acute pain

Lessons From Prince On Chronic Pain

/ Thomas Cohn, MD

The death of Prince shocked the nation, a great artist lost to early, and his death has since been linked to opioids. Many celebrities have struggled with drug and alcohol addiction, but this story seems different. Prince did have a problem it appears with opioid addiction, as he died from an overdose most likely of fentanyl mixed in with oxycodone. He knew he had a problem, but for some reason he was slow to seek treatment, and help was just hours to late. The reason why this celebrity death is different is that Prince had chronic pain, and opioids were being used to help control symptoms.

Chronic pain is estimated to affect about 30 percent of the population in the United States as well as throughout the world. As a musician, Prince had apparently developed several injuries related to his work. He definitely had hip arthritis with deterioration of at least one of his joints. He may also have had other injuries, possibly pain related to repetitive stress on joints from hours of practice and playing multiple instruments. According to some reports, Prince would have definitely benefited from hip surgery and possibly a replacement. However he was a Jehovah’s Witness and this surgery was against his beliefs. Instead of taking care of it surgically, he chose other strategies.

Pain and the Pressure To Perform

Prince, like every other professional, felt the obligation to always be up and performing. Everyone wants to hide their suffering from others, and many people will go to any end to be able to look their best. For performers like Prince, either he showed up and gave a great show or he would probably no longer have a career. As far as his health, he made it a secondary priority. Chronic pain does not discriminate, and crosses all social, cultural and economic groups. No one gets special privileges, only you may be able to afford more treatments. Celebrities are also not immune from overdose, addiction, and certainly not death.

Chronic pain in Prince’s case was a result of hip joint destruction. As with all painful conditions, there are multiple ways to treat it.  The best way when it has become severe, and when the circumstances are similar to his, is surgical replacement. This usually solves the problem and mostly eliminates the pain while restoring near normal function. Unfortunately, personal religious convictions limited this option. Other good treatments would have been:

  • Exercise
  • Anti-inflammatory medication
  • Possible cognitive/behavioral therapies

Long-term opioids are not a good choice. The worst choice was self-medicating with opioids obtained illegally, since there is no way to know what they might contain. Chronic pain is not a sexy disease, and no one wants to be the poster child for such a disease. Maybe Prince will be the poster person. Unfortunately, he be a sobering reminder about the drawbacks of self-medication.

Chronic pain is extremely common, if you have pain, first start working with a primary care physician. If it is not responding to straight forward management, get a pain management specialist on the team to help find better solutions. Pain has many solutions, opioids are only one of many tools, and usually it is not one of the better ones, and it is generally extremely poor for long-term use. If medications are part of pain treatment, then one provider and one pharmacy is needed, and street drugs are off limits. Further, the primary prescriber needs to be screening all patients for abuse since it is difficult to determine who will be an abuser of medications. Lastly, if one does become addicted to medication, then it is time to get over embarrassment and get treatment so you do not end up overdosing.

Chronic pain is a difficult problem, it occurs in a third of the population in general. If you have pain, get good advice and obtain knowledgeable medical treatment.

Cloudy With a Chance of Chronic Pain

/ Thomas Cohn, MD

Chronic Pain Rain MinnesotaNew research from across the pond shines some light on the correlation between some weather patterns and expression of chronic pain.

For their study, researchers conducted a study called the Cloudy Project that involved more than 9,000 patients with chronic pain. Each day, patients would track their levels of daily pain through a smartphone app. When pain levels were entered, the app also recorded the local weather at that date and time. Patients recorded their pain levels for a total of 18 months.

Pain and the Rain

After looking at the data, researchers uncovered a link between poor weather and greater expression of pain. As the cold winter months turned to spring and the sun was up longer and more often, researchers noticed that pain levels dropped and severe pain was experienced far less frequently. They also noticed that pain levels spiked again during a rainy stretch in June. Researchers said there certainly is a correlation between chronic pain expression and the weather, but they want to conduct future studies to better understand why this correlation exists.

“Once the link is proven, people will have the confidence to plan their activities in accordance with the weather,” said Will Dixon, a professor of digital epidemiology at Manchester’s School of Biological Sciences. “In addition, understanding how weather influences pain will allow medical researchers to explore new pain interventions and treatments.”

Dixon called for individuals with chronic pain to reach out to the Cloudy Project about the chance to participate in future studies and help medical researchers better understand the mechanisms behind chronic pain.

“To work out the details of how weather influences pain, we need as many people as possible to participate in the study and track their symptoms on their smartphone,” Dixon said. “If you are affected by chronic pain, this is your chance to take do something personally — and easily — to lead to a breakthrough in our understanding of pain.”

Some Opioids May Actually Hinder Healing

/ Thomas Cohn, MD

Pain Opioids Pill AddictionA recent study on rats has brought to light another problem with using opioids for pain treatment. In the study, rats had an experimental trauma to the sciatic nerve causing leg and foot pain.

One group was given opioids to control pain while recovering from the injury, while the control group was not given any medicine and allowed to heal on their own. The opioid treatment group took at least 16 weeks to heal, while the other group healed in eight weeks, and the control group actually reported more complete healing. The opioid group showed signs of prolonged inflammation throughout the treatment period. The untreated group did not have signs of ongoing inflammation. Now as a reminder, this study was in rats, not in humans.

The significance of the above study is that the use of opioids in humans does have many negative effects. We know that these medications cause problems from cognition to constipation, depression, and many other medical issues. The current leading concern is addiction. Now if the above research holds true in humans, or has even a partial effect in humans, using opioids for pain may be inhibiting recovery from injury and prolonging pain and inflammation.

Having The Reverse Effect

The goal of most physicians when treating pain is to promote recovery from difficulties that may be causing damage to the body. Pain physicians promote multiple strategies to treat painful conditions. Medications are one strategy. More effective treatments often involve physical therapy in order to promote healing and more natural restoration of function. It takes strength and endurance to function normally. Return to normal function after injury takes a lot of work, there is not a magical pill to reverse pain.

As time goes on, the more we learn about medications, the more we realize that every substance that we put in our bodies has the potential to create more problems. Most medications prescribed by physicians are relatively safe, but they can all cause problems. If we want to do the best thing for our bodies, we need to often go back to the basics. The body needs the right exercise, food, nutrition, and rest. Treat the body right and it will not be angry and painful. Doctors can only help a person so much, the rest is up to the patient to take care of themselves.

Applying Pain Lessons To Our Every Day Life

/ Thomas Cohn, MD

Managing Chronic Pain health wellnessI try to skim the medical news every couple of days to see what’s making waves in the field of pain management. Most of what I see has to do with a variety of topics related to musculoskeletal medicine and pain.

A lot of articles I see have limited value to my current practice, but some topics have interest because there is science that may be important if it is applied in a more broad way. Other things are interesting because they are rooted in obvious facts.

Last week, the Star Tribune had an item on cancer prevention. JAMA Oncology had an article that 63 percent of men’s cancer and 41 percent of women’s cancer was preventable. The interesting thing was that if we just lived a healthy lifestyle, a lot of cancers would not occur. The obvious is the simple stuff, like not smoking and wearing sunscreen. The other aspects are a bit tougher, like eating healthier foods, not being obese, exercising, and sleeping adequately. It is a potent reminder of how we live life significantly impacts our overall health. The best way to cure cancer is to prevent cancer in the first place.

Another article in the paper was on baby powder causing cancer.  The most common cancer was ovarian, but lung cancer may also be linked.  The connection to cancer is that baby powder is a very fine particulate.  It is also very similar to asbestos.  If these fine particles get inside the body, they can cause immune reactions and stimulate abnormal tissue growth as well as cancer.  So a supposedly harmless substance we use can cause deadly problems.

Take Away Points

There is a message here from these news pieces about cancer that applies to all of us. The first is that if we work at keeping ourselves healthy, we will have less illness and medical problems.  Secondly, keeping compounds that naturally do not belong in our bodies out helps prevent cancer.

Applying this logic to pain management is natural. Let’s first look at the ideology of keeping ourselves healthy to prevent chronic pain. Exercises including stretching, strengthening and aerobically conditioning the body all help prevent pain. I used to be able to do parts of a program sporadically and function fairly well. As I have aged, consistency with a well-rounded program of exercise has been essential, as skipping days does not work well for me. Getting enough quality sleep is a problem; I have not yet focused on how I will try to improve my sleep. Eating healthy has been issue, but I am slowly changing my diet, lowering my carbohydrate intake, and concentrating on protein, vegetables, fruit and some cheese. I am trying to find a diet plan that makes sense and is sustainable.

The second point of focus is not adding things into my body that may not be healthy. That means keeping my medicine intake to what is necessary to prevent illness, such as taking cholesterol medicine (I have a familial variety of high cholesterol), and asthma medicine when needed. I keep away from addictive medicines. Overall, the most important aspect of health and pain control comes down to eating right, exercise, and good sleep. There is very little magic and a lot of personal work put in on my end, and my body thanks me for it.

Opioids – Why Patients and Physicians Are Frustrated

/ Thomas Cohn, MD

Frustrated patient and physicianEvery week there is a new article on the opioid epidemic. The focus is all on the number of people addicted to pain medications and how people are dying every day. Today an article appeared in the paper on how one of the drug companies is making a long acting opioid and how it can make people become addicted. Other stories are focusing on those who already have addiction problems. The real problem is the need for better treatment for pain, for both acute and chronic. 

Chronic pain affects 30 percent of the worldwide population. Until the last several decades, many people did not survive long enough such that pain was a problem for decades of their lifetime. Now, life expectancy is often into the 80’s and many have chronic, painful conditions for nearly half of their life. The range of treatments is limited, and there is often no full cure for a lot of conditions that result in pain, despite the fact that western society expects the physician to have a miracle cure. Even the most knowledgeable patients often have unrealistic expectations to be pain free with the next treatment option.

Patient and Physician Need To Work Together

Yes, the United States of America has an opioid addiction problem. The real problem, however, is a lack of education for the patient and physician on how pain can be treated. On top of this is the focus on treatment of addiction versus the better treatment of pain. One of the main problems leading to opioid addiction is the lack of medications to treat pain. Other treatments for pain are not as easy as taking a pill. Physical therapy, behavioral interventions and injections may be better, but they are more difficult for the patient and definitely more costly.

The most frustrating problem for physicians is insurance coverage for newer medications, maintenance physical therapy, psychological therapies, alternative therapies, comprehensive pain programs and sophisticated interventions. It is easier to get coverage for an opioid for pain than get psychology to prevent the need for opioids. The same is true for allowing a trial of a spinal cord stimulator versus allowing for a back surgery. An intervention that has a cheaper overall cost and is safer within a year or two will not be covered by insurance. Further, the insurance companies often will say a treatment is experimental, such as a radiofrequency neurotomy or the use of Lidoderm patches, refusing to cover the expense while gladly paying for highly addictive opioids.

Pain patients and physicians are equally frustrated by the lack of coverage for alternatives to opioids. Instead of focusing so much on the bad outcomes of opioids and treating addicts, investments need to be placed on using alternative treatments and funding research to develop better pain treatments. One third of the population suffers from pain. It is about time the pharmaceutical industry, government, and even insurance companies invest in better pain management strategies.