Is Your Chronic Pain an Addiction?

January 8, 2016 / Thomas Cohn, MD

New research out of Northwestern University suggests that chronic pain can rewire your brain so a person actually becomes “addicted” to chronic pain.

The new research published in Nature Neuroscience examined how brain neurons in rats were affected by negative emotions and pain. When looking at the rodents, researchers noted that some rats experienced a hyper-excitable collection of neurons after an injury or pain. These neurons not only controlled some negative emotions, but their hyper-expression was also associated with a drop in the neurotransmitter dopamine, which plays a large role in our reward motivation. In essence, the brain was misconstruing why these neurons were firing, and it slowly became addicted to their hyper-expression. In essence, your body becomes addicted to pain.

“The study shows you can think of chronic pain as the brain getting addicted to pain. The brain circuit that has to do with addiction has gotten involved in the pain process itself,” explained corresponding author A. Vania Apkarian, PhD, adding that pain is both sensory and emotionally based.

New Understanding, New Solution?

With their new understanding of how some people’s body’s perceive pain, Dr. Apkarian began working on new ways to treat chronic pain. Using a combination of two different drugs, they were essentially able to rewire the brain so it stopped seeing pain as a rewarding behavior.

“It was surprising to us that chronic pain actually rewires the part of the brain controlling whether you feel happy or sad. By understanding what was causing these changes, we were able to design a corrective therapy that worked remarkably well in the models,” said the study’s lead author Dr. D. James Surmeier. “The question now is whether it will work in humans.”

The team hopes to take their study to the next stage and see if it produces a similar positive affect in humans whose brain’s have been affected by chronic pain.

More Than 90% of Patients Who Overdose Prescribed More Painkillers

January 5, 2016 / Thomas Cohn, MD

A new report suggests that more than 90 percent of patients who suffer a nonfatal overdose on prescription opioid painkillers are prescribed more pills following the overdose.

In certain situations, opioids can and do help prevent some of the pain caused by chronic conditions, but they are prescribed far too often by doctors who don’t take the time to get to the underlying cause of pain. The findings confirm this unfortunate trend.

The research, published in the Annals of Internal Medicine, suggest that not enough is being done to help treat pain patients, and the patients are the ones suffering. According to the findings, 91 percent of pain patients who suffered an opioid-related nonfatal overdose were later prescribed more opioids, and opioid overdose survivors who continued to take medications were twice as likely to have another overdose within two years.

It’s saddening but not surprising that these findings have been published, especially when you consider that the Centers for Disease Control and Prevention recently published an article saying opioid induced overdoses have reached epidemic levels. According to the CDC overdose deaths from prescription opioids and heorin have increased 200 percent since 2000.

Opioid Epidemic

Lead researcher Mark LaRochelle of the Boston Medical Center hopes the findings will be a wake up call for doctors who prescribe a lot of opioids.

“The intent of this study is not to point fingers but rather use the results to motivate physicians, policy makers and researchers to improve how we identify and treat patients at risk of opioid-related harms before they occur.”

For their study, researchers examined insurance claim data of more than 50 million people who filed a claim between 1999 and 2010. After narrowing their list down to 3,000 people who had suffered an opioid-induced nonfatal overdose on their prescription, researchers checked to see what care the patients received after their near death experience. Shockingly, nearly all of the survivors continued to receive opioid painkiller prescriptions, and, of the patients who remained on painkillers, 70 percent of them were prescribed medications from the same doctor who prescribed them the medications they eventually overdosed on. According to researchers, those doctors may have continued prescribing opioids after the overdose because they may not have known about the overdose, or they still felt the benefits outweighed the potential downfalls. They also believe some doctors may be ill-equipped to be making opioid judgments after an overdose.

The CDC issued guidelines suggesting that physicians should cut back on opioid prescriptions after a nonfatal overdose. Instead, they should pursue physical therapy or non-opioid painkillers.

Related source: ZME Science

Light Emitting Diodes and Chronic Pain Treatment

December 28, 2015 / Thomas Cohn, MD

Every once in a while there is something cool and new in the press. Recently I found an item on a technology site about the use of light from light emitting diodes (LEDs) shining on the spine or peripheral nerves to block pain signals. The concept is that light shined on the nerves or spine can affect the activity of neurons.

The information that I have found so far on this subject is very limited. The field is know as optogenetics. Apparently, there are light sensitive proteins in neuronal tissue. By illuminating these proteins, their activity can be modified. The proteins may then affect the ability of a nerve to transmit signals, and of special interest was whether pain signals could be affected by light.

Pain and Light

The initial interest in this field was generated with work on the brain. Light could be directed on various areas of the brain after a portion of the skull was surgically removed. Once light was directed to various structures, related behaviors would change. Originally the work was done with animals, mostly mice. The work has not progressed beyond that level as of yet.

The initial problem was directing a light to a particular area. Light sources were bulky as well as power sources. Fiber optic developments have included extremely fine, skinny fibers that are now flexible. These can then be guided to precise locations to target specific nerve tissue. Doctors can use minute LEDs that are small, low power, and that can be adjusted for maximum effectiveness to impact changes on the proteins and nerve cells. The whole system now has shrunk in size such that the light souce, fiber array to the nerves, and the power is transferred to the light by radiofrequency.

The first prototype device has now been designed and is being tested on a trial basis with mice. The light source was tested in the epidural space and over the sciatic nerve. By activating the light they could induce behaviors that were associated with pain. This the first step in studying the use of light and its ability to affect nerves that transmit pain signals. The concept is fascinating in the fact it is using a totally different process unlike surgery or drugs to control nerves. What will be the future of this technique and how it can be used best is only a guess. Hopefully it will lead to another technique that can help manage pain with fewer consequences like some other treatment methods.

A Bed for Back Pain

December 23, 2015May 10, 2016 / Thomas Cohn, MD

As Shakespeare wrote, “Sleep, perchance to dream…” is often an evasive quality for those who have chronic back pain. Patients are always asking if they should get a new mattress or bed to help with their back pain. Television commercials are always bombarding us with information that if your mattress is over eight years old, you need a new bed. If you decide to replace your mattress, there are so many to choose from. In reality, a good bed should last for years (my current bed is 15 years old) and the materials of today’s beds are meant to last a long time. The main issue is finding a good quality comfortable bed.

Back Pain – What To Look For In a Bed

If you have pain, the mattress should allow the spine to stay in a neutral position while lying down, usually on one’s back or side. The spine has several natural curves from the head to the pelvis. Unfortunately, some people have more curvature than others, but no one has a flat back. The mattress and its cushioning should conform and support the curves of the body so that they stay in a neutral and unstressed position. The bed topper and the central bed material should provide this support comfortably.

Over the last ten to twenty years, three new types of mattresses have taken hold; memory foam, latex, and adjustable airbeds. A combination of these technologies is often used together to develop the best overall experience. Basic mattresses are a core of some type of foam rubber that have layers of more expensive latex foam, cool memory foam and some sort of fiber toppers. Airbeds have a core designed with an adjustable air bladder and then often have similar toppers as other mattresses. Each combination has its advantages.

Memory foam mattresses and toppers have been gaining popularity over the recent years. It was first developed for the space program, and now has many slightly different formulations. Different densities of foam now are layered together and respond to weight and temperature in order to contour to that shape and also absorb motion. Since they are dependent on the body temperature to mold and shape to form, they tend to be warm to sleep upon. If you are always to warm, they may not be best choice unless it is made of newer technology that keeps one cool.

Latex mattresses are made of natural or synthetic foam rubber. They tend to be very uniform in support and may be a bit bouncy. They tend to be a bit firmer overall in support. If you like a firm bed, latex mattresses will definitely provide this type of support.

Air mattresses are beds that use an adjustable air chamber system to support a frame with foam layers surrounding it. Instead of the old coil spring mattress with one level of stiffness, the core is now a sophisticated, adjustable air chamber. The mattress then conforms and places even pressures on all areas of the body. King or queen mattresses have different adjustments for each side of the bed, so if partners like different settings, that is possible. Further, if you like to change the hardness of the bed at times, it is easy to fine-tune the stiffness to your position or preferences.

What’s The Best?

The picture of the best mattress often becomes somewhat more confusing. Many mattresses are a combination of multiple forms. The core of the mattress is either coil springs, latex foam, or an air chamber with choices of multiple types of cool memory foam and latex comfort foam, with some cloth/fiber padding as topper material that is about 3 to 4 inches thick above the core material. The combination of core and topper determine the comfort for each individual.

The last subject that arises with beds is the adjustable frame bed. Some of the beds have heads that elevate, adjusting to different angles, some have head and legs that have adjustable positions. These beds have traditionally been for people who have breathing problems at night and need the head elevated, or those who have difficulty moving in and out of bed. Some people like these beds if they read or watch television in bed. Generally, the adjustable bed is a luxury, using a couple of extra pillows can be a cheaper and easier solution than a fancy adjustable bed frame.

Finding the right mattress can be a challenge. At this time, I advise that you make sure the topper on the mattress is high quality, is comfortable and it should contour to your spinal curves while on your back or sleeping on your side. The core material may be a personal preference, but with an air chamber that is adjustable, this allows you to change your mind and make changes as your sleeping situation may change. All good mattress seem to be expensive. Choose wisely, keeping cost, comfort and future flexibility in mind.

Connecting The Medical Dots

December 21, 2015April 5, 2023 / Thomas Cohn, MD

Medicine today has become fractured. Primary care does basic analysis of a problem and basic care of that problem, while specialists have become such experts that they often can not see past their own rabbit hole. Few doctors are willing to look at the whole picture, analyze the patient as a person and all the problems presented. When someone takes the time and connects the dots, something special happens, and a path to the future can be found. For many patients, finding the doctor that has the experience to listen, to ask the right questions and to find the source of the problem can take years.

One Patient’s Dots Become Connected

Being a patient can be very frustrating. The other day I had a new patient with back pain, which is a pretty normal complaint for a referral. The patient was referred from an orthopedic spine surgeon who felt the patient was not a candidate for surgery. She was in her mid-30’s and had neck and upper back pain. She also has had longstanding scoliosis, a prominent curvature of the spine, and she had been to a number of previous providers for the problems and wants answers and a solution.

I usually work with a scribe. When I started my visit with the woman with scoliosis, she was fascinated. Within in a couple minutes and a few choice questions, my scribe saw a light in my brain go on and the discovery of the unifying diagnosis that no one in the past had a clue about. The patient had scoliosis, but had been double jointed, had shoulder and knee joint issues, had heartburn, and cardiac problems. She also had siblings that were double jointed. The unifying theme was a genetic-based connective tissue disorder, probably a form of Ehlers Danlos syndrome or Marfan’s disease. This will need to be confirmed by further testing and probably genetic testing.

Finding a diagnosis that connects the dots changes the whole picture of a problem. It no longer is a set of random of events causing pain. Now there is a reason and a pathway to follow to manage the problems. There is also knowledge about the course of the disease and a way to anticipate future medical issues.

Unfortunately, most patients never can connect the dots. Primary care physicians often do not have the time to address more than one problem at a visit. Specialists are only interested in their small corner of the world. My world often consists of looking at odd medical issues. Many times helping a patient means having to analyze the past, ask a few questions, closely listen to what a patient says, and bringing together the story to develop a pathway to the future.

The best patient care is provided by those providers who can see the big picture. Medicine has been fractured by the pressures to see as many patients as possible if providing primary care, or staying in your specialty only for others. Seeing the big picture and connecting the dots is a lost art. Changing lives for a patient means being able to go beyond the ordinary and really trying to answer the all their questions to uncover a long-term solution.