The Uphill Battle Against Chronic Pain

Pain Pills insuranceOn Thursday May 4, 2017, a headline article in the Minneapolis StarTribune was on the effect of opioids on chronic pain. The article was written about a study at the Minneapolis VA hospital about not using opioids for patients with chronic pain. The study was done by Dr. Erin Krebs, an Internist who studied patients at the VA. The study involved two main groups of patients who all had back, hip or knee pain. One group received opioids and the other did not during a year of treatment, and both received extensive use of alternative pain management techniques.

The conclusion drawn by Dr. Krebs is that chronic pain patients do not need opioids since the non-opioid group did well with decreased pain intensity. Furthermore, Dr. Krebs, by her limited study, is implying opioids are ineffective to manage chronic pain and should not be used. This is a significant disservice to chronic pain patients and is an especially irritating claim being made by a physician who has practiced in pain management but only in an academic setting and is not even Board Certified in Pain Management.

Chronic Pain and Insurance Coverage

The first take home message for pain patients is that chronic pain is incredibly complex, opioids are only one medication management tool among many treatment options. This study is very limited, and the patient population does not truly reflect the complexity of many pain management practices with people who have multiple medical problems with multiple body locations of pain.

The patients in the study were given comprehensive and unlimited access to a number of treatments from physical therapy, psychological counseling, exercise, acupuncture, interventions and a variety of medications. In the “real” world, it often is extremely difficult to obtain insurance coverage on an ongoing basis for appropriate treatments including for anything that is not generic for medication, exercise programs, or psychological counseling (if a psychologist with interest in pain is even available).

Often the most appropriate management options for a patient are rejected by insurance companies, including a variety of interventional treatments, exercise programs, and non-narcotic medication. Proven interventions like spinal cord stimulation are rejected while the insurance companies have no problems with opioids. Patients who have failed all conventional treatments may benefit from a trial of options such as medical marijuana, and this is definitely excluded by insurance coverage.

The Complexity Of Chronic Pain

Chronic pain is not a single entity. It is a very complex outcome that is associated with multiple medical problems. Pain physicians and most doctors are not treating a single problem like osteoarthritis of the hips or knees – the main group of patients in this study by Dr. Krebs. Simple problems such as those in this study are often easily managed with a combination of conservative strategies and can oftentimes be treated quite well without opioids.

Now, most physicians are trying to avoid the use opioids for these issues when they can. Unfortunately, most physicians do not have enough training and experience in treating many of the problems that cause pain and up until recently, opioids were the easy solution to see a patient in a limited time and get them out of the office with a smile on their face. The solution to the opioid epidemic problem is much more complex then demonizing patients and a medication.

Most physicians are usually trying to do the right thing for their patients. Pain physicians are especially aware of the issues in treating these complex patients. First, coverage for alternative medical treatments for pain must be more easily approved, especially when recommended by a Board Certified specialist. Secondly, pain affects over 30 percent of the adult population and research into pain needs significant funding. Third, addiction to opioids is a separate issue beyond pain management, and needs to be treated in a different sphere, as only a small number of pain patients are addicted versus dependent on their medications. Lastly, there are multiple treatments for pain available, if alternative treatments were easily covered when recommended, less use of problematic drugs would surely occur.

If the media was more interested in telling the life of both legitimate pain patients and their treating pain physicians, a better understanding of how pain affects one’s life may occur. Too many people who have not been there are casting judgement on patients and physicians who are trying to treat a very complex problem. A third of the world population suffers from some sort of chronic pain, far exceeding the number who suffer any other medical problem, but there is hardly any money being spent on research and promoting safe management strategies. Moving forward will require less negative casting of the patients and physicians treating these problems and more investment into positive solutions.

Sleep and Caffeine May Play Key Role In Controlling Chronic Pain

sleep caffeineNew research out of Boston suggests that sleep and caffeine may play integral roles in controlling chronic pain flareups.

It’s probably not a huge surprise that sleep is beneficial for controlling chronic pain, as we’ve talked about the restorative benefits of sleep on our blog many times before, but the part about caffeine is interesting. Here’s what the researchers had to say.

Benefits of Sleep and Caffeine

For their study, researchers looked at the effects of sleep (or lack thereof) and caffeine on mice and their pain sensitivity. Researchers began by tracking normal sleep cycles and measuring brain activity, then they began to disrupt this healthy sleep cycle by giving mice toys and activities that entertained them and kept them awake (much like Netflix or our iPads do for humans).

“Mice love nesting, so when they started to get sleepy (as seen by their EEG/EMG pattern) we would give them nesting materials like a wipe or cotton ball,” says Dr. Alban Latremoliere, PhD and pain expert at Boston Children’s Hospital. “Rodents also like chewing, so we introduced a lot of activities based around chewing, for example, having to chew through something to get to a cotton ball.”

Researchers kept mice awake for up to 12 hours in one night or for six hours five nights in a row. They examined that fatigue, stress and pain sensitivity all increased during this time.

“We found that five consecutive days of moderate sleep deprivation can significantly exacerbate pain sensitivity over time in otherwise healthy mice,” says Dr. Chloe Alexandre, a sleep physiologist.

Caffeine’s Role

According to researchers, common painkillers did not help mice combat pain, and morphine was less effective in sleep-deprived mice, meaning chronic pain patients who are tired may have to up their morphine dose in order for it to be effective. However, researchers found that caffeine helped to block pain sensitivity.

This led researchers to conclude that a good night’s sleep combined with caffeine during the day (along with other good habits like regular exercise and a healthy diet) may be more effective for managing chronic pain than simply relaying on analgesic medications.

“Many patients with chronic pain suffer from poor sleep and daytime fatigue, and some pain medications themselves can contribute to these co-morbidities,” Dr. Kiran Maski, M.D. at Boston Children’s hospital who studies sleep disorders. “This study suggests a novel approach to pain management that would be relatively easy to implement in clinical care.”

Opioids and a Healthy Mindset For Managing Pain

Pain MindsetThe most common treatment option in America for individuals suffering from chronic pain is opioids or pain medications. According to statistics, the US is home to 5% of the world’s population yet we consume 80% of the world’s opiates. Our pain isn’t any different than pain felt by someone in Africa or Asia, so why do we rely so heavily on opioids?

According to Dr. Aneesh Singla, it’s because we have the wrong mindset when it comes to setting expectations for opioid effectiveness.

The Myth of Zero Pain

The Centers for Disease Control and Prevention states that the number of prescription opioids sold in the US since 1999 has quadrupled, yet the number of Americans reporting pain hasn’t changed. That’s because opioids are viewed as a solution, not as an aid to simply decrease pain while other treatments are performed. Opioids will never cure a chronic pain condition on their own, yet we expect them to rid us of all our pain. In a recent article, Dr. Singla said this problem can sometimes be traced back to the physician, who fails to explain that a chronic pain situation is not a zero sum game.

“I believe that pain is protective to us and that opiates will never cure pain 100%; so we set expectations for perhaps 50% pain relief from opiates, so that opioids are not overused in search of 100% pain relief,” said Dr. Singla. “I tell my patients that a 50% reduction in pain is a reasonable goal when treating chronic pain, and we seek this with multiple treatment options, not simply through opiates.”

There are two key takeaways from that quote. First, that the main goal of pain care treatment needs to be a reduction in pain, not its elimination. If you’ve been dealing with chronic back pain for years, it’s unreasonable to think that treatment will completely cure the problem and leave you with zero pain or discomfort, so the focus needs to be on making every day or every week less painful than the previous. The second point is that opiates alone will never solve this problem.

Opioids and Pain Expectations

We talk about pain medications on this blog and on our social channels a lot, and it’s interesting because the topic often brings out a knee-jerk response from different people. When we write articles about painkiller abuse or that pain will never be solved by a pill alone, many people are quick to defend their responsible opiate use and feel that we are attacking individuals who truly need pain pills to help them get through their day. The problem is that knee-jerk reaction couldn’t be farther from the message we’re trying to convey when talking about addiction, abuse or painkillers in general.

Opioids can be a key component to effectively managing chronic pain. We aren’t against opioids at all. What we’re trying to show in these articles is that our current views on them are misguided and that they need to be re-evaluated. It starts with the pharmaceutical companies who only care about their bottom line; It trickles down to the doctors who over-prescribe or under-educate patients on what they should expect from the opioids and how they can be used in conjunction with other treatment modalities, and it ends with the patient who decides to take an extra pill because their back is more painful than normal because they’ve skipped their last three physical therapy sessions.

Managing pain is not easy, and opioids play a vital role, but we need to do a better job of setting expectations and pairing pills with active rehab options to ensure the best results for our patients.

The Link Between Chronic Pain and Insomnia

chronic pain insomniaThe following guest article was written by Katrina Rice.

Anyone who suffers from chronic pain from health issues like rheumatoid arthritis or osteoarthritis knows the drastic effects it has on their way of living – whether it be restricted mobility, increased medical expenses or reduced social life, accomplishing tasks seem to become quite unbearable every single day. And at night, sleep is disrupted due to the aching hips, back, knees and legs.

According to medical experts, arthritis sufferers are highly likely to suffer from insomnia as well. But recent studies show that restless nights and arthritis symptoms are a “two-way street” problem. Chronic pain can lead to a lack of sleep, and sleep deprivation can make chronic pain worse.

Doctors have recently become more focused on treating insomnia to improve the health conditions of patients suffering from chronic pain. One important note to remember is pain and insomnia work in a cycle. According to Professor Alan Silman, a medical director of Arthritis Research UK, “Pain induces insomnia and insomnia induces pain”.

Arthritis and Insomnia

Osteoarthritis is the wear and tear or degradation of bone tissues whereas rheumatoid arthritis is when the immune system attacks the joints. Much of the pain patients feel is due to the inflammatory responses of their body whenever it travels to their joints. It is fully understood by experts that disrupted sleep does increase the number of inflammatory markers and further aggravates the joints.

Inflammatory compounds in the body play a vital role in sleep disturbance. This disturbance will then alter the natural cycle of hormones in the body and affect the underlying levels of inflammation. Other cytokines (pro-inflammatory messengers) may also be involved in this activity. While insomnia releases more damaging inflammatory chemicals in the body, it also means the body misses out on the opportunity to heal when sleeping. After all, sleep is the longest time when the body is at rest and has low inflammation levels. So it is really the best time for the damaged cells to heal.

Effects Of Sleep Deprivation On Chronic Pain

The most notable effect of sleep loss in chronic pain is the low production of growth hormones. The growth hormone is vital in many body processes including cell development, weight regulation of the body and tissue repair, as well as replacement of collagen and bone cells. Though the growth hormone is released in the body at any time of the day, the biggest bursts come from the moment our bodies fall into deep sleep. But if deep sleep is not achieved, the body may not produce enough growth hormones. Furthermore, lack of sleep makes patient irritable and weary – this makes them even more sensitive to pain.

There are a number of treatments and alternative remedies that can be used to help ease the pain, but NSAIDs are usually prescribed for those who experience severe pain. Other forms of treatment come in natural supplements like glucosamine, chondroitin and curcumin supplements.  Patients with osteoarthritis usually choose glucosamine, but curcumin pills are also becoming more popular among arthritis patients. As for side effects, you can easily search reviews and testimonials in Google.

The bottomline is that chronic pain sufferers are stuck in a vicious cycle and they need to get out of it. In order to help them increase their pain threshold and reduce chronic inflammation, getting enough rest is a must. Here are six tips to use to help achieve a good night’s sleep.

  • Avoid taking afternoon naps. No matter how much you want to rest, it only gives you more energy in the evening. Keep yourself occupied when you start feeling sleepy in the afternoon.
  • Use lamps with warm light instead of ceiling lights. Warm lights have a soothing effect and can help you feel calmer and sleepier.
  • Avoid coffee, tea or any caffeinated products after 3:00 p.m., and never drink alcohol after 9:00 p.m.
  • Keep your waking and bed time consistent every day. This helps your biological clock get used to the routine and will eventually follow that pattern on its own.
  • Eliminate midnight snacking.
  • Do not gain weight, and instead, try to lose more pounds. Excess body fat can put more pressure on your joints. Gaining more weight means your fat cells will expand and your body will eventually start producing more cytokines – a fuel for inflammation.

Katrina Rice is a mom and a freelance writer. She strongly believes in the concept of holistic wellness through healthy and natural living, traveling and immersing one’s self in new activities. A self-proclaimed health enthusiast, she hopes to inspire more people to turn to natural treatments in addressing health issues.

Understanding Opioids, Addiction and Naloxone

opioids safety drugsChronic pain patients have a multitude of possible treatments available for the management of symptoms. Strategies often include exercise, physical therapy, chiropractic care, massage, injections and medications. One of the more frowned upon treatments is opioids, but sometimes they are used successfully. With the current opioid crisis, many pain patients fear using them and want to be safe if they have them in their possession.

Opioid Safety

The most important rule with regards to use of any medication, especially opioids, is to never take more than what has been prescribed. Opioids can build up in the body and suddenly become deadly if too much is taken. Running out early can cause opioid withdrawal syndrome and while it is uncomfortable, it is not dangerous to your health. If you are taking opioids, expect your doctor to closely monitor your medication and behavior while taking these drugs. Since they are highly addictive and abused, most doctors will tightly control prescriptions and refills. Drug testing, opioid contracts, behavior screenings, depression screenings and monitoring of other medications are standard. Mixing of medications like sedatives, anti-anxiety treatments like benzodiazepines, and using any street drugs often will lead to ending a prescriptions for opioids, and often there is zero tolerance of any safety rules due to the extreme danger inherent with opioid misuse.

Mixing Street Drugs and Opioids

The latest step in opioid safety is the prescribing of naloxone in addition to the opioid. Naloxone is a drug that can block the opioid receptors for most opioid-type drugs, and it can prevent an accidental or purposeful overdose. In Minnesota it can be obtained at most pharmacies even without a prescription, and can be given effectively as either an injection or as an intranasal spray. Anyone who is routinely taking an opioid or has opioid medications in the home should likely have naloxone too, in case they accidentally or purposefully take too much, or someone else takes their medications. If you are on these medications, ask your doctor about having a safety prescription for naloxone.

Using street drugs for an addiction to opioids or for pain is high-risk behavior. The singer Prince was using Percocet obtained from street sources to control his hip joint pain. The Percocet he obtained had allegedly been mixed with fentanyl, which is an extremely potent opioid and caused his overdose death. If you are addicted to opioids, are using them to get high, use heroin, or have family or friends that is misusing opioids, you can obtain naloxone and this may save someone from an overdose death.

Successful Opioid Treatment

Opioids can be helpful in treating pain, but they are extremely difficult to use due their limited safety. More physicians are very reluctant to prescribe these medications and their long-term efficacy and safety is limited. More information has become available on how opioids actually tend to increase pain over time versus being helpful. Pain management specialists will work with patients to find alternative strategies to these dangerous medications.  

One last issue with regards to all medications, especially opioids, is how to dispose of unused or outdated prescriptions. In the past, medications were often flushed down the toilet or thrown out in the trash. The environment does not do well with those methods, and it tends to lead to contamination of our waterways and ground water. Freshwater fish are starting to show significant levels of some commonly disposed medications. The best way to get rid of unwanted medications is to bring them to your local police or sheriff’s department where they have disposal lock boxes. These medications then are handled as hazardous waste and usually incinerated at high temperatures to completely destroy them and turn it to relatively safe ash.

If you’re struggling with an opioid addiction or want a doctor to help get to the bottom of your pain, contact Dr. Cohn today.