acute pain

Let’s Focus On The Pain Epidemic, Not The Opioid Epidemic

/ Thomas Cohn, MD

pain opioid epidemicA recent article in the Star-Tribune noted that every three weeks, the death toll from opioid overdoses matches the death toll from the attacks on the World Trade Center on September 11, 2001. Not only is this a concerning number, but trends show that the death toll from opioid overdoses is continuing to skyrocket. The government and even President Trump have stated that the opioid epidemic is a problem that needs to be solved, but are they looking at the problem in the right way?

The opioid crisis is a huge issue, but it’s only a symptom of a larger problem, which is the pain epidemic in America. More people are turning to opioids in the United States because more of them are fighting a losing battle against pain. We need to be finding solutions to the pain problem, because the opioid crisis is a symptom of the problem of pain.

Stopping Pain

Think of it this way. Let’s say you’re in your house and you see smoke. You run to the kitchen and notice a fire behind the stove. You quickly fill up some water from the sink and douse the flames with water, stopping the fire in its tracks. It’s great that you stopped the fire, but you wouldn’t just go back into your living room without investigating what caused the fire to start in the first place. If you don’t fix the faulty wiring that caused the fire, you’re prone to another fire in the future.

In the above instance, throwing water on the fire is like trying to treat the opioid epidemic. It is a problem that needs to be addressed, but unless we also focus on the root problem, which is pain (or faulty wiring in this case), then the problem is only going to continue to be cyclical. Eliminating opioids may reduce the number of overdose deaths, but it will also hurt patients who use them responsibly to manage their pain, and severely cutting back on opioids will do NOTHING to solve the pain problem.

What We Need To Do

Enough about what’s wrong with the current system – here’s a definitive list of what we as a nation need to do in order to fix the opioid crisis and the pain problem in America.

  • We need to educate both patients and doctors about how opioids work in conjunction with a multi-faceted approach to pain management.
  • Opioids can play a role in pain care, but they can’t be the only treatment option. They can help manage pain, but they are not a long term solution to treat pain. Anybody who is only taking pain medications for their condition is at a high risk for dependency and has a low chance of ever recovering from their pain.
  • We need to open up insurance coverage to other non-traditional methods of pain management. Let’s get creative with pain management, because what works for some will not work for others.
  • We have to pound home the message that there is no magic pill for pain, but tangible solutions are within your reach.
  • Doctors need to do a better job of pushing people towards tangible solutions instead of quick fixes. Things like physical therapy, aqua therapy, cognitive behavioral therapy, yoga, etc. over writing a quick prescription.
  • We need to invest research funding into pain treatments, whether it’s medical marijuana or new diagnostic tools, we need to spend money on solving the problem of pain. Invest in pain solutions like we’re investing in treating cancer or diabetes.

If we can check off all the items on this list, I’m confident we can find new ways to treat pain, and in turn combat the opioid crisis in America.

The Truth About Chronic Pain

/ Thomas Cohn, MD

When it comes to chronic pain, one thing is clear – You are not alone. In fact, chronic pain affects roughly one in three people in the world. Whether it’s a sore back, neck pain or complex regional pain syndrome, we all deal with different kinds of pain. But just because our pain is different, doesn’t mean we’re not all going through something similar.

To help illustrate this point, we turn to our friends at WallMassagers.com. They specialize in pain management tools and they’ve created this wonderful infographic to help explain just how widespread chronic pain is in the United States. Check out the infographic below!

chronic pain infographic

A Doctor Who Understands Your Pain

/ Thomas Cohn, MD

spine pain cohnI have been known to preach a little about the work it takes to control pain. It is not about taking a pill or just going to therapy and it will all be better. I often offer advice and I rarely cut people a lot of slack. I also do not like opioid medications, but that is for obvious reasons related to effectiveness and addiction. But most people wonder if I actually understand pain. The answer is yes, I deal with my own issues daily, but my patients are not paying to listen to me complain. The reality is I had to learn what works for me to manage my issues.

My Pain Story

My story started in medical school. Keeping in shape was important just to have the energy to spend countless hours in class and studying. At one point, a housemate convinced me to try weightlifting. The second time I tried I had the weights in the wrong position, lost my balance, and took out my back. I probably herniated a disc in my lower back, but there were no scans available then. I did therapy and over months it became manageable most of the time, not slowing me down if I was generally careful and not doing stupid things.

In my mid forties, 20 years later, my back started to become more noticeable. I had regular low back pain, and it started to frequently radiate down the leg. I gave up on running since that set it off, and just tried to keep in reasonable shape. This worked until I was in my late forties, and then finally I had a MRI scan that showed a significant slippage at the bottom of the spine, a disc that was pretty much shot and a lot of narrowing where the nerves exit the spine. The radiologist that read the scan had only one question for me, and that when was I thinking about having surgery. Surgery had not crossed my mind since my issue was pain. I decided to follow the advice I had given others; If there was no weakness and no loss of bowel or bladder control, surgery was not the answer.  

Conservative management was my goal. I had a couple of lumbar epidurals that brought down the worst pain and I did a few physical therapy sessions and they gave me a ton of exercises. The exercises were repetitive, and they seemed to be focused on the same muscles, doing all of them took about 40 minutes and they were boring. As the pain improved, I gave up on the program. Within 18 months the pain was again bad and I had another epidural, but I thought I needed to condense the exercise program. I narrowed it down to a set of core exercises that were all different parts of my core muscles, and I added a stretching regimen. Core work was about 10-20 minutes depending on what I did, and stretching was only about 5-10 minutes at the most.

My kids were hockey players, and my daughter had scoliosis and had exercises and a balance board. When I tried the balance stuff, I was terrible and it proved to me I needed to work more on core. I also felt since I was getting old, general strengthening would be a good thing to add to my workouts to reduce muscle loss. Lastly, I needed to also throw in general aerobic conditioning to maintain cardiac health.

Finding What Works For Me

The workout for the last few years has been pretty consistent. I start every day pretty early to get it done. After I climb out of bed, I stretch for a couple of minutes, and my dog gets a belly rub while I loosen up my back. After that comes core work that includes planks on a balance board, sit-ups, leg lifts and upper body/core with rubber tubing. I use a universal gym machine for additional strengthening and a roman chair device for abdominal work and pull-ups. Cardiac/aerobic workouts rotate between an elliptical, bike and rowing machine doing intervals. The rowing machine is the most recent addition. It supposedly works 85 percent of all your muscles, and it really seems to loosen things up and get the body moving well without stressing things out. During the summer I get outdoors and bicycle. Since I have a big dog, she gets twice a day walks daily year around.

As with everyone, as we get older, we all start to gain weight. I like to eat, and often enjoy snacking on junk food. Eventually my wife convinced me that I needed to change my habits. I had to stop eating as much carbohydrates, eat more vegetables and protein, and get rid of sugary drinks and snacks. I am no where near the weight I was in college, but I think I probably have more upper body muscle and some extra gut, but I have lost a few pounds.

For most people with back pain, sleep is a huge problem. Like many, I never feel well rested. I used to be a stomach sleeper, but with my back, extension is the worst position and that is absolutely out.  Side or back sleeping is feasible. Multiple pillows are my best friends keeping my knees bent while on the back, between the legs while on the side, and adjusted under my neck to keep that in a neutral position. A good memory foam pad adds to the comfort level to help relieve pressure points. I am not a deep sleeper, and after four hours stiffness often wakes me up. Instead of fighting it, I get up and stretch for just a few seconds, and then go back to bed and I can sleep for several more hours. For me, sleeping over 7.5 hours just hurts my back, so I get moving after that amount of time. To fall asleep, I do not do work right before bed, I do some reading and try to clear my mind of anything serious.

Like everyone else who has back pain, I have to take care of my back. It is not easy to do, but it is a priority to stay healthy.  It would probably help me if I could figure out how to get more sleep at night since some experts say this is good for general health. Maybe I should try to meditate, but this would also take time, and I am not yet into that either. I may spend to much time exercising, but a large part of it is walking my dog, and someone has to do it. Eating a more healthy diet has reduced my weight slightly. To lose more weight, another major change and reduction in calorie intake would be necessary and no fun. Life is a matter of balancing multiple options. If you have pain, one of the best treatment options is a comprehensive exercise program. There will never be a magic solution for pain, it will always require lifestyle choices.

Chronic Pain After Surgery

/ Thomas Cohn, MD

chronic pain cpspIn the vast majority of cases, a surgical procedure helps to eliminate or reduce pain in the targeted area. However, in rare cases, complications or unforeseen circumstances can result in the onset of what’s known as chronic postsurgical pain.

Today, we’re going to take a closer look at CPSP, and how it is prevented and treated.

Treating Chronic Pain After Surgery

Medical experts define chronic postsurgical pain as pain that persists for at least two months after surgery and is not attributable to a preexisting condition. Oftentimes CPSP is considered neuropathic in nature, and patients describe the pain as shooting, burning, tingling or electrical in nature. Some procedures that have a higher rate of CPSP after surgery include:

  • Amputation
  • Coronary artery bypass surgery
  • Thoracotomy
  • Spine surgery
  • Breast surgery
  • Hip surgery
  • Hysterectomy
  • Inguinal hernia repair
  • Cesarean section

Doctors believe that CPSP develops because stress from the operation, inflammation or nerve damage results in neuronal hypersensitivity that results in the expression of chronic pain flare ups long after the surgical site has healed.

Risks and Prevention

There are a number of factors that increase a person’s risk of developing chronic postsurgical pain after an operation. Those factors include undergoing repeat surgeries, lengthy surgeries, open procedures instead of minimally invasive surgeries, and undergoing an operation in a previously injured area. On the doctor’s end, a surgeon can increase a person’s risk of developing CPSP if there is intraoperative nerve damage, which is more likely to occur in difficult operations, surgeries involving severe trauma, or surgeries near the spinal cord and central nervous system.

The main way surgical teams prevent CPSP is through surgical techniques and improved operative practices. If possible, the surgeon will opt for a laparoscopic procedure in lieu of an open procedure, because minimally invasive options have a decreased likelihood of CPSP. Another thing surgical teams will do is carefully administer analgesic agents with different mechanisms of actions during the pre-, intra- and post-operative periods. These approaches reduce peripheral and central sensitization and are associated with enhanced efficacy and fewer adverse reactions.

Should you develop CPSP after an operation, reach out to a chronic pain doctor in your area to see what solutions are available to you.

Doctor Killed For Not Prescribing Pain Pills To Patient

/ Thomas Cohn, MD

pills doctor killedLast week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated.  Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.  

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.