There Are No Magic Pills For Chronic Pain

June 10, 2016 / Thomas Cohn, MD

As we’ve said in a bunch of previous blogs, there’s no “magic pill” to cure all your symptoms associated with chronic pain. It takes hard work on the patient’s end and a medical team dedicated to finding the right solution. It’s not going to be easy, but it will be worth it.

Recently, I read a story about one family’s plight with chronic pain and felt compelled to share it. Originally posted in the New York Post, Michelle Makin pens a piece about how one family has battled through the troubles associated with chronic pain, learning the lesson we preach – that’s there’s no magic pill, but solutions are in reach.

A Daughter’s Battle Against Chronic Pain

As Veronica marks her 16th birthday this month, we are sharing an update in hopes of de-stigmatizing and demystifying life with chronic pain, fatigue and other undiagnosed chronic illnesses.

It’s been a year since Veronica lay bedridden, unable to breathe normally, felled by a mysterious combination of neurological and physiological complications that dozens of doctors couldn’t quite pinpoint. We thought we had a definitive answer when she was diagnosed with Tourette syndrome last July. But it turned out to be the tip of a medical iceberg.

Though her alarming bout with ‘‘air hunger” dissipated and she willed herself back to school part-time, she could still barely make it through each day. Despite normal blood tests, her exhaustion, brain fog, migraines and weight loss made it nearly impossible to function.

If you’ve suffered from chronic illness, you know the social ostracism that comes with it. ‘‘It’s all in your head,” ‘‘Stop being so dramatic” and ‘‘You don’t look sick” are some common responses from armchair doctors.

For teens, the isolation is wrenching. Veronica lost almost all of her ‘‘friends” last summer — too shallow or self-absorbed to care or comprehend her condition. Depression set in. We were losing her to an abyss of hopelessness.

Then came the Mayo Clinic. The renowned Rochester, Minn., practice runs a Pediatric Pain Rehabilitation Center for adolescents and young adults with chronic illnesses. It’s basically a three-week boot camp to equip young patients and their families with skills to get their lives back through cognitive-behavioral therapy, physical therapy, occupational therapy and recreational therapy.

We learned that Veronica’s basket of seemingly random co-morbidities is common among those diagnosed with dysautonomia, postural orthostatic tachycardia syndrome, hypermobility and pain-amplification syndrome. Her brain and body are wired differently; the triggers are unpredictable. We learned that the ‘‘what” of Veronica’s symptoms didn’t matter as much as the ‘‘how” to help her cope day to day.

There are no magic pills. It’s a tough-love crash course in hard work, personal responsibility and mind over matter. I’m not exaggerating when I say some patients enter the program in wheelchairs or on crutches — and leave on their own two feet with the ability to walk or even run after months or years of inactivity. The goal isn’t to eliminate pain or cure sickness, but to restore functionality.

For Veronica, exposure to and bonding with other teens saddled with similar conditions — and in some cases, much worse — was life-changing. It’s one thing to be told by a specialist ‘‘you’re not alone.” It’s another to join a family of survivors riding the chronic-illness roller coaster together.

Since completing PPRC last fall, Veronica has had more good days than bad. She didn’t let her migraines, second shoulder surgery for subluxation, severe joint pain or OCD stop her from finishing her sophomore year of high school. She has remained close to several of her fellow PPRC grads and made new friends at home.

She received a lot of help along the way. A caring counselor helped her become an athletic trainer at her school, which enabled her to rebuild her social life.

Mental-health professionals successfully treated her OCD and depression using a combination of medication and exposure therapy — an agonizing but effective treatment that required her to confront her fears. Gifted physical therapists continue to treat her joint pain and train her to manage it.

One of the most intriguing aspects of PPRC is the mandate to stop dwelling on symptoms. Talking and thinking about pain or fatigue all the time reinforces the neural pathways for pain and fatigue.

Instead, we focus on the small triumphs each day. We measure life, to borrow blogger Christine Miserandino’s famous analogy, by the spoonful: getting up on time, being able to walk on the treadmill for 10 minutes, completing simple chores, eating well, having a good laugh, breathing free and easy.

So, how’s Veronica doing? The short answer is that she’s doing — and that’s a gift we never take for granted. Happy birthday, my sweet 16 badass. Per aspera ad astra.

Opioids – Why Patients and Physicians Are Frustrated

May 25, 2016May 25, 2016 / Thomas Cohn, MD

Every 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.

Stop Telling These 3 Lies To Your Doctor

May 23, 2016 / Thomas Cohn, MD

If you’re like most Americans, odds are you bend the truth a little once you enter the doctor’s office. While it may seem harmless, lying to your doctor can have serious consequences. We all have unhealthy habits, and none of us are perfect, so we don’t expect you to eat healthy all the time and get 90 minutes of exercise each day. It’s perfectly normal to have some flaws, but when you lie to your doctor about your health habits, it only makes it harder for us to provide you with the utmost care. Here’s a look at three subjects people often lie about, and why that can be problematic.

Falsehoods in the Doctor’s Office

Here are three subjects that people often lie or bend the truth about when the topic is broached by the doctor:

1. Their Symptoms – This is especially true for chronic pain patients, but the reasons behind the lies may be different than you expect. For starters, some people with chronic pain overstate their symptoms because they are fed up with failed treatments and hope the doctor will take their concerns more seriously. Unfortunately, sometimes this leads to over-prescribing or giving harmful doses, which can lead to health issues or dependency. On the flip side, many patients don’t want to be defined by their chronic pain, so they play off symptoms like they are no big deal. This too makes it difficult for your physician to give you the best care. Great doctors will believe what you say and won’t judge you for saying them, so be open and honest about everything you’re experiencing.

2. Their Food Choices – As we alluded to above, nobody sticks to the perfect diet each and every day, and that’s fine. However, you need to be honest with your doctor about your dietary choices. Oftentimes the food we eat can affect how our bodies perceive pain. If you eat a lot of junk food or a heaping helping of spicy options, it can lead to inflammation in our joints, which may make pain worse. If your doctor can pinpoint some food choices that may be impacting your pain, this can help you get a better grip on your chronic condition. However, your doctor is not going to be able to help if you don’t open up about your regular diet.

3. Liquid Intake – Fluids are very important if you want to combat your chronic pain, but only the right ones will do the trick. Dehydration can make pain worse, so you want to make sure you’re getting plenty of water throughout the day. Most people are pretty honest about their water intake, but a liquid they often lie about is their alcohol intake. Alcohol may serve to “numb” the pain in the short-term, but it’s damaging other structures and making pain worse in the long run. Whether it’s out of embarrassment or the idea that their doctor may think less of them if they knew the extent of their drinking, many people skirt the truth when talking about alcohol intake. Your doctor isn’t going to judge you – he just wants to help get your condition under control. If you’re grossly underestimating your alcohol intake, your doctor may overlook that as a potential solution, or it could impact the effectiveness of your pain medication.

In the end, just be open and honest. We’re here to help, not to judge anyone for their lifestyle choices.

Here are the 12 Recommendations the CDC Should Have Made

May 19, 2016 / Thomas Cohn, MD

Opioids and the management of pain have been in the spotlight recently, and rightfully so. Many physicians felt like the recent CDC guidelines for doctors in regards to how they prescribe opioids for chronic pain fell short of addressing the real problem, mainly because CDC Director Tom Frieden placed the blame for the opioid addiction crisis on doctors, calling the problem “doctor driven.” Instead of a sweeping generalization saying that doctors are the problem, physicians feel that the new guidelines don’t address other complex challenges, like medical insurance coverage, legislative policies and clinical realities.

Dr. Lynn R. Webster, former president of the American Academy of Pain Medicine, opted to pen an op-ed that included 12 recommendations the CDC should have made instead of their current guidelines. Rooted in stronger evidence than many of the CDC guidelines, Webster believes these 12 recommendations would better address the problem of opioid addiction, and we tend to agree. You can see Dr. Webster’s entire piece by clicking here, or you can see the 12 recommendations below.

The following are 12 additional recommendations with a stronger evidence base than most of the CDC guidelines, and that would be far more likely to reverse the harm from opioids while not creating more suffering for people in pain. In Utah, a multipronged, state-funded program that included provider education (Pain Med 2011;12:S73-S76) with elements from the eight principles mentioned below was followed by a 28% reduction in the number of unintentional, opioid-related drug overdose deaths from 2007 to 2010, as reported by the Utah Department of Health:

1. Apply the “Eight Principles for Safer Opioid Prescribing” endorsed by the AAPM.

2. Use abuse-deterrent formulations when an extended-release opioid is indicated.

3. Remove the cap on the number of opioid-addicted people who can be treated for addiction with medications such as buprenorphine.

4. Allow nurse practitioners to prescribe medication agonist therapy for opioid addiction.

5. Recommend affordable, perhaps free, access to buprenorphine and methadone therapy in line with public policy that recognizes addiction as a disease.

6. Push U.S. and state legislatures to issue mandates to payors demanding a minimum level of benefits for patients in pain to increase coverage for evidence-based alternatives to opioids.

7. Remove methadone as a preferred opioid for pain from state formularies.

8. Ask that payors require prescribers to demonstrate methadone-specific knowledge before being allowed to prescribe methadone for chronic pain.

9. Encourage the U.S. Congress to increase funding to find safer and more-effective alternatives to opioids for the treatment of acute and chronic pain.

10. Recommend legislation for partial prescription filling for Schedule II controlled substances to reduce the quantity of unused prescription drugs.

11. Implement the National Pain Strategy as a top priority.

12. Consider prescribing naloxone with all extended-release opioid prescriptions.

Extended-Release Oxycodone Approved By FDA

April 29, 2016May 10, 2016 / Thomas Cohn, MD

The US Food and Drug Administration has approved extended-release oxycodone (Xtampza) as another option for controlling chronic pain.

The FDA gave the drug tentative approval at the end of 2015, but the agency gave extended-release oxycodone the official green light earlier this week. The pill, known as Xtampza ER, comes in the form of capsules and is intended to be taken twice-daily for patients who deal with constant or severe chronic pain.

The extended-release formula is designed in such a way that abusers are unable to get a quick high off the drug. The drug maintains the extended-release property which helps stop people from crushing, chewing or manipulating the pill to get a concentrated effect. Dr. Jeffery Judin, Director of Pain Management and Palliative Care at Englewood Hospital and Medical Center, said the drug’s design should help prevent abuse.

“Abuse-deterrent opioids are critical component to fighting the widespread national epidemic of prescription opioid abuse,” said Dr. Gudin.

The medication comes in 10 mg, 15 mg, 20 mg, 30 mg and 40 mg strength, and is expected to be launched for patient use in the United states by the middle of 2016. Side effects of the drug includes gastrointestinal distress, nausea, headache, sleepiness and stomach pain.

This drug may eventually be a viable option for someone who deals with mild to moderate chronic pain throughout the day. The extended-release formula is great because it helps prevent opioid abuse, and it can provide long lasting relief. That said, when any new drug hits the market, there needs to be careful observation to understand how it is best managed and used to control symptoms. Extended-release pills also tend to be more expensive than regular drugs and sometimes aren’t covered by insurance. We’ll keep our eye on this drug and the reports surrounding it in the coming months.