Does Chronic Pain Increase Likelihood Of Cognitive Decline?

June 6, 2017 / Thomas Cohn, MD

Recently, a new report published in the Journal of the American Medical Association suggests that there may be a link between chronic pain and the eventual onset of cognitive issues. But do these findings really suggest that chronic pain leads to an increased risk of cognitive decline, or is there something bigger going on? We take a closer look in today’s blog.

For their study, researchers at the University of California at San Francisco decided to look at how chronic pain impacted a person’s mental health. They began by examining data collected on more than 10,000 individuals over the age of 60 who were taking part in a different nationwide study. Patients in that study were surveyed about their pain scores and cognition in 1998 and 2000. Patients were then monitored over the next decade.

Chronic Pain and Brain Health

After looking at the data at the end of the study, researchers found that individuals who said they were persistently bothered by moderate or severe pain declined 9.2 percent faster in cognitive and memory tests over the next 10 years compared to those who said they were not in pain. Moreover, patients who complained about persistent pain exhibited a 7.7 percent greater chance of developing dementia than patients who did not experience regular pain.

“A persistent report of moderate to severe pain, which may reflect chronic pain, is associated with accelerated cognitive decline and increased dementia probability in a large population-representative data set of elders,” wrote first author Elizabeth Whitlock, MD, a postdoctoral fellow in the UCSF Department of Anesthesia and Perioperative Care. “Clinicians should be aware of this association, which persisted after extensive statistical adjustment for confounding health and demographic factors. Patients reporting ongoing pain may be at higher risk for current and incident cognitive impairment and physical debility.”

Pain Can Compound Mental Health Issues

The authors go on to make another key point about the problems associated with persistent pain and the onset of cognitive problems like dementia. Since individuals with pain oftentimes take opioids or other painkillers, cognitive decline can make it difficult for the patient to remember to take their pills or to get the correct dosage, which can be downright dangerous.

“Elderly people need to maintain their cognition to stay independent,” said Whitlock. “Up to one in three older people suffer from chronic pain, so understanding the relationship between pain and cognitive decline is an important first step toward finding ways to help this population.”

However, the study says the results don’t paint a perfect picture of the link between chronic pain and cognitive decline. Since a good deal of patients are on a variety of different pain medications to help control their pain, researchers said that the pills could be contributing to dementia and other cognitive problems, and pain may not play a role.

Hopefully future studies will look closer at the role opioids may play in cognitive decline. Regardless, this study is just more proof that we need to be investing more time and energy into seriously working to find solutions to the myriad of chronic pain problems in the US and throughout the world.

Vitamin D’s Role In Controlling Chronic Pain

May 25, 2017 / Thomas Cohn, MD

When it comes to controlling chronic pain, we all know how important it is to get a restful night’s sleep, but that’s easier said than done when you’re in regular pain. However, new research suggests that adding something to the mix may help control pain and provide you with a better night’s sleep.

According to research published in the Journal of Endocrinology increasing the levels of Vitamin D in the body can help manage chronic pain conditions, including arthritis. The correlation between the sun vitamin and pain control is no secret, as previous research has suggested that the vitamin can help inhibit the body’s inflammatory response, which sometimes triggers pain sensations. Other research has shown that Vitamin D deficiency has been linked to sleep disorders, so correcting the problem may lead to a better night’s sleep, and in turn, less pain.

New Findings on Vitamin D

The newest findings regarding Vitamin D are that when used in conjunction with a good night’s sleep, it can actually make other treatment methods more effective. This means that patients who increase their levels of Vitamin D and who partake in physical therapy for their chronic pain condition may notice more pain relief than individuals who only partake in physical therapy.

“We can hypothesize that suitable vitamin D supplementation combined with sleep hygiene may optimize the therapeutic management of pain-related diseases, such as fibromyalgia,” said Dr. Monica Levy Andersen, who led the review.

They concluded that pain management specialists and primary care physicians should consider asking patients about their Vitamin D intake or begin monitoring it in order to see if increasing intake on a daily basis helps to mitigate symptoms from certain pain conditions. Now, it’s important to remember that simply taking a Vitamin D supplement isn’t going to take your pain from a level 8 to a level 2, but there’s a chance that when paired with other treatment options that it could help take your symptoms down a level or two. It’s certainly something worth exploring.

The Uphill Battle Against Chronic Pain

May 15, 2017 / Thomas Cohn, MD

On 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

May 9, 2017 / Thomas Cohn, MD

New 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

May 4, 2017 / Thomas Cohn, MD

The 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.