1 in 4 Misuses Chronic Pain Meds

April 15, 2015 / Thomas Cohn, MD

New research published in the journal PAIN suggests that approximately 20 to 30 percent of opioids prescribed for chronic pain are misused. Additionally, the current rate of opioids addiction hovers around 10 percent.

“On average, misuse was documented in approximately one out of four or five patients and addiction in approximately one out of ten or eleven patients,” who were prescribed pain pills as part of their treatment for chronic pain, said Dr. Kevin E. Vowles and colleagues. They added that the new findings provide “updated and expanded” estimates of the opioid problem in America.

Increased Prescriptions, Increased Addictions

To see how increased opioid prescriptions have fueled pain pill addictions, researchers analyzed 38 reports to measure three separate opioid-related problems:

Misuse
Abuse
Addiction

Researchers examined documented cases of dependence, withdrawal and overdose to come to their conclusion. Opioid misuse was classified as “using opioids contrary to instructions, regardless of harmful or adverse effects.” After adjusting for variables, researchers concluded that between 21 and 29 percent of people who are prescribed opioids misuse them.

“If it is accurate that approximately one in four patients on opioids display patterns of opioid misuse, but not addiction, then perhaps more efficient targeting of treatment resources would be of benefit,” said Dr. Vowles.

As for opioid abuse, which is classified as continued opioid use with actual or potential harmful effects, researchers suggested that about 8 to 12 percent of patients abuse their medications.

Dr. Vowles and colleagues concluded by saying that physicians should seriously evaluate if a patient is a good candidate for an opioid prescription, as the dangers seem to be outweighing the benefits.

“We are not certain that the benefits derived from opioids, which are rather unclear…compensate for this additional burden to patients and health-care systems.”

Related source: Medical News Today

5 Tips To Prevent Joint Pain While Exercising

April 10, 2015 / Thomas Cohn, MD

Regular exercise is extremely important, especially if you are dealing with a pain problem. Although it can be difficult to find the motivation to work out, exercise will help build strength in your muscles and actually provide some temporary pain relief. Some people have the motivation to work out, but exercise causes their joint problems to flare up. Today, we provide five tips to help prevent joint pain during your workout.

1. Stretch – Jumping straight into your exercise routine is a quick way to trigger your joint pain. Much like a car in the winter, it takes some time for our joints to start moving fluidly. Just like it’s not good to floor it five seconds after starting your car when it’s -10 degrees outside, it’s not smart to jump on the treadmill without letting your joints warm up.

2. Switch up your routine – Try to work out different areas of the body throughout the week. Going for a run every day is fine, but you’re leaving yourself open to overuse injuries, and you’re putting a lot of stress on your feet and knees. Instead, work out your upper body on Monday and Thursday, and strive for a lower body workout on Tuesday and Friday. This gives your joints some time to recover between workouts.

3. Find what works – This may sound obvious, but find a workout that works for you. If you have joint pain in your knees, consider exercising on a stationary bike or in a pool to help with weight bearing. If your back pain flares up while biking, try going for a walk or a run. Keep a log of what works best for you so you can create a pain-free exercise routine.

4. Try alternative methods – There are plenty of ways to get your exercise in without going for a run or a swim. Some more popular alternatives for people with joint pain are yoga and Pilates. These low-impact activities help increase joint mobility and flexibility. Additionally, yoga has been shown to ease pain and swelling in people with rheumatoid arthritis. If other exercises are causing too much joint pain, give yoga or Pilates a try.

5. Don’t overdo it – The right amount of exercise if great for your body, but overdoing it can actually make pain problems work. When developing a workout plan, start slow and progressively work your way up to longer routines. Additionally, if you begin to feel pain, stop your workout or transition to a different exercise that doesn’t impact that part of your body.

Understanding Pain Centralization States

March 30, 2015 / Thomas Cohn, MD

One of the newer ideas that is gaining better understanding in the pain community is the concept of pain centralization. This is the general category that a lot of other pain problems fall under. The most common condition is Fibromyalgia, but other conditions such as TMJ, irritable bowel syndrome and some tension headaches are similar. The main characteristic is that the disturbance is processed differently by the brain, and a diffuse increase to pain fiber stimulation then occurs. There are an altering of levels of neurotransmitters affecting pain transmission.

The key finding in all the conditions characterized by centralized pain states is a significant increased sensitivity to sensory stimuli. Chronic pain is often found in multiple regions of the body over a period of time. Multiple other types of symptoms also occur including fatigue, sleep difficulties, mood changes and memory problems. Symptoms are often triggered by a stressful event, such as an infection, brain injury or trauma. Multiple discrete areas of pain are found, and can be present with other diseases such as rheumatoid/osteoarthritis and hyper-laxity conditions like Ehlers-Danlos or Marfans Syndromes.

These conditions are a continuum of pain problems starting from acute peripheral pain to chronic centralized diffuse pain. It affects from 2-8% of the population, and is about twice as common in females. There is a strong familial correlation and it can be worsened with stress and anxiety.

New Understanding of Centralized Pain

Research has now shown there are definite abnormalities present in these patients. Functional MRI scans have shown an increased connectivity in regions of the brain that sense pain signals and decreased activity in areas that inhibit signals. Along with this is a change in the balance of neurotransmitters, those that facilitate pain reception including Substance P, Glutamate, Serotonin, and Nerve Growth Factor are elevated. Those transmitters that inhibit pain are decreased, such as Norepinephrine and GABA.

Treatment of these conditions is difficult. Nothing works in everyone; it is a matter of using multiple strategies. Medications that have have proven effective include some antidepressants like tricyclic’s, cymbalta and cyclobenzaprine, and seizure medications like gabapentin and lyrica. Tramadol, low dose naltrexone and cannabinoids have shown modest benefits, but they aren’t typically as effective. What absolutely does not work and sometimes makes things worse are opioids. Other beneficial treatments with strong evidence include aerobics, strength training and cognitive behavioral therapy. There is little benefit from acupuncture, massage, chiropractic and manual therapy, and most injections including trigger points.

In a lot of chronic pain conditions, a common thread is emerging. There appears to be a short circuit in the brain and the volume control for pain sensitivity is turned to high. Normal signals become overly amplified in the brain and are considered painful. The normal ability of the brain to inhibit pain signals for the periphery is also decreased. The brain then becomes stuck in a state of hypersensitivity. The new directions of research is to find ways to correct the changes seen in these centralized pain states.

What Pain Professionals Are Saying About Marijuana

March 23, 2015 / Thomas Cohn, MD

Marijuana is a controversial topic in society. Some people want it legalized while others demonize the compound. The reality in the medical field is somewhat in the middle. The first thing that needs to be understood is that in most circumstances, medical experts are primarily interested in all the compounds in marijuana except for THC. That means most medical professionals are interested in what cannabinoids or cannabidiols (CBD) compounds are present and what medical purpose they serve. The major compound that is present in almost all available marijuana is THC, which also happens to be the compound responsible for the high one receives from marijuana.

For pain professionals, there is good understanding of the action and effects of THC. Most strains available in states that have legal marijuana, including strains that are “medicinal” in use have high amounts of THC, 10% or greater in amount, and virtually no other cannabidiols, or less than 2%. In the years of the hippie generation, the 1960’s and 1970’s, THC to CBD ratio was 1:1, and averaged 1-2%, while the really good stuff was just around 5%. Now available in legalized states, most available strains are minimum of 10% with up to 30% THC.

Medically, the best comparison of legal marijuana at this time, is to alcohol. The risk of dependence to THC is about 9%, including when using once a week (in reality this is a very strong way to become dependent), compared to alcohol which is 15%. Regular use, once a week, is known to increase depression, suicide, impulsivity, schizophrenia and psychosis, especially if use is started under the age of 20. It also leads to an 8-point loss of IQ in the young. Further, smoking does cause problems with the lungs. Recommending regular marijuana is no different for medical professionals to recommending drinking alcohol. The risks and associated problems are clearly out numbering benefits.

Need To Understand More

What we know about cannabidiols is just the beginning. In marijuana, we know there are over 100 different types. Our experience so far has found that they have some properties that may be helpful in about 30% of patients with neuropathic pain associated with MS and HIV. In low back pain, we’ve learned:

It has helped in anxiety but not with pain.

More people respond to acetaminophen then marijuana.

The future of cannabidiols is interesting for pain. It is unlikely that many professionals would be enthused to prescribe a substance that has the risk profile of THC. Once we can find the particular cannabidiols that have medical uses, it is likely that we will try to study them fully and make them commercially available for specific conditions. Cannabidiols may be helpful in the future, but we still don’t know enough right now to safely prescribe marijuana for a wide range of conditions.

Could Chili Peppers Be The Key To Chronic Pain?

March 19, 2015 / Thomas Cohn, MD

Red Hot Chili Peppers isn’t just the name of a band, it could be the key to unlocking the problem of chronic pain.

According to researchers at the Institute of Physiology of the Czech Science Academy, capsaicin receptors contained in chili peppers can help quell chronic pain. Capsaicin receptors are the part of the chili pepper that makes the food spicy.

Institute spokeswoman Diana Moosová said capsaicin plays a significant role in blocking TRPV receptors, which participate in the transfer and triggering of painful stimuli. These receptors can be activated and blocked through a variety of stimuli, one of which is hot temperatures and low pH levels. Capsaicin fits that bill perfectly.

“Our experiments have proved that the TRPV1 receptors in the central projections of neurons of spinal ganglions play an important modulation role in the transfer of information provoking pain,” said Jiří Paleček, head of the functional morphology team. “By blocking these receptors’ activity, the pathologically increased sensitivity to mechanical and temperature impulses, which is a symptom of many chronic painful conditions, is considerably decreased.”

In essence, when you eat chili peppers, the compound capsaicin causes an initial excitation of nuerons inside your body. This leads to a period of enhanced sensitivity, but as Newton Third Law taught us, for every action there is an equal and opposite reaction. The firing of these neurons is followed by a “refractory period with reduced sensitivity and, after repeated applications, persistent desensitisation,” according to a similar study.

So while peppers may cause painful flare ups in the short term, over time, they might actually help you to desensitize to chronic pain.

Related source: Oxford Medicine, Prague Post