobile will make many things better, and hopefully decrease obesity and possibly pain.

Treatment of Sacroiliac Joint Pain

/ Thomas Cohn, MD

SI JointThe sacroiliac (SI) joint is the large joint that joins the pelvis to the sacrum of the spine. It has limited movement, and helps in maintaining proper spine and pelvic alignment. Multiple ligaments and core muscles keep the pelvic bones and sacrum moving correctly. The joint is innervated by small branches of nerves from the sacral levels of the spine. Normally the joint is not painful. When the joint is not aligned properly or if it has become osteoarthritic, it may feedback painful signals. Pain from the joint is felt most commonly in the buttock region on the side of the dysfunction.

Many structures in the body can cause low back pain. The sacroiliac is a critical structure in helping transmit and cushion forces between the upper body and the pelvis and legs. When the joint does not move correctly, it may become a source of pain. Similarly,  pain to the joint may also come from any nearby structure, including muscles, bursas, lumbar discs, lumbar facets, pelvic organs, and any of the nerves in the lumbar and sacral region. Furthermore, pain from another structure may cause muscles in the region to tighten and cause the sacroiliac joint to move abnormally and become painful as a secondary problem. Treating the SI joint then is only successful if the other problems are being managed.

Diagnosing Sacroiliac Pain

The diagnosis of sacroiliac joint pain is based on a combination of patient history, physical exams, radiologic studies and on diagnostic and therapeutic joint injection. Typical history is for pain in the region of the joint without a history of another problem in the area. An exam is not overly reliable, but stressing the joint region and direct palpation of the area often produces pain. X-rays and MRI scans sometimes show degeneration of the joint, but pain is not well correlated to changes seen on any of these studies. Unfortunately, the only reliable proof of pain from the SI joint is actual joint injection with subsequent pain relief after placing anesthetic into the joint.

Treatment of the sacroiliac joint ranges from the most conservative management to aggressive surgical interventions. The first line of treatment is with Physical Therapy. Strengthening and stretching of the muscles in the region is necessary. Anti-inflammatory medications and muscle relaxants may help control symptoms. Chiropractic or osteopathic type adjustments of the region may restore and improve mobility. If the above conservative management is not adequate, then consideration of injection of the joint under fluoroscopy with steroid and being evaluated by a Physical Medicine Pain Specialist would be reasonable. A Pain Specialist can help determine if there are multiple factors contributing to the SI joint pain and that more than just the joint needs further treatment. Recently, some surgeons have also been fusing the SI joint, but the outcome at best is guarded.

Pain Treatment in Minnesota

Pain in the sacroiliac joint can be simple or complex. It may be just the joint or it may be related to any combination of irritated structures in the lumbar region. If the simple management is not improving the pain, a full evaluation by a Pain Specialist may significant improve the outcome.