Ibuprofen and Naproxen For Chronic Pain

November 16, 2016 / Thomas Cohn, MD

New findings on the success of certain anti-inflammatory drugs uncovered that ibuprofen may not be the best option for individuals with certain types of chronic pain.

The study took a look at the success of a couple of different anti-inflammatory medications – ibuprofen, naproxen and celecoxib – in managing chronic pain caused by inflammation. Researchers tracked thousands of patients who took one of the three medications for pain management over the course of roughly two years. The conditions being treated were most often osteoarthritis and rheumatoid arthritis.

Anti-Inflammatory Drug Findings

At the outset, researchers expected individuals in the celecoxib group would have slightly more adverse heart events, as the drug and similar drugs were believed to be linked to potential heart problems. However, not only was that not the case in this study, celecoxib actually outperformed the other two medications.

Researchers found that celecoxib did not cause more heart attacks, strokes or deaths compared to ibuprofen, and it actually exhibited lower rates of kidney problems.

“In almost every measure, ibuprofen looks worse, naproxen is intermediate and celecoxib is the best,” the study’s lead author wrote.

However, researchers cautioned against simply switching off of ibuprofen simply because of the study results. If you don’t have a preexisting heart condition or you don’t take ibuprofen on a regular basis, you shouldn’t have to worry about additional heart risks. If your current regimen is working, then discuss any potential changes with your doctor before switching up your routine.

Additionally, researchers noted that the study did not evaluate celecoxib’s effectiveness at treating chronic pain itself. Instead, they were only examining at whether or not specific anti-inflammatory drugs came with additional health risks.

Pain, The Brain, and the Emotional Link Between The Two

November 9, 2016 / Thomas Cohn, MD

The definition of pain is always worth remembering, especially when one spends their days trying to treat this vexing problem. For the record, by the International Association for the Study of Pain, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The take home message is that pain is always subjective. Pain is always considered unpleasant and therefore is also an emotional experience. The definition purposely avoids tying pain to a noxious stimuli and activity of sensory receptors for nocioception. Pain is always a psychological state.

As a specialist in medicine, learning is never done. Several weeks ago, I was again at a major national meeting. This time it was for the annual meeting for Physical Medicine and Rehabilitation, which brings together practitioners in this specialty from around the world. This is my specialty, and practitioners in this discipline have an extremely broad range of practice. One of the few common threads is we tend to treat people who have had some sort of “injury” to their body, and our goal is to restore function. Pain and the comprehensive management of the problems associated with it are always a major topic.

The Brain and The Emotional Pain Link

Pain is so complex because it is an event that occurs in the brain. If a patient is complaining of pain, one always is trying to determine what are the associated emotional components. When the symptoms have not resolved quickly with management, then the emotional components often become more important than the actual stimuli that are occurring. By the time a patient is seen by a pain specialist, the emotional components of pain are often some of the most important to treat to solve the overall problems. The hardest thing for most patients to understand is that pain is an emotional experience, and if pain is ongoing, many patients become anxious about the pain and depressed. Furthermore, if depression, anxiety, or personality issues are pre-existing conditions to pain, then treating the psychological problems often become a necessity to successfully treat pain.

In the brain, the regions that are responsible for interpretation of pain are actually in the same area as those for anxiety, stress, and sensations associated with depression. If there are a lot of signals for pain, they can secondarily stimulate stress, anxiety and depression regions. If there is significant anxiety and depression, pain often becomes intolerable. Pain and the associated emotional problems often appear inseparable. Further, many feel that if someone wants to treat the emotional aspects of pain, then it must not be real and its all in their own heads.

If the patient has ongoing issues with anxiety, stress and depression, the body interprets emotional pain as physical symptoms. Treating the peripheral issues often provides no relief of pain because there is still an emotional experience occurring. Both the patient and the physician become frustrated since the experience of pain is so complex with multiple levels of meaning. Further, addressing psychological issues that may have existed for years is often more daunting then treating a simple structural issue that caused noxious stimuli, but once the two start interacting, often they become inseparable.

Pain is an emotional experience. Treating both the emotional aspects of pain, the stress, anxiety and depression often is the only way to improve the function of a person. Having a patient recognize the importance of the emotional aspects of pain and start addressing these issues can be miraculous in successful pain management. Often the toughest discussions with a patient are how pain affects a person emotionally and the quality of their life. Recognizing stress, anxiety and depression is often equally important in effectively treating other body symptoms.

Consider Chronic Pain When Voting on Tuesday

November 7, 2016 / Thomas Cohn, MD

It is not glamorous, but voting is essential. One of the most important issues to medical practitioners is the need to maintain access to healthcare. The United States is one of the wealthiest nations in the world, but we also have one of the most expensive systems with some of the poorest outcomes. The tough decisions that would make healthcare more affordable are often blocked for ridiculous reasons, especially those protecting big business and privacy. Currently, like it or not, the biggest issue is the Affordable Care Act (ACA), known as Obamacare. Voting is critical if you want to maintain access to healthcare.

Many of those who have pain have chronic conditions, or have had injuries to the back or neck. Prior to the ACA, health insurance companies could deny care to those with a previous injury or chronic condition, or could just make insurance costs so high that it was not a feasible expense. Despite its recent problems, more people do have health insurance and costs are more affordable for those who do have chronic conditions. Without the ACA, in the past myself, and two of my kids would likely have been unable to be insured, do chronic health issues or back problems. If you have never had a health problem, insurance is easily obtainable. Now, the law requires everyone have insurance, spreading the risk pool across a wide spectrum and reducing costs. Throwing out the ACA and the guaranteed ability to be insured at a reasonable cost is not an option in life for most patients with chronic pain.

Healthcare Costs in America

The cost of the healthcare is an issue in this country. The problem is our elected representatives have no onus to develop sensible healthcare changes in our country. The first thing that is necessary is that insurance companies should be allowed to work across state lines to broaden their base of clients and lower their overall risk profile. They also should be considered basically minimal profit, such that the cost reflects the product, not the profit to investors. Second is to move to a better level of control of the drug/pharmaceutical industry. The fact that the government does not place any control on these companies have led to the outrageous charges for medications. If one buys the same drug in Mexico, India, or Canada, the cost often is 10 percent of what is paid in the United States.

Data is the best way to improve our healthcare system. The best way to improve our system is actually quite simple; every person must have a unique medical identification code, and every medical record is kept electronically in the same way in one single system. If anyone sees a doctor, every other doctor who treats that person can see what has been done and will not need to duplicate tests or services. Statistics then can be data mined for any condition and treatment and soon it would become clear to see what works and what doesn’t work for any management option. The cost should plummet once we stop repeating tests and start seeing what really works for management of various problems.

Going backwards and throwing out the ACA is not viable option for anyone who needs to see a physician regularly or who has had a chronic medical issue. Vote for those who recognize the need to maintain the ability to obtain insurance. Also, vote for those who will stand up for changes to big businesses like the insurance and pharmaceutical industry. Lastly, get over the fear of the government having access to your personal health data, if they know everything about you financially since you pay taxes, what is the difference if they are actually trying to improve your health and make the system less costly? The United States ranks about number 40 in the world for the quality of healthcare, behind many third world countries. It is time people step up an vote for leaders who will improve the quality of our lives, not the politicians’ own pocket books.

Fitness Trackers and Weight Loss

November 4, 2016November 4, 2016 / Thomas Cohn, MD

Fitness trackers like the Fitbit have been part of the health craze for several years now. Two claims are common for these devices:

That they will improve fitness levels, and;
Help people lose weight.

Recent studies have shown that these devices may improve the number of steps taken but fall short on helping patients lose weight or improve health. The study was performed at Duke-NUS Singapore Medical School. In general, knowing how many steps one takes has not translated to improved overall health.

Fitness Tracker Study

The study involved 800 adults, divided into four groups, and the interventions with the trackers lasted for six months. The goal was to boost activity to 50,000 to 70,000 steps a week. Three groups received trackers, and incentives to use the trackers varied and one group was a control group without the trackers. The control group was just given information on the benefit of exercise. The study lasted six months, and the groups given the trackers were successful at boosting their physical activity and maintained their activity the best at one year out. However, 90 percent of those with a tracker stopped using them by a year after the conclusion of the study. The most telling outcome was increased activity did not cause any improvements in blood pressure or weight loss.

The reality is that improved cardiovascular health and weight loss is more complex than just increasing the number of steps taken. Cardiovascular health has several components, to lower blood pressure one must have a degree of higher intensity aerobic conditioning. The heart rate must get to a high level to be effective at possibly lowering your blood pressure. Weight loss is extremely complex, and goes well beyond exercise. Fitness trackers like the Fitbit are best to be considered motivational devices. Everyone has a different reason for exercising. Some people are self motivated and just exercise because they want to and may have personal goals to achieve. Some people like to go to health clubs and find exercising a social pursuit. Others exercise for health reasons, such as controlling cardiac disease or diabetes. A fitness tracker allows some to maintain personal goals. Checking the amount of steps may keep a person going to meet their goals. However if your goal is better cardiovascular fitness or weight loss, it will take more than just walking a certain number of steps. If weight loss is a concern or cardiovascular fitness is your need, working with a physician or other professional may be beneficial for more guidance.

The Politics Of Pain

October 31, 2016 / Thomas Cohn, MD

The problems with opioids have been all over the news. Now it is the political season, and the politics of pain have occasionally been making news. It’s generally about how awful the pharmaceutical companies have been and how they have been behind the current problems. Whenever we try to point blame, it is worth remembering that both the problems and solutions are complex. Drug companies may have recognized the market for pain medications but without a demand for the product, even with the best sales, the problems would not have developed. Further, doctors have also been blamed, always over prescribing pain medications.

The treatments for pain are as varied as the causes, as there is not a single treatment that works for all. Unfortunately, the culture in the U.S. often wants a quick fix, and if a pill helps, most want that solution. The harder solutions of modifying activity and exercise often have few takers. The easy solution is taking an opioid medication, and when people started to realize that it helps temporarily, many people have insisted on being prescribed these medications.

Patient rights and quality care have also been an issue in prescribing medications. Countless times patients have said it is their right to take certain medications and that if a patient has pain, it is the obligation of a healthcare provider to prescribe opioids to control their symptoms. Now with multiple sites providing online evaluations and ratings of care providers, patients dissatisfied with not being prescribed certain medications will rate a provider badly.

Prescribing Opioids

The politically correct position currently, at least for healthcare managers, politicians, and lawmakers, is to say opioids are always bad and doctors should not be prescribing these medications since they only cause addiction and death. The truth is obviously more complex, but these medications are appropriate for certain people, especially when all other treatments for pain have failed.

Years ago, the pharmaceutical companies were notably behind the push to have opioids more widely prescribed. Today, we have a better understanding of the problem with these medications, and we have some alternatives in management of pain. As cynical as it was for drug companies to push for prescribing medications, now the push for more addiction management due to opioid problems. One of the most important solutions to reducing opioid usage is to fund research for better treatment alternatives and to discover more about what causes ongoing pain.

The opioid crisis is real and it affects an alarming number. Yes, there is a need for stemming the crisis, but most of the money being proposed is to go for addiction treatment, and often people who directly profit are behind the treatment programs. Another group is pushing for legalizing marijuana for the treatment of pain, and many of those pushing the hardest will again directly profit if this is legalized. Those in the trenches trying to appropriately diagnose and treat pain, and those who are suffering from pain currently have little financial support. Even though a third of the population struggles with pain, very few resources are being targeted towards a better understanding of the mechanisms behind pain and new treatment alternatives. Pain is not glamorous, and there is no high profile celebrity pushing the cause for better treatments. Unfortunately, there are many people pushing causes related to pain for personal profit, from addiction treatment centers, pharmaceutical companies, to disingenuous entrepreneurs pushing for legalizing marijuana. When looking for solutions, they need to be based in the best interest of those in pain.