What Pain Patients Want From Their Doctors

November 11, 2019 / Thomas Cohn, MD

Last weekend in the StarTribune there was an editorial on opioids and pain from a neurologist and Chief Medical Officer Regions Hospital. It seemed a bit self-congratulatory about how great he is doing at reducing opioids and how unnecessary they are in most pain situations. It is great to talk about not using opioid medications especially for chronic pain, however if the main job one has is to be a pain medicine specialist, a better understanding of pain and its impact on an individual’s life is needed.

The article brags how many fewer opioid prescriptions have been written by HealthPartners clinics. By the sounds of it, no one was educated on treating pain and way too many scripts were being written. Physician education on management strategies for pain is woeful and minimal time in medical school and residency is spent on training physicians about pain. The best strategy to prevent chronic pain is to aggressively treat acute pain and prevent chronic symptoms from developing. Use a comprehensive strategy early and reduce the impact of pain. Opioids are just one of many tools to treat symptoms, and many better tools are available and should be employed.

Nobody enjoys having pain. Convincing someone that pain is normal is one of the worst strategies to reduce opioid use and abuse. Patients with pain do not want to be told pain is normal, they want their physicians to help determine what is wrong and find good ways to reduce symptoms to a manageable level. Telling a patient pain is normal just informs the patient as a physician you do not care what is wrong and whatever you tell the patient next, they already have the expectation that you have only your own agenda and not their interest first.

Reading the editorial as a pain physician, it was maddening to see the lack of knowledge with regards to how patients feel about their medical problems. Almost everyone knows about the opioid epidemic, but when one has pain, they want compassion, respect and help with understanding their problem finding solutions. They do not want to hear about opioid problems. They want a physician that will help lead them to answers, listen to what they are saying and give them a pathway to improvement. The expectation is that physicians have answers beyond opioids these days, and from a patient’s perspective, bragging about your reduction of the use of these medications is snobbery. Solve the patient’s problem and be empathetic. As a medical big wig, tell your insurance company to pay for proven alternative solutions and give the clinical doctor the ability to use all the tools necessary to help their patients without fighting your bureaucracy.

How Are Opioid Regulations Affecting Chronic Pain Patients?

October 21, 2019 / Thomas Cohn, MD

In the wake of increasing opioid overdoses across the country, lawmakers have called for much stricter regulations in how providers prescribe opioids to patients. The goal of the changes were to stop doctors from “taking the easy road” and prescribing opioids to patients because the doctor doesn’t want to take the time to dig into the problem and work towards a real solution. Lawmakers also undoubtedly thought that if fewer people have access to clinical opioids that overdoses would also decrease.

But how are these regulations actually affecting those individuals who are plagued with chronic pain? According to a new study, the changes aren’t exactly having the intended effect.

The Effects Of The Prescription Opioid Crackdown

According to a recent study published in the International Journal of Drug Policy, there have been a number of unintended and potentially harmful side effects associated with the recent prescription opioid crackdown. Researchers say that many patients on long-term opioid treatment for chronic pain reported experiencing the following in the wake of the crackdown:

Negative physical side effects
Emotional distress
Degraded relationships with their primary care provider

Although the study was relatively small in size (97 patients with chronic pain, mean age 61.3 years), the results were both interesting and alarming.

Negative physical side effects – According to the study, patients believed that their medications helped control their chronic pain, helped them sleep and provided them with the ability to think clearly without being bothered by daily pain. When they were tapered off their medications, they said their pain increased, and they had difficulty sleeping and concentrating.

Emotional distress – Many patients believed that stricter prescription opioid regulations would inhibit their access to vital pain medications and hinder their day-to-day well-being. Other patients responded that they went as far as to seek mental health counseling to deal with the stigma of being seen as an opioid user.

Degraded Relationship With Doctor – Finally, patients also reported that their relationship with their primary care physician worsened due to the new regulations. One patient felt angry with her physician for “enforcing a required opioid agreement” while another felt that he was being viewed by his doctor as a potential abuser as opposed to a patient.

“In addition to known side effects, patients also experience the burden of public discourse and associated institutional changes in opioid prescriptions as extremely stressful, placing a burden on their emotional health and relationships with their primary care providers,” noted the study authors. “ Chronic pain is a biopsychosocial phenomenon, requiring multi-faceted approaches and solutions.”

It takes a doctor who is willing to put in the time and effort with the patient, and a patient who is interested in active solutions to pain, in order to win the fight against chronic pain. Don’t get discouraged by recent regulations, just do what you can to find a specialist who takes your pain seriously and who won’t stop until you find relief. Dr. Cohn has done this for countless patients, and he can do it for you too. For more information, contact his office today.

A Closer Look At Acute And Chronic Pain

October 7, 2019 / Thomas Cohn, MD

Chronic pain is usually different from acute pain. Acute pain is considered to be directly related to stimulation of sensory receptors for noxious stimuli located throughout the body. It is often related to direct damage or trauma to the body. It also is the normal physiologic response to the various types of sensory receptors that is perceived as noxious or painful. Acute pain is relatively short lasting and is a direct response to direct stimulation of sensory receptors with lengths from seconds to usually less than several months. Chronic pain however is long in duration, lasting over three months and becomes independent of direct stimulation of sensory receptors for acute stimuli.

Chronic and Acute Pain

Chronic pain most often is characteristically different from acute pain. It often involves the nervous system changing on a peripheral and central basis such that sensory signals are perceived differently. In the limbs or other areas, sensory receptors become increasingly able to respond to any stimuli and then sending a signal out into the central nervous system. The nervous system essentially becomes primed for responding to sensory inputs and blasts out a powerful danger signal out of proportion to the intensity of the event. A small touch on the arm could feel like being hit by a sledgehammer.

Chronic pain is divided medically into three types;

Nociceptive
Neuropathic
Central sensitization

It can also be a combination of these. As pain becomes more chronic, the central nervous system becomes more involved and pain has more centralized components. The secondary outcomes of chronic pain over time also become prominent with increased healthcare utilization and often decreased quality of life.

There are multiple correlations in a person’s life that are associated with chronic pain. Common attributes include being female, early life trauma, family history of pain and mood disorders, genetics, sleep disturbances and mood disorders. Certain types of pain that more commonly become chronic include headaches, low back pain and fibromyalgia/diffuse myofascial pain, while the psychological factors of anxiety, depression, catastrophizing, and PTSD are linked to developing chronic pain.

Well-managed and aggressively treated chronic pain comprehensively reduces the incident of chronic pain, but as pain continues ongoing aggressive management can impact the intensity of long-term issues. It is important to treat all aspects of a painful condition. Often there are multiple factors stimulating pain and all the physical problems need to be addressed from muscles, nerves, tendons, ligaments, joints, bones and any other system involved as well as the psychological impacts.

Comprehensive management of symptoms is one of the keys to successful outcomes. Using traditional medical strategies including medications and physical therapy in conjunction with techniques like acupuncture, meditation and improving sleep hygiene may all be necessary in managing pain. Aggressive management of acute pain, especially traumatic or post-surgical, helps reduce the incident of the development of chronic symptoms.

Acute pain is a common arena for most regular physicians. Comprehensive initial management of acute painful conditions reduces the development of more chronic problems. If the pain is showing tendencies toward becoming chronic, involvement of a pain specialist can reduce the impact of the long-term symptoms.

Daith Piercings, The Vagus Nerve, and Migraines

September 9, 2019 / Thomas Cohn, MD

Daith piercings have been showing success in helping to control migraine headaches. Now there is new research that seems to shine more light on what has been thought to be the mechanism that contributes to the success of this treatment. Research into dementia has recently been done with stimulating the ear with a slight bit of external and intermittent vibration. The research suggests that this may help prevent dementia. The mechanism of action is thought to be by stimulating the ear, a branch of the vagus nerve is also being affected and this is what is producing the results. Similar to what we assumed was happening with the daith piercing, vagus nerve stimulation is the key factor at play.

The latest information on stimulating the ear and the vagus nerve comes from a study out of England and the University of Leeds (Bretherton et al, 2019, in Aging). Stimulating the outer ear for 15 minutes a day for two weeks with gentle electrical vibratory signals improved the relaxation signals and parasympathetic activity. The researchers determined that they were electrically stimulating a branch of the vagus nerve that is in the region of the tragus. In older people (55 years and older) they may have a high sympathetic outflow and this leads to stress, tension, depression and low energy. The transcutaneous electrical stimulation of the ear rebalanced the system and seemed to slow the effects of aging. The major caution was this was a small study so one does not know if these findings would be present in a large controlled study.

The initial research at the University of Leeds in England was done in 2015 and was done in healthy young people. Stimulating the ear with transcutaneous electrical stimulation at the vagus nerve improved autonomic function. Normalizing autonomic function means decreasing sympathetic tone, stress, tension and most likely vascular tone. This would also mean blood vessels would not constrict and could impact the occurrence of migraine headaches.

What It Means For Migraines

Vagus nerve stimulation has a history that is long standing. Vagus nerve stimulation devices were implanted after 2005 for treatment of major depression. They also have been used for gastro-intestinal disorders, epilepsy, and some inflammatory disorders. Now there is an FDA-approved device (GammaCore) to stimulate the vagus nerve through the skin to relieve migraine headaches.

Daith piercings we now know are not placebo treatments for migraine headaches. It is pretty clear they work through stimulating the auricular branch of the vagus nerve in the region of the tragus in the ear. Stimulating the vagus nerve will increase parasympathetic activity and decrease excessive sympathetic tone. This would likely decrease the vascular events that surround migraine headaches. Furthermore it may reduce overall personal stress and anxiety that may be migraine triggers. The piercing would cause physical stimulation of the vagus system and thus rebalance the autonomic nervous system in the body. If piercing is not an option, then using a transcutaneous nerve stimulator (TENs) unit with a very light current to the tragus unit would likely do the same. The good news is that science is validating the practice of this piercing.

As a side note, research is underway specifically on the daith piercing. Studies are being done in England and elsewhere in Europe with regards to the effectiveness of this technique. Whether the daith piercing will work for any one individual is unknown. Since migraines may have a number of triggering causes, the effectiveness of the daith piercing is likely dependent on whether a component of the migraine is related to autonomic balance in the body and if it can be corrected with vagus nerve stimulation. Hopefully we continue to learn more about vagus nerve stimulation and how to best treat these types of migraines in the near future.

New Technologies For Pain Management

August 19, 2019 / Thomas Cohn, MD

Medicine is evolving as electronic technology invades all aspects of medical care, and pain management is no exception. The areas that have changed the most are imaging technology and implantable devices. What is interesting to patients is how imaging can improve care and implantable devices may help when nothing else is working. The improved imaging makes diagnostic and treatment decisions easier and also makes interventions more precise when tied to management by an astute clinician. No matter how good the technology is, without the skill of a good clinician to understand the medical problem, no solution would be helpful.

The new implantable technology available is peripheral nerve stimulation. This is designed for treatment of pain that is related to damage to a peripheral nerve, such as in the arm or leg. Pain can often be traced to an isolated nerve and preventing that nerve from propagating the pain signals helps to control the problem. These pain issues arise sometimes after amputations with phantom pains, and can be seen after trauma when nerves are damaged. These problems can also occur with surgeries like joint replacements, orthopedic interventions, spinal operations and some fractures. When the pain is not resolving and an isolated set of nerves can be found and successfully blocked with local anesthetic, then nerve stimulation may be appropriate. This is a treatment to consider when simpler interventions like medications, physical therapy, and injections have not been successful.

Nerve Stimulation For Pain Management

The idea of peripheral stimulation has been around for a long time. In the distant past, traditional spinal cord stimulators were used for peripheral nerve stimulation. Unfortunately, at some point this began being abused and since those systems were extremely expensive, this process stopped. In the last two years, new systems have been designed specifically for peripheral nerve stimulation that are very technologically advanced and effective.

One example is electrode stimulation. The electrode is a very thin wire coated in silicone that can be delivered to the right place along the specific nerve with a needle guided by ultrasound imaging. The wire contains a special signal receiver that can be used to help stimulate the nerve and drown out pain signals. Most importantly, the signal generator is now a very small rechargeable unit that is placed on the skin over the end of the electrode. In the near future the electrode may connect even further from the generator such that it may be able to be carried in a pocket or other safe place.

The new technology is FDA approved for peripheral nerve pain from any type of nerve injury. The easiest insurance approval is Medicare, but other providers are starting to approve of such treatments when proven simpler treatments have failed. There currently are at least two manufacturers of equipment, the difference appears to be mainly in the generator’s ability to deliver a variety of signals that may effectively block pain signals and not be uncomfortable to the patient. From experience developed in spinal cord stimulation, the electrical signals can be varied such that the nerve pain is blocked but the patient does not feel any other odd sensations. The net effect is that one can perform activities that were once painful without the ongoing sense of pain.

For pain patients, this new technology is nice since the only thing implanted into the body is a thin wire to the appropriate location. Testing prior to implant is first by a local nerve block with a long lasting anesthetic. If that is successful, than a trial implant can be done for a week or longer to determine if a final implant would be indicated. The permanent implant is a brief outpatient procedure and can be easily removed in the future if necessary.

Pain patients who may benefit from peripheral nerve stimulators include those where pain symptoms have a definite peripheral nerve origin and the pain can be extinguished by blocking just one or possibly two nerves that are nearby each other in the body. The first problems that have been treated have been pain related to shoulder injuries that do not resolve with surgery. Other common orthopedic problems include knee and foot pain after trauma or other surgery with nerve damage or nerve pain afterwards. Amputation phantom limb pain and complex regional pain syndrome are other pain problems that may benefit from this technology. An interventional pain specialist who does implants should be able to help determine if the pain problem may be helped with such treatment. Not all pain problems can be helped and if the pain is coming from multiple pain generators or is centrally generated in the brain, this treatment is less likely to be helpful.