Chronic Pain – Is It Anyone’s Fault?

April 25, 2016May 10, 2016 / Thomas Cohn, MD

The epidemic of opioid abuse has been flooding the news media, and the CDC has recently published new guidelines for prescribing opioids. Advocates associated with addiction wrote the guidelines without input by those providing primary care or pain management. This has led to a very unbalanced set of recommendations. The press has also been publishing countless articles blaming medical doctors for causing the addiction crisis by overprescribing pain medication.

Unfortunately, managing pain is quite complex. In medical school, doctors are taught basic concepts of how opioids work and how long they last in the body. Beyond understanding how opioids are used to treat pain, very little else is taught in medical school or specialty training about treatment of pain. Addiction education also gets very little time in the overall training of doctors. Furthermore, it is drilled into physician’s head that one must relieve pain and suffering. Then, most medical providers naturally tend to prescribe the easiest solution, opioids.

The Blame Game

One of the largest medical problems affecting all patients is chronic pain, afflicting over a third of the population worldwide. The problem of pain far exceeds medical problems like cancer, heart disease, and diabetes. In the United States, barely 2 percent of the research dollars in medicine go to the study of pain, and there is no coordinated center in the National Institute of Health or other government agency to sponsor further investigations.

The problem of providing pain management for those suffering from chronic pain and those with expertise in this field is clear. There are millions of people, a third of the population who suffer from chronic pain. The field of pain management is very small with only a few thousand experienced providers. The tools to provide pain management are somewhat limited. One of the most effective tools for pain has been the main tool for several hundred years – opioids. It is often not the best drug for pain in many patients and situations. However there is no money available for many better treatments and research with regards to new and better tools is limited.

Insurance companies also severely limit the options. Drugs that are not addictive are often denied since the use is outside the original approval guideline set by the FDA. Other times the insurance companies will only approve drugs that are not approved FDA treatments because there is similar generic drug. Non-drug treatments like additional or long-term physical therapy, massage, or comprehensive pain management programs are also denied due to upfront costs. Thus physicians are forced into prescribing pain medications that may be addictive since better treatments are not covered by insurance.

The physician and the chronic pain patient did not cause the opioid epidemic. It is a complex problem. To solve the issues associated with pain, there needs to be better education of doctors as well as patients about management strategies. Money needs to be spent on more than treatment of addicts, but on solving the complex facets surrounding pain. Allowing pain experts to prescribe appropriate treatments including medications and comprehensive programs is a start. Research on the mechanisms of pain and how these might better be managed whether with new medications and strategies also needs to be performed. The guidelines likely will only educate people that there is an opioid problem. The solutions are much more complex than the new guidelines proposed by the CDC and written by addiction specialists who run a multi-million dollar string of treatment centers.

Pacing Yourself With Chronic Pain

April 18, 2016 / Thomas Cohn, MD

If one has chronic pain issues, sometimes life requires compromise. Our bodies change as we age. Just like a car, when we are young, not much maintenance needs to be done. As we get older, the parts become worn and it takes more work to keep us running. We can no longer just add fuel and go, we have to do routine maintenance and do special work to keep the body moving. Going full speed ahead may not be the wisest move, and slowing down might be helpful.

3 Aspects of Health and Wellness

In order to keep going, one of the most important aspects of care is to exercise. There are three components to a good program; stretching, strengthening and aerobic conditioning. Like a three legged stool, all of these components are necessary to prevent one from collapsing. When one is young, doing only one aspect may be okay, but if you have chronic pain, without all three it may not work.

Stretching – Muscle tightness and “spasms” often cause pain, so stretching of these areas significantly reduces muscle tightness and pain. Stretching often needs to be done several times a day, once should be fairly extensive, but short 30-60 seconds of isolated stretches may be extremely helpful throughout the day.

Strengthening – Strengthening is essential to maintain the body’s power and ability to perform activity. To be able perform an activity, one needs to have the muscle strength. Performing strengthening of the muscles by using exercises that push the body against gravity, or using machines, weights or bands are simple ways. Simple exercise routines can be found easily in apps for your smart phone or by searching the internet especially for the neck and low back region.

Aerobic Conditioning – The last leg of the stool is aerobic conditioning. Aerobic exercise ranges from walking, to pool exercises, to workouts on treadmills, ellipticals, or bicycles. Conditioning should be for about 30 minutes and be 4-5 times a week.

If one has chronic pain, the intensity and speed that one went at life prior to injury often needs to be decreased. Going all out at any activity often will cause more problems. Despite doing the appropriate exercise, once injured the body is often not perfect thereafter. Expecting to be able to do everything the same as what one did 20 years ago is unrealistic. Spring cleanup or housework that was once done in a single day may now require splitting up the routine over several days and paced out. It may take just a bit longer, but the job will still get done. It often does not matter what route one takes, as long as one gets to the same endpoint.

Once a new car leaves the dealer, it is always deteriorating unless it is never used. Once we reach adulthood, the body is always slowly growing older. It will never be quite the same as it once was in the past. Maintenance is always needed. Pacing ourselves through life will give us longevity. Getting to the endpoint is what is important. Speeding will garnish a ticket; more pain and will not make the journey especially enjoyable.

Chronic Pain Across America

April 15, 2016 / Thomas Cohn, MD

Chronic pain is defined as any pain that lingers for more than 12 weeks, and you may be surprised to learn that it affects more than 100 million Americans every year. As part of our effort to help spread awareness about chronic pain and how these complicated conditions are treated, we wanted to share this handy infographic we found on the web.

If you enjoy the infographic, check out some of these related articles that focus on the diagnosis and treatment of chronic pain in America!

Surgeon General Wants To Help Stop Overprescribing in Medicine

April 11, 2016April 5, 2023 / Thomas Cohn, MD

Speaking ahead of the annual meeting of the Association of Health Care Journalists, U.S. Surgeon General Vivek Murthy, MD, MBA, said that he is committed to reducing the number of prescription drug and substance abuse overdoses in the US.

As part of his effort to reduce overdoses, Murthy is reaching out to physicians and medical professionals who prescripe opioids for pain. He plans to write more than a million physicians, nurses, physicians assistants and dentists with a “personal entreaty” to change prescribing practices.

“Nurse practitioners, physicians, and dentists … they want to relieve suffering, they want to treat pain,” said Murthy. “What we have found is that many precribers were never really trained in how to treat pain safely and effectively. “That’s something we want to change.”

In his speech to the AHCJ, Murthy noted that left unchecked, opioids and prescription painkillers can lead people to search for newer, more powerful drugs, like heroin. According to Murthy, 80 percent of heroin users say their addiction began with prescription drugs.

“I see prescribers as being essential part of solution to opioid crisis,” he continued. “Unlike many other substances like heroin and other illicits, the majority of supplies of misused prescription opiates are coming from legally written prescriptions. That means doctors, dentists, nurse practitioners, and physician assistants have the power to turn the tide on the opioid epidemic by virtue of their ability to prescribe, and their ability to inform and educate patients. Our goal is to build a national movement in medicine to take on this crisis as one we’re uniquely positioned to solve as prescribers.”

To get a better idea of the scope of the problem, Murthy’s office plans to produce the office’s first-ever report on substance abuse, addiction and health.

“The goal of that is to bring together the best possible science on treatment and recovery, so we can equip practitioners, patients, and policymakers with the information they need to promote better health and treat addiction,” he said.

Also Addressing Physician Burnout

Murthy stated that opioid and substance abuse overdoses were one aspect of healthcare that he wanted to focus on, but the other topic centered around physician burnout. Physicians and individuals in the medical profession have some of the highest burnout rates of any job, and they routinely score low on tests of emotional well-being. Murthy and colleagues say the emotional drain is pushing skilled workers into other industries at a time when we need to be hiring more doctors.

My colleague Dr. Lance Silverman dives into the topic of physician burnout on his blog.

Heroin Abuse From Chronic Pain Pills

April 4, 2016May 10, 2016 / Thomas Cohn, MD

Heroin abuse used to be considered a rare problem. Over the last five years it has become a major concern, along with the abuse of prescription opioids like Percocet, Norco, oxycodone, hydromorphone and hydrocodone. When prescription drugs are hard to find or to costly, people may turn heroin since it is relatively cheap. Heroin is also becoming cheaper and more pure. It can also be deadly just like prescription opioids.

All narcotics/opioids have beneficial uses for the treatment of pain. They are only one of many tools available to treat painful conditions. All chronic users can become dependent on such medications, meaning that they will have withdrawal symptoms if they suddenly stop their use. Addiction is the use of a substance despite its harm to the person and the inability of the person to stop its use despite knowing the damage the drug is causing.

How Addiction Occurs

Narcotic addiction occurs in many different ways. Often it starts with appropriate medication use and changes to use to get high and numb the brain. Others like getting high off of recreational drugs like marijauna and move from other substances including alcohol and more potent drugs. In the United States, starting in about the late 1980’s, opioids began being pushed for the treatment of pain. Probably over 90% of all opioids used for pain in the world are used in the United States. With the abundance of drugs for pain being used, unused and stolen, supplies have flooded the streets, leading to a massive addiction problem across this country.

Heroin is a potent derivative from the opium plant that gives a person a narcotic type of high. In the 1960’s and before it was crudely derived and not very pure, and was not greatly used. More recently it is much more pure, being manufactured by drug cartels in Mexico, and now it can often be purchased for much cheaper than prescription opioids. As addicts need stronger doses of opioids to get high, they begin to substitute heroin when their drug of choice is not available. Heroin is now being found everywhere in this country, from city to suburb, urban to rural areas.

The newest problem with heroin is that it is being mixed with very potent opioids, especially fentanyl to deliver a stronger high. Unfortunately the mixing of fentanyl may be quite random, and very small amounts are 50 to 100 times more potent than most other opioids. This mixed heroin with fentanyl has now become a deadly problem on the street. If one takes their usual amount of heroin and if it also contains fentanyl, it can cause a lethal overdose. Opioids can be reversed with a drug called naloxone, but only if it is given before the opioids stop a person’s breathing.

The drug addiction crisis with opioids is a multifaceted problem. More money needs to be spent on the treatment of addiction, and managing this as an illness. But to reduce opioids overall, much more money needs to be spent on pain research to better understand all aspects of pain and to develop new and better approaches to managing and curing painful conditions.