The Dangers of Prescribing Pain Pills

November 10, 2014 / Thomas Cohn, MD

Opioid overdoses are a rampant problem in the United States, and the abuse of opioids is an epidemic. Multiple drugs are being abused, and those who are abusing are using multiple drugs. Deaths linked to opioid overdoses often involve multiple medications. Furthermore, unfortunately, some physicians contribute to the problem by running clinics that readily handout prescriptions for opioids without even really evaluating a patient for real disorders.

Pain pill abuse is clearly a problem in our society. Unfortunately, the problems of abuse reflects on everyone, including those trying to prescribe correctly and the patients who have legitimate problems. Pain physicians have a large stake in the issue. Treating pain requires many tools, and using opioids is only one option. Since every patient a pain physician sees does have some sort of pain problem, it is invariable that they may prescribe opioid medications occasionally. Pain physicians, since they tend to prescribe dangerous medications, try to be extra careful in their use of these medications.

Treating The Complex Problem

The first thing to realize is that pain is a complex problem, and there are multiple ways of treating these issues. A pain physician will usually try to find a solution that is the most appropriate for every patient based on the diagnosis and patient needs. There is no risk-free magical pill that will cure a person of their ailment. Treatment is complex and often requires management of multiple interacting problems. The best solutions usually involve quite a bit of work by the patient to change various aspects of their lifestyle, like eating healthy, getting more exercise and drinking fluids.

All physicians need to pay attention to treating pain appropriately. Throwing a pill at a pain problem is not always appropriate. Finding a diagnosis and treating the problem in a comprehensive fashion is necessary. Patients may need to be drug tested to determine if they are using medication appropriately, and the state drug database should be checked to see if a person is doctor shopping for medication. Setting down rules for the use of controlled medications is always necessary, and if long term prescribing is being done, a contract with the patient may be reasonable.

The fact of the matter is that most pain pill addictions and overdoses begin with a legitimate prescription and worsen from there. The medications are not stolen or illegally produced. To control abuse, physicians must take responsibility to prescribe medications appropriately. If a patient has pain that is not improving, a pain specialist is beneficial to help a patient find a comprehensive approach to managing the symptoms. Chronic pain problems often do not have quick or easy solutions. Solving the issue of opioid abuse will require physicians to take an active role in finding solutions to difficult problems.

4 Sleep Problems Made Worse By Chronic Pain

November 6, 2014 / Thomas Cohn, MD

Pain often causes sleep problems. Sleep problems occur in over 50 percent of patients with chronic pain. Sleep disruption can worsen pain and affect your whole life. Patients will often feel rundown, tired, depressed and very stressed. Relationships with your family, your spouse, and at work may be affected. Solving sleep problems is complex and may take significant time.

Sleep problems can be divided into 4 categories:

Difficulty falling asleep
Troubles staying asleep
Inability to achieve deep restorative sleep
Waking up and being unable to fall back asleep

Each type of problem may need a different solution. A person with chronic pain may have multiple problems with their sleep cycle.

Sleep Hygiene

Good sleep hygiene is the most important initial treatment of sleep problems. Activities that cause problems prior to sleeping include drinking caffeinated beverages and alcohol. Alcohol may initially cause tiredness, but later in the night it often disrupts sleep cycles. Another activity you should avoid before bed is exercise. Physical activity can stimulate the body and keep you awake. The bedroom should be considered a place for sleeping and not for watching TV or doing work related activities. The bedroom should be considered a calming and relaxing place. Other helpful habits include trying to wake up at the same time each day and if awake in the middle of night, don’t spent significant time lying in bed but get up and do another activity until tired again.

When simple tweaks and conservative treatment does not help improve sleep, working with your physician for a more comprehensive treatment strategy is beneficial. A sleep study is often especially helpful in determining the issues preventing good sleep. Sleep studies are also helpful in planning a treatment strategy to solve all related problems.

Multiple medications are available to help with sleep, but many can actually interfere with parts of this sleep cycle. Narcotic medications and other antidepressants may help with pain at night but often interfere with portions of the deep sleep cycle. Newer medications like Ambien and Lunesta are helpful in allowing the patient to fall asleep, but may not be helpful in keeping a person asleep. Recently, melatonin at doses of 5-10 mg has been found to be helpful in maintaining good sleep cycles and reducing pain.

Chronic pain often interferes with sleep, which can lead to worsening pain. Improving your sleep cycle can often greatly improve the quality of life. Sleep problems can be simple, but often with chronic pain they are complex. The solution to a good night sleep may require multiple changes and routines, but with the help of a pain specialist and a sleep expert, relief can be found.

Pain Management for Senior Citizens

November 3, 2014 / Thomas Cohn, MD

A recent article in the latest edition of the Journal of the American Medical Association discusses the problems with opioids and the elderly. The article discusses the fact that there has been a large increase in hospitalizations tied to the usage of these medications. The problems are multifaceted, as overuse, over reliance and lack of understanding all lead to health problems in the elderly.

Chronic pain is a major health issue, especially as we grow older. Recent studies have shown that about a third of the population suffers from some sort of medical problem that causes chronic pain. Unfortunately, the science of treating pain has not kept up with the recognition of it as a problem. Furthermore, we have recognized the risks of acetaminophen with liver toxicity and the dangers of anti-inflammatories like ibuprofen with the kidneys. With the dangers of those drugs, opioid use has been pushed.

The practice guidelines for the management of pain from the American Geriatric Society has actually promoted the use of opioids for moderate to severe pain. They have discouraged the use of stand-by drugs like acetaminophen and anti-inflammatories. Unfortunately, in the elderly, opioids are very difficult to use safely, especially if one is not an experienced clinician. Senior citizens tend to be much more sensitive to medications, and “regular” doses can cause falls, liver toxicity, cardiac toxicity and cognitive impairment. Furthermore, half of the authors of the guidelines had significant financial ties to manufactures of opioids.

Careful Management

Chronic pain in the elderly, as it is in any other group of patients, is not one size fits all solution. Pain is a complex entity and needs to be treated as such. The multiple causes of the pain need to be diagnosed and each contributing factor should be treated with the most appropriate management option. Joint related pain may be best treated with an anti-inflammatory medication while neuropathic pain may need a seizure type drug. Furthermore, depression may be a factor and that may also need separate treatment since pain and depression centers in the brain are closely situated.

Management of pain is complex. Careful determination of all the causes and selective treatment by a skilled and knowledgeable practitioner is beneficial. More research on pain and treatment is necessary since the problem is so large. Pain specialists are often the experts needed to find the best management options.