Concerning Behaviors Associated With Pain Pill Abuse

painkiller abuse signsOpioid management is probably the most charged topic that we talk about frequently on our blog. Many of our patients and readers take some type of opioid medication to help manage their pain, and they get nervous or angry when they hear big government talk about restricting opioid access due to an increase in overdoses. The majority of people take their pain pills responsibly, and they are concerned that the minority who are abusing pills will make it impossible for them to get the opioids they depend on.

Opioids certainly have value in a pain management program, but we also don’t believe they should be the only treatment option that is being tried. And if you are going to take opioids, you need to be sure you use them responsibly and they aren’t abused by others in your home. One way in which doctors and family members can help stop painkiller abuse is by looking for certain concerning behaviors that are often associated with opioid abuse. We take a closer look at some of those behaviors in today’s blog.

Behaviors Associated With Pain Pill Abuse

Here are some of the behaviors that doctors and family members can look for that may suggest a person is dealing with a substance abuse or pain management problem:

  • Missing appointments.
  • Taking their pills for something other than pain.
  • Using more medication than prescribed, or asking for a refill before the prescription end date.
  • Repeated inquiries to get an increased pill dosage.
  • Being aggressive or hostile to healthcare staff or family members.
  • Taking medication in combination with alcohol or other drugs.
  • Lack of participation in other treatment modalities.
  • Bouncing around from doctor to doctor or clinic to clinic.

If someone you now is demonstrating a few or all of these behaviors, reach out for support. Contact Dr. Cohn or reach out to your specialist to learn ways to talk to your loved one about painkiller abuse and how to get them the help and support they need. It’s never an easy conversation, but it’s one that needs to happen.

The consequences of painkiller abuse can be deadly, so don’t sit back and do nothing. Contact a healthcare provider or addiction services center to ask about the next steps in the process. We’ve also compiled a few links that you can check out if you suspect that a friend or family member is abusing pain pills. Please don’t hesitate to reach out if you have any questions.

What’s New With Complex Regional Pain Syndrome?

crps painComplex regional pain syndrome is often seen as a weird and devastating problem. One of the biggest issues is the lack of identifying it as an issue and beginning the right type of pain management. Fortunately, in my practice, we are known for being able to deal with it and often find good solutions to manage it. Treatments can range from simple to complex. In the educated pain community, a better understanding is occurring. Unfortunately, it seems that some pain doctors are not furthering their education when it comes to CRPS.

Improving Treatment of CRPS

The good news is that we are starting to get a better with diagnosis and treatment of CRPS. The prognosis in general is that the symptoms in most people will resolve within a year; this occurs in 75 percent of people. The understanding of CRPS is better nowadays, and it does not just occur spontaneously. It is not an entity without a cause. It occurs in context with some sort of injury.

Usually it occurs in either the arm or leg, and it is often related to either surgerical trauma or actual physical trauma. Examples include an arm with multiple fractures or a hand injury coupled with carpal tunnel syndrome. In the leg it is often associated with multiple fractures or an ongoing sprain in the foot and ankle. It is also more common in people who already have a sensitized nervous system, such as someone with a neck or low back problem, a diabetic, or someone with fibromyalgia. The research is also showing that there may be a genetic component (there may be 80 or more genes that are involved) and some people may be prone to this occurring, but there is no test yet available.

The answer to why a person has uncontrolled pain is that there are too many sensory “pain” type signals going to the brain for too long of a time period. With most injuries, healing rapidly occurs, especially when treated promptly. Injuries to the foot and hand are more complex since there are multiple tendons, ligaments, bones and nerves present and many of these can be damaged. The medical community often does a great job of fixing the obviously fractured bones, however, if the trauma is with sufficient force to fracture a bone then it can damage surrounding things like tendons, ligaments and nerves.

These “soft tissue” structures are much harder to see and to determine if they are damaged. Repairing them also may be hard and sometimes things like damaged nerves are not really possible to surgically treat. All these structures in the hands and feet must work in a very complex manner; one part not moving correctly often will send messages back to the brain that all is not well. These continuous error messages to the brain start becoming amplified and a short circuit occurs telling the pain signals that there is a problem in the area and something needs to be done to stop the problem. The amplified pain signals is what we perceive in CRPS.

The Goals Of Treatment

The goal of CRPS treatment, if identified early, is to find and fix the issues present. As a medical provider, the goal of understanding CRPS is not that the patient is crazy, it is that something is wrong and what can we do to fix and address the problem. To control the pain, a patient with signs of CRPS must first determine what are all the issues that may be contributing to the problem. A comprehensive evaluation is necessary and all the patient’s medical history can be extremely important. Everything from concurrent medical problems to psychological issues can contribute to the problem.

More frustrating may be that not all of the medical problems contributing to the CRPS may be treatable. Sometimes the fracture damage of an arm or leg cannot be fully corrected. Damaged ligaments, bone misalignment and nerve injury are not able to return to normal function. The signals that tell our brain that something is wrong cannot be turned off since there is no mechanism to shut them down completely. This is especially true in severe trauma or where there are secondary conditions reinforcing the signals like spine problems or diabetes. For the physician, the first mission is to find out what are the problems causing the abnormal signals and correct them. A team approach is often the best since it may take an expert in pain to identify all the problemed areas and the expertise of a variety of specialists to intervene if a fix is available. As noted above, 75 percent of the people will experience symptom relief within in a year, meaning successful management strategies can be implemented.

Identifying CRPS early within the first few weeks to months leads to the best treatment. If pain after an injury does occur, is severe and continues past normal healing time, seek the help of a good pain physician. The mark of good pain physician is one who frequently sees and treats complex problems. Many pain physicians confine their practices to the simple straightforward pain problems; these tougher issues need the physicians that know medical and interventional treatment options and are active in ongoing evaluation and management including high levels of intervention. Physicians who do mostly medical or interventional managements and not both are unlikely to have a full knowledge of the complex issues contributing to CRPS. Understanding and communicating with the patient is essential. Find a good physician that does understand CRPS and the strategies to have the best chance at finding pain relief.

Multifaceted Approach To Treatment

Not all CRPS cases can be easily resolved. Obviously, not all injuries can be corrected and when there are multiple problems contributing to CRPS, it may be an ongoing issue. The treatment plan often needs to include physical therapy to improve functional problems associated with the body parts involved. With any significant injury, it often takes a lot of exercise for a long period of time to restore function, and it may involve complex strategies to retrain the body. The efforts with physical therapy need to be continued on your own, and stopping the exercises does not work for recovery.

Psychology is another important aspect to manage and improve when it comes to CRPS treatment. The pain is not imagined, and psychologists can help the patient understand how the brain decides to perceive the pain signals and how patients interpret them. The brain can only do a couple of things at one time and psychologists often can help train the brain not to pay attention to these pain signals. Recognizing the associated cognitive issues like the perception of pain and that depression is not a sign of being weak leads to more successful outcomes.

CRPS is a complex phenomenon and involves understanding of all parts of the syndrome. There are now a variety of medications used for treatment. Common medications include those that affect nerve signaling like Gabapentin and Lyrica. Some depression medications also decrease nerve signaling. Cymbalta does this well, and older medications like amytriptyline and nortriptyline can also be very helpful, and they may also help with related sleep problems. Newer medications that have found to be helpful range from those used to treat osteoporesis like Boniva (or many of the other drugs in this category know as biphosphonates), to Botox, Viagra, and odd blood pressure medications like clonidine. Ketamine, an anesthetic, is used occasionally but is difficult to safely administer, works for a limited amount of time, may have significant side affects, is costly and often insurance does not cover its use.

Spinal Cord Stimulators For CRPS

For the most refractory cases of CRPS, implantable devices are one of the best and most cost effective treatments. These devices are primarily spinal cord stimulators (SCS) but sometimes may include intrathecal pumps to deliver medication directly to the spine. A good pain physician will be able to coordinate and make sure all the conservative medical issues are addressed prior to working with implantable devices.

If this is the first suggestion without working with a team to address all the other issues, be careful with proceeding forward. SCS systems are wonderful treatments, but there is a lot of marketing being done toward physicians with these devices so an experienced implanter is needed since treatment with these systems may need to be aimed at multiple targets. There are systems that can be used just for a specific target known as DRG spinal cord stimulators and they are good when there is absolutely no other problem contributing to a foot or ankle CRPS that is not fixable (they are not used for hand and arm CRPS).

Multiple companies make SCS units. It is debatable who has the best unit, but other factors like manufacturer support and MRI scan safety also need to be considered. Properly placed, a SCS’s effectiveness can usually be determined after a trial period of about 5-7 days. Improved function, improved ability to stand, walk, do activities, and sleep are the goals associated with a SCS. If nothing is working, implantable pain pumps are reasonable. These do have risks but they can greatly improve the patient’s quality of life. A variety of medications can be delivered to the spine and the best medication may not be an opioid, but Ziconitide, which is a snail toxin.

CRPS is a complex issue, in reality it may affect the whole body due to the impact of the pain. It takes a team to treat and help the patient through this medical problem. A good pain physician will help one navigate the treatment path of CRPS. It is a very tough medical problem, and its not only in your brain. Treatment needs to be an interaction with your provider who fully understands and helps with coordinating and providing care for all the issues. CRPS does feel like a scary medical problem, but good pain physicians can lead one to a successful outcome.

Chronic Pain and Your Credit Score – An Interesting Link

chronic pain creditChronic pain has many obvious drawbacks, but it also has many hidden consequences. We know that chronic pain can be costly to treat, but new research suggests that it can have a severe impact on your buying power or your ability to secure credit.

According to a new study published in the National Pain Report, a survey of 840 chronic pain sufferers found that a whopping 63 percent were unable to secure credit. As you might have guessed, this has far-reaching consequences for pain sufferers.

Chronic Pain and Your Credit

Researchers said that there were a number of different reasons why chronic pain sufferers had difficulty securing credit. Some of the most common challenges individuals with chronic pain run into credit-wise include:

  • Difficulty obtaining credit because chronic pain makes it hard or impossible for them to maintain employment.
  • High interest on credit cards or loans that they are able to secure.
  • Difficulty getting a cell phone contract.
  • Inability to get approved for a home loan or apartment rental.
  • Inability to secure utilities, like electricity, propane or gas.
  • Difficulty getting automobile or life insurance, and when they do, rates are often very high.

“The inability to secure credit brings a long list of challenges, particularly for those who also suffer with medical conditions, like pain,” said Jim Shanahan, President and CEO of Prepaidian, Inc, a company who specializes in Prepaid debit cards that are intended to provide buying power for people who are unable to secure credit. “You may be unable to get a checking account, or pay exorbitant fees on those accounts, in addition to trying to manage medical bills.”

How To Improve Your Credit While Dealing With Chronic Pain

Improving your credit score while you deal with chronic pain isn’t always easy, but there are things you can do to improve it bit by bit. For example, always try to make your payments on time, even if it’s just the minimum amount. Paying on time helps to improve your credit score. Secondly, don’t be in a rush to close your accounts. Closing accounts, even ones you don’t use, negatively impacts your credit score because it limits your buying power. If you absolutely have to close out an account, see if you can increase your line of credit on a different account. Even if you don’t plan to spend that much, your credit score improves when you have more potential buying power at your disposal.

Secondly, try to settle up past due accounts. Odds are if you’re willing to pay at least a portion of the bill, the credit card company will be willing to erase the debt, because getting some money is better than getting nothing. You can call in and see if they’ll waive late fees or some interest charges, because it never hurts to ask, and if waiving a fee gets the credit card company their money, oftentimes they’ll be willing to compromise. It never hurts to ask.

Lastly, if medical bills from chronic pain are stacking up, try to get on a payment plan with your health center or insurance company. Making regular payments and working towards a zero balance will do wonders for your credit score. Explain your situation, and people may be more willing to help.

Tips For Staying Pain Free and Fit While Traveling

thanksgiving travelingWhile on vacation it is easy to lose all motivation to stay in shape. Extreme temptation is present to eat too much, to indulge with lots of fatty or sweet foods, and not to exercise. It is not fun to take the time to exercise versus sleeping or to say no to foods that the heart desires. However, staying a bit more fit is often easier than one may think, and making it a priority will serve you well. If you have chronic pain problems, keeping up with an exercise program will make travel go much smoother.

Exercising on the Go

If one stays at a hotel, most places have some exercise equipment available. Business travelers often exercise early in the morning, and if there are only a few pieces of equipment present, you may have to adjust your timing during the day if using it is important to you. Oftentimes no one else will be using workout equipment during the middle of the day and before dinner. I have often worked out with no one else around hours before dinner. The other benefit of exercising before dinner is that exercise tends to reduce your appetite.

Starting the day with exercise often helps get the body moving and decreases overall pain throughout the body. Many routines do not require any significant amount of equipment and can be done anywhere. The first thing is to spend 5-10 minutes with a good stretching routine. If you have low back pain, work at sitting on the ground and touching the toes, stand and touch the toes, and then do hip stretching by leaning forward with the pelvis. Tight muscles hurt, and although initially a stretch might slightly increase pain, as the muscles loosen, the pain often goes away.  

Strengthening does not require any amount of special equipment. Core strengthening can be done without any or with simple things like rubber tubing or bands. Basic core exercises to do include planks, leg lifts while lying or sitting, stomach crunches and supermans. Planks should be held for only 30-45 seconds and repeated one or two times. They can be done with leg and arm lifts and performed on the side to make them more difficult while working more muscles.

Using a balance board or balance cushion can add even more of a challenge, and these portable boards and can be found for $20-50. Rubber tubing can also be used for strengthening, and anchoring it in a door allows a number of exercises for the arms, trunk, lower back and legs. Affordable rubber tubing for exercise with a variety of resistances, handgrips and door anchors with a carrying sack can be found on Amazon. Just doing balance exercises requires no equipment and works the core muscles too.

Finding Time To Exercise During Holidays Or Vacation

Maintaining general conditioning may be one of the easiest tasks while on vacation. Start walking and do some sightseeing. Walk to a restaurant or take a walk in the morning or evening. Explore the area where you are on foot and spend 30 minutes to an hour just walking every day. Google maps will even give you walking directions an estimated time of when you’ll arrive. If more ambitious, go for a run, go swimming or in many cities there are now inexpensive bike sharing services that allow one to explore the area and get some exercise.

Lastly, while on vacation, eat sensibly. Try to keep to a similar diet while traveling as you do while at home.  A high protein meal plan with fresh fruits, salads and vegetables will keep you from overeating. Keep the simple carbohydrates down like the bakery goods, pasta, potatoes and desserts. Avoid stuffing yourself at meals, eating late at night, and drinking lots of alcohol. It is okay to splurge somewhat, but if you do not overeat you definitely will feel better.

Thoughts On Attending The Latest Pain Conference

conference meetingEvery physician is required to obtain continuing education credits. Depending on a when one was board certified, the types of boards one has, and what state you live in, the number of credits needed each year varies.

At least once a year, I try to attend some sort of conference in order to to add to my knowledge about how to treat pain. This year I have ventured into the new realm of the American Society of Regional Anesthesia (ASRA). Since pain care crosses the line into a number of different disciplines, one of the best ways to improve is to pick up knowledge outside your normal specialty.

Thoughts From The ASRA Meeting

For the last several days I have been at the annual pain meeting of the ASRA. It is a group of about 5,000 practitioners, which is actually one of the smaller major groups involved in pain management. Each group has a different focus, and finding a good balance is hard. So far I have enjoyed the meetings; it’s like being back in an intense school all day long. Best yet, most of the information has been very relevant to my regular practice. It also has included a lot of practical knowledge, and there hasn’t been too much esoteric academic information or stuff aimed at an someone just beginning to practice pain medicine. Many of the pain conferences are aimed at physicians who do not do any advanced procedures or only at physicians doing injections, and both extremes can be lacking balance for patient treatment.

One of the most important things a conference does is challenge your thinking. Hopefully questions are entering your mind about what can you improve upon and how to do better patient care. A conference like this is great. It is not focused on a single topic and there are many areas of my practice it could impact. General topics have ranged from very specific aspects of implantable pain technologies to the best ways to evaluate and treat very specific medical problems. One odd topic that has caught my interest is how to deal with changing government regulations to prevent burnout of physicians.

The hot topic at any of these conferences is now opioid use and abuse. However, at a pain conference it is not about a crisis of addiction, but a crisis of lack of treatments available to treat complex pain. The money is being spent on addiction management and not finding treatments that would manage the root cause of pain, and thus markedly reduce addiction.

The hardest thing at a conference (besides sometimes staying awake) is trying to sift through what is truly good information. After going to enough of these conferences, one begins to recognize those who are in it for self promotion. Every conference seems to have several people who promote the latest fad. If there is no money to be made with regards to a topic, the information is probably more science and less sales.

Learning new information is good. Missing seeing patients is tough, but the time gone is for the good of all patients in order to provide the best care. Benefits will be made on everything from what to do for patients to learning new things that may help tough patients. New treatments now will be tried for everything from CRPS to knee or elbow problems. The only sad part of going to these conferences is that often I see no other pain physicians from my location, but I’m certainly glad I went to this conference.