New research published in the journal Mayo Clinic Proceedings suggests that activities like yoga, Tai Chi and other complementary health approaches may help alleviate discomfort associated with some types of chronic pain.
Lead author Richard L. Nahin, Ph.D., of the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH), suggested that activity options like Tai Chi and yoga may help prevent symptoms from chronic pain, especially when paired with other treatment options like regular exercise, a healthy diet and certain pain medications.
“For many Americans who suffer from chronic pain, medications may not completely relieve pain and can produce unwanted side effects,” said Nahin. “As a result, many people may turn to non-drug approaches to help manage their pain.”
Chronic Pain, Yoga and Tai Chi
For their study, researchers identified 150 randomized, controlled U.S. clinical trials conducted over the past 50 years that examined non-drug approaches to chronic pain. Specifically, the research targeted five common sources of pain, which were:
The treatment techniques analyzed were considered effective if patients reported that it led to improvements in pain severity and pain-related disability/function. After looking at the data, researchers found that both yoga and acupuncture were safe and effective for chronic back pain, while Tai Chi and acupuncture may be most beneficial for patients with osteoarthritis of the knee. Massage therapy was also somewhat beneficial for patients suffering from neck pain when it was managed with one-hour sessions 2-3 times per week.
“These data can equip providers and patients with the information they need to have informed conversations regarding nondrug approaches for treatment of specific pain conditions,” said David Shurtleff, Ph.D., deputy director of NCCIH. “It’s important that continued research explores how these approaches actually work and whether these findings apply broadly in diverse clinical settings and patient populations.”
At the end of the day, the study paints an interesting picture at some non-drug techniques that can be used in conjunction with other lifestyle interventions to provide relief. Simply getting massages or doing some yoga isn’t going to fully rid you of your pain, but it can play an important role in a total pain management plan. There is no magic pill to cure many of the above conditions, but with a multifaceted approach that involves treatment with a physical medicine pain specialist, relief can be found.
The death of Prince has been a turning point of how serious the opioid addiction epidemic has become. Almost every medical pain specialist has been aware of the problems with opioids, pain and addiction, but now others are taking note. There are many concerns with prescribing opioids, from whether they actually help control pain, are there better treatments, and how many additional problems they are causing. We know one of the big problems caused by opioids that has become horribly worse is opioid addiction. Many people with and without pain are addicted to opioids. A new way to help treat addiction is in development – vaccines.
The information for this blog comes mainly from an article by Susan Giados published in the July 9,2016 issue of Science News Magazine. For those who are interested in a variety of scientific topics, this is a twice a month magazine, usually about 30 pages long packed with short fascinating articles. Well worth looking into.
The Heroin Scene
Heroin and opioid medications are accounting for about 30,000 overdose deaths a year. Here’s how it came to be popular in the US.
1960’s – Heroin first came on the drug scene in big numbers in the early 1960’s. It was a strong drug that produced an intense high. Most users came to the drug while searching for more intense highs, but the drug was not particularly pure or cheap.
1970’s – Major education and opium eradication efforts into the 1970’s suppressed its use.
1980’s and 1990’s – The late 1980’s introduced long acting opioids like OxyContin onto the market, and big pharma pushed these drugs as safe and as the answer to any all pain was simply to take a pill.
2000’s – By the early 2000’s opioids were the first and most common way to treat pain, and every doctor was prescribing them. The rate of addiction rose drastically, and as the awareness has grown, the access to prescriptions has slowly become harder. Opioid addicts now were everywhere.
Now comes into play some very interesting economics. Addiction itself has driven a market to supply people with opioid medication. It spawned an under culture of “pill mills” where almost anyone could go and get a supply of opioid pills. Many people would “doctor shop” for pills, use some and sell the rest for money. Drug cartels started to get into the mix manufacturing and selling them, further fueling addicts. The government then started clamping down on the supply since about 2010. The drug cartels have long had the ability to make heroin, and now they knew they could make large, pure amounts cheaply. For addicts, those who got hooked on pain pills for any number of reasons now saw heroin as a cheaper and often easier to obtain option than prescription medications. Now heroin has become a major problem as more addicts are turning to that to treat their cravings and pain.
Addiction to opioids has become a huge problem. There now are three medications that are used in the treatment of addiction; methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are used to reduce cravings, and must be continued indefinitely. Naltrexone is used to block receptors and is used almost exclusively to reverse opioid overdoses. Unfortunately of those who seek treatment for addiction, only 25% end up receiving medications to help prevent relapsing back into addiction. Vaccines were first attempted in the 1970’s, but the science and cost of development were barriers, and the methadone was cheap and easy to use.
Addition and Vaccines
Now a little additional primer on addiction. Opioid drugs alter the brain pleasure circuitry and cause changes in the structure and function of the brain. Opioids act on the nucleus accumbens in the brain, and they increase the amount of dopamine in the brain. Opioids also act on the mu receptors throughout the nervous system, stimulating dopamine. These are the same chemicals that stimulate the pleasure centers in the brain and reinforce enjoyable activities like eating, sex or listening to good music. Dopamine, in other words, is what is stimulated by compounds like opioids and by stimulating pleasure. Over time, drugs of abuse can change the circuitry in the brain, decreasing the sensitivity of the reward centers and disrupt the centers involved in self control. Addicts tend to lose the ability to enjoy the normal every day activities, and then they need higher and higher doses of drugs to stimulate euphoric/happy feelings. The need to feel pleasure drives the brain, impairs decision making and self-control, and then the only drive is to take drugs just to stay on an even level.
The goal of a vaccine is to train the body’s own immune system to identify the specific offending drug molecules and rid the body of them at even high doses. One of the vaccines being developed is aimed at heroin and its breakdown product morphine. To be effective, heroin in the body breaks down quickly to morphine, and both these compounds need to be targeted to be helpful. The other problem is when going after a drug, there are millions of molecules in the body suddenly, unlike an infection with a few replicating viruses. So to develop a robust vaccine to stimulate the body’s immune systems and chemicals to rid it of certain compounds like opioids is a bit difficult.
So far scientists have been successful in developing a vaccine specific for heroin and the breakdown to morphine that works in rats. The vaccine trains the immune system to neutralize the compounds and even fatal doses of drugs can be handled. The intake of heroin or morphine no longer produces a high, and drug seeking is not pleasurable. A series of three shots was able to produce months of ability to block drug seeking and pleasure by specific opioids. A second vaccine similar to the one for heroin is being developed for fentanyl. After a number of months, the brain starts to reset to more normal patterns of stimuli producing pleasure versus the strong pull to using narcotics. Blocking the drug seeking and pleasure of opioids does also affect all the pain relieving abilities, and the vaccines essentially cause the body to destroy these compounds making them ineffective for any purpose.
Using vaccines is another tool to control addictive behavior in the future once they are perfected for human use. They will be only for specific compounds, like heroin, morphine and fentanyl and not every single narcotic in general. They will be targeted at the most abused compounds and in that way allow a person still to be able to use certain other opioids if necessary for pain control.
Addiction does occur in the pain patient population. The percent of addicted patients in studies is highly variable, on the low side it may be 2-5 percent, although a common number is up to 17% or higher. Addiction is occurring when the need to take a drug is overriding, judgement is impaired and normal activities are suppressed over the needs for getting and taking the medication. Further, the amount of drug needed is escalating fairly rapidly. When addiction becomes an issue, then being weaned from the whole category of drug is needed and appropriate psychological help for addiction and full treatment is necessary.
A 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.
I 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.
Chronic pain and prescription opioids are two topics that have been making national headlines over the last few weeks. The CDC announced a new set of recommendations for prescribing opioids and the FDA has required new warnings on opioid medications to ensure labels include more descriptions of the risks, especially for abuse, addiction, and overdosing.
With all the news about the issues with opioids, there has been more interest in alternative strategies toward chronic pain management. In the past, comprehensive chronic pain management programs were a preferred strategy. Over the past ten years, most programs have disappeared due to a lack of insurance coverage. The cornerstone of all these programs is combining conservative use of medications, interventions, and the strong input of physical therapy and behavioral health treatments.
Different Pain Treatment Options
Physical therapy (P.T.) is one of the essential needs of everyone with pain in order to develop a daily exercise program. Further therapy can maximize overall capability and improve the ability to function. The goals of therapy are three-fold. To work on overall strengthening and core muscles, aerobic conditioning, and stretching. Muscle strength allows one to be able to hold up the body and perform activities. Core muscles give the spine the ability to be upright, and most of us do not have good strength in these groups,and with a strong core, spine pain is much better controlled. Pain is often caused by tight muscles, so stretching keeps the muscles at the right length and decreases spasms. All three activities are necessary. It is like a three legged stool; Without doing one of the three, the stool tips over. You need all three bases to be stable.
The next method is a behavioral health intervention, and the goal is to train the brain to help control the interpretation of sensory signals. The brain has incredible power to manage all the signals it receives. Pain sensations are specific sensory signals, and the interpretation of the signals can be consciously modified. Normally the brain would just read these sensory signals as painful. If the brain is receiving many painful sensory signals, a short circuit can occur and the pain can become centrally amplified and intensified. Using techniques taught by psychologists, one can learn to modify the perception of the pain signals and essentially ignore them. Multiple different techniques have been used successfully including progressive relaxation, self-hypnosis, mindfulness, cognitive behavioral therapy and distraction. Again, to be successful with any of these therapies, one has to be interested and willing to put in the time and effort to make the techniques work.
Acute and chronic pain can be very successfully treated and managed with a variety of techniques. Opioid medications in reality are only a very small tool to control these symptoms. Controlling the opioid misuse requires patients to move beyond the want for a simple solution that takes no work. Chronic pain is not well treated with opioids for the long-term. It takes time and effort to control chronic pain, if one does not put in the work, there likely will not be a good solution.
New research published in the journal Mayo Clinic Proceedings suggests that activities like yoga, Tai Chi and other complementary health approaches may help alleviate discomfort associated with some types of chronic pain.
