acute pain

The Overdose Issue: Narcotics and Benzodiazepines

/ Thomas Cohn, MD

Pain Pills KillThe recent death of actor Philip Seymour Hoffman has brought to the forefront the issue of narcotic overdose. Many of the famous actors who have died of medication overdose have done so with a whole cocktail of drugs found in their system. Many have overdosed on a combination of multiple prescription medications, street drugs and alcohol. The mixture of drugs is especially lethal, since the effect of the mixture makes many drugs more toxic. A very common mixture found in overdose cases is the combination of opioid/narcotic and benzodiazepine. The source of these medications is most often the primary care provider.

Opioids and Benzodiazepines

Opioids have a very legitimate use for the management of pain. The prescription of these medications for acute pain on a very short-term basis by primary care providers is definitely appropriate. Once pain becomes chronic, pain management becomes much more complex, and the prescription of opioid medications should be in consultation with a trained pain physician. Since there are many advanced treatments for pain, the inclusion of a pain physician will reduce the over-prescribing of opioids. Furthermore, pain physicians will be able to better monitor appropriate medication use and determine early when the medications are not advisable.

Benzodiazepines are medications used for anxiety. Short-term use of these medications for anxiety is reasonable if prescribed by a pain physician. Anxiety and depression are closely related, and if the patient is depressed, treating the condition with an anxiety medication will not help resolve the feeling of depression. Ongoing anxiety is usually a sign that the patient is depressed, and a physician should prescribe a depression medication and not a benzodiazepine.

Pain and Depression

In the brain, the centers for pain and depression are next to each other and they interact with one another. Significant pain will cause stimulation in the area that controls your mood, thus, a patient with chronic pain will often be depressed. A primary care provider will often treat individual symptoms through a combination of opioids and benzodiazepines, which is safe as long as they are taken in the recommended amount. A patient may not realize the danger of these medications and may overdose if they take too much in a short period of time or in combination with other drugs.

The other main issue is that these medications are, for the most part, widely prescribed.  These medications are available in the public, and they are being traded and sold, which opens them up for abuse. A person with an addiction has easy access to these medications either legally or on the street. Better management of patients who actually need these medications will greatly reduce the amount of medication on the street. Better education of all medical providers on pain management will also help. Experts trained in recognizing pain and depression symptoms can help decrease the amount of excessive or unnecessary pills that flood the market.

The more we know, the more we can do to help keep people safe.

When to Seek Medical Attention for Abdominal Pain

/ Thomas Cohn, MD

abdominal painAbdominal pain is fairly common and is usually not cause for alarm. Every structure in the abdomen can cause pain, including:

  • Stomach
  • Intestines
  • Liver
  • Spleen
  • Kidneys
  • Bladder
  • Appendix
  • Sexual organs
  • Blood vessels
  • Muscles

Since every organ and structure tends to have some type of sensory innervation, they can all be sources of pain.

Almost everyone has experienced pain from the stomach and intestines.  From overeating, to acid reflux and indigestion, to constipation or diarrhea, the problems are common.  Most of these issues are short lived, inconvenient, and not serious.  When they are intense and do not resolve quickly, sometimes they do require medical intervention.

When to Seek Medical Help

The main concern with abdominal pain is when to seek medical attention to help determine the cause.  Signs that indicate a need for further attention include:

  • Fever
  • Inability to eat or drink fluids for over a day
  • Ongoing vomiting
  • Vomiting blood
  • Severely painful abdomen and not being able to touch it
  • Painful urination
  • Passing blood in urine or stools
  • Difficulty breathing due to pain
  • Acute traumatic injury

Since there are so many different organs and structures linked to the abdomen, diagnosing the cause of pain may be difficult.  The starting point is always the history and story provided by the patient. A physical exam gives the next set of information.  With this basic information, the clinician then can determine the best tests to help find the answers to the cause of the pain.  Tests may include blood and urine analysis, X-rays, CT scans, ultrasounds, and sometimes invasive scopes of various systems.

Treating Abdominal Pain

Treatment options for abdominal pain are as variable as the causes.  Since the vast majority of causes are not life threatening, treatment is often simple.  Serious problems often require the intervention of medical specialists to guide the evaluation and treatment.  Self-diagnosis and treatment for minor problems is fine.  But when the symptoms are more serious, find a medical specialist who you can trust.  If looking up information on the Internet, stick to respected medical sites like WebMD, Mayo Clinic, and the NIH (National Institutes of Health).  Do not panic about information you read on the Internet but use it to discuss concerns with your provider.

Can Antidepressants Relieve Pain?

/ Thomas Cohn, MD

antidepressantsPain and depression are closely linked in the brain, and medications used in depression can be helpful in the controlling pain.  Some antidepressants directly impact pain, while others only affect depression.

Antidepressants are most helpful in treating pain caused by damage to nerves or by an overactive nervous system (aka neuropathic pain).  Specifically, antidepressant medications can help treat the following painful conditions:

Acute injury and surgical pain may be helped, but is still being studied.

Types of Antidepressants

There are two types of antidepressant medications that are used to control neuropathic pain:

  1. Tri-cyclic antidepressants (TCAs), such as amitriptyline, Nortriptyline, and desipramine
  2. Serotonin/noradrenaline reuptake inhibitors (SNRIs) such as Cymbalta and Savella

Antidepressants such as Zoloft, Prozac, Celexa, and Effexor have no affect on pain.  These medications decrease nerve transmission and nerve sensitivity. The TCAs have many side affects including dry mouth, low blood pressure, sedation, and urinary problems.  The newer SNRIs have very few side affects.  Cymbalta is very effective in a number of neuropathic pain situations including diabetes, radiculopathy, and fibromyalgia, while Savella only is known to work in fibromyalgia.

Pain & Depression are Closely Linked

The nerve fibers that transmit pain sensation travel through the brain in the same regions that process emotional signals.  These regions actually interact with each other.  Stimulating depression centers can increase the perception of pain.  When depression is not controlled, and a patient does have pain, rarely will the pain be controlled no matter what the treatment.  Therefore, treating depression is often essential in effectively treating pain.  Many people do not want to admit that they might be depressed, and thus not treating the depression does affect the pain level perceived.

Pain and depression in the brain are closely linked.  Neuropathic pain is often treated with a variety of medications, many of which are antidepressants.  Pain itself can change a person’s function and activity level, and cause depression.  Treating the concomitant depression that pain may cause does help manage the severity of pain in many patients.  Some medications treat both pain and depression, others may only treat depression, treating both together is often very effective in controlling pain.

Do Pain Medications Cause Kidney Stones?

/ Thomas Cohn, MD

kidney stoneKidney stones are tiny pieces of mineral or salt in the urine that are incredibly painful when passed. Pain meds are often used to ease discomfort during stone passage. But can these pain medications also cause kidney stones?

What are Kidney Stones?

Kidney stones are considered one of the most painful acute conditions.  They are caused by a variety of things such as:

  • How the body metabolizes various compounds (calcium, for example).
  • Not drinking enough water
  • Other medical conditions like gout
  • Genetic predisposition

As stones are passed from the kidney through the ureters to the bladder, they can be extremely painful.  Stones are often as small as a grain of sand. As they are passed from the kidney they irritate the structures on the way out of the body.

Identifying & Preventing Kidney Stones

Stones are often suspected when there is blood in the urine without any additional signs of infection.  In most cases, once you have a kidney stone you have no choice but to pass it. The only thing you can do is take pain meds to manage the pain during passage. In more severe cases, surgical procedure may be necessary to remove the stone. Analysis of the stone after it is passed can determine a prevention strategy moving forward.

Pain Medications & Kidney Stones

Pain medications are often used to control the extreme pain caused during the passage of a kidney stone.  It is common that people when passing a stone have such severe pain that they go to a hospital.  Powerful opioid and narcotic medications are useful to control the severe discomfort.

Pain medications themselves have not been known to cause kidney stones.  They have been used as an essential tool in the treatment of acute passing of stones.  Treatment is usually only necessary for a few hours to several days with opioid medications.  In rare cases with people who have recurrent stones, frequent use of opioid medication on a temporary basis is necessary. This should only be a temporary solution until a renal specialist can develop a more definitive management strategy.

Low Back Pain – A Common Problem, often Mistreated

/ Thomas Cohn, MD

low back pain minnesotaLow back pain is a very common issue – 85% of the population will experience back pain at some point in their lives. However, back pain is often treated improperly and as a result, it has become a costly problem in American society.  A lack of understanding of back pain, its causes, and usual treatment, leads to costly management.

Acute Low Back Pain

Acute low back pain is pain that has been present less than 3 months.  Most back pain can be treated conservatively.  Only rarely is back pain a serious medical emergency.  There are many structures in the back that cause pain, including:

  • Vertebral discs
  • Bones
  • Joints
  • Nerves
  • Muscles

All of these can cause pain.  Fortunately, most pain is caused by muscle strains and irritation of joints, discs or nerves.  Initially all of these are treated the same, with ice and heat, minimal rest, stretching, and then muscle strengthening of the core.

Medications should be kept simple – use Tylenol or anti-inflammatories like naproxen to manage the pain.  If pain is more severe, see a primary care physician for referral to a Physical therapist.  Very short-term use of narcotic pain medicine is useful if other medications cannot be taken but these are not advised for more than several weeks.

If Back Pain Persists

If back pain persists for more than a month, despite basic management, you should seek out an expert in low back pain.  The best medical doctors to evaluate and treat this type of pain are board certified physicians in Physical Medicine and Rehabilitation.  These physicians are experts in the musculoskeletal and nervous system.  They can guide a person through a detailed exam and diagnosis and more advanced treatments.

Surgery, MRIs, & CT Scans

Back pain is rarely a medical emergency.  If a patient has had cancer and has new onset of back pain, aggressive evaluation is necessary to determine if cancer is affecting the region.  Low back pain with loss of control of the bowels, or loss of muscle function in the legs is the other case when aggressive evaluation is necessary.

Back pain is usually relatively benign.  Most pain will resolve within weeks with conservative treatment.  Only in rare cases (such as cancer) should MRI or CT scans be obtained.

Surgery should only be considered if nerves are compromised, or bowel or bladder control is lost due to the spine being injured.