Pain, The Brain, and the Emotional Link Between The Two

November 9, 2016 / Thomas Cohn, MD

The definition of pain is always worth remembering, especially when one spends their days trying to treat this vexing problem. For the record, by the International Association for the Study of Pain, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The take home message is that pain is always subjective. Pain is always considered unpleasant and therefore is also an emotional experience. The definition purposely avoids tying pain to a noxious stimuli and activity of sensory receptors for nocioception. Pain is always a psychological state.

As a specialist in medicine, learning is never done. Several weeks ago, I was again at a major national meeting. This time it was for the annual meeting for Physical Medicine and Rehabilitation, which brings together practitioners in this specialty from around the world. This is my specialty, and practitioners in this discipline have an extremely broad range of practice. One of the few common threads is we tend to treat people who have had some sort of “injury” to their body, and our goal is to restore function. Pain and the comprehensive management of the problems associated with it are always a major topic.

The Brain and The Emotional Pain Link

Pain is so complex because it is an event that occurs in the brain. If a patient is complaining of pain, one always is trying to determine what are the associated emotional components. When the symptoms have not resolved quickly with management, then the emotional components often become more important than the actual stimuli that are occurring. By the time a patient is seen by a pain specialist, the emotional components of pain are often some of the most important to treat to solve the overall problems. The hardest thing for most patients to understand is that pain is an emotional experience, and if pain is ongoing, many patients become anxious about the pain and depressed. Furthermore, if depression, anxiety, or personality issues are pre-existing conditions to pain, then treating the psychological problems often become a necessity to successfully treat pain.

In the brain, the regions that are responsible for interpretation of pain are actually in the same area as those for anxiety, stress, and sensations associated with depression. If there are a lot of signals for pain, they can secondarily stimulate stress, anxiety and depression regions. If there is significant anxiety and depression, pain often becomes intolerable. Pain and the associated emotional problems often appear inseparable. Further, many feel that if someone wants to treat the emotional aspects of pain, then it must not be real and its all in their own heads.

If the patient has ongoing issues with anxiety, stress and depression, the body interprets emotional pain as physical symptoms. Treating the peripheral issues often provides no relief of pain because there is still an emotional experience occurring. Both the patient and the physician become frustrated since the experience of pain is so complex with multiple levels of meaning. Further, addressing psychological issues that may have existed for years is often more daunting then treating a simple structural issue that caused noxious stimuli, but once the two start interacting, often they become inseparable.

Pain is an emotional experience. Treating both the emotional aspects of pain, the stress, anxiety and depression often is the only way to improve the function of a person. Having a patient recognize the importance of the emotional aspects of pain and start addressing these issues can be miraculous in successful pain management. Often the toughest discussions with a patient are how pain affects a person emotionally and the quality of their life. Recognizing stress, anxiety and depression is often equally important in effectively treating other body symptoms.

Consider Chronic Pain When Voting on Tuesday

November 7, 2016 / Thomas Cohn, MD

It is not glamorous, but voting is essential. One of the most important issues to medical practitioners is the need to maintain access to healthcare. The United States is one of the wealthiest nations in the world, but we also have one of the most expensive systems with some of the poorest outcomes. The tough decisions that would make healthcare more affordable are often blocked for ridiculous reasons, especially those protecting big business and privacy. Currently, like it or not, the biggest issue is the Affordable Care Act (ACA), known as Obamacare. Voting is critical if you want to maintain access to healthcare.

Many of those who have pain have chronic conditions, or have had injuries to the back or neck. Prior to the ACA, health insurance companies could deny care to those with a previous injury or chronic condition, or could just make insurance costs so high that it was not a feasible expense. Despite its recent problems, more people do have health insurance and costs are more affordable for those who do have chronic conditions. Without the ACA, in the past myself, and two of my kids would likely have been unable to be insured, do chronic health issues or back problems. If you have never had a health problem, insurance is easily obtainable. Now, the law requires everyone have insurance, spreading the risk pool across a wide spectrum and reducing costs. Throwing out the ACA and the guaranteed ability to be insured at a reasonable cost is not an option in life for most patients with chronic pain.

Healthcare Costs in America

The cost of the healthcare is an issue in this country. The problem is our elected representatives have no onus to develop sensible healthcare changes in our country. The first thing that is necessary is that insurance companies should be allowed to work across state lines to broaden their base of clients and lower their overall risk profile. They also should be considered basically minimal profit, such that the cost reflects the product, not the profit to investors. Second is to move to a better level of control of the drug/pharmaceutical industry. The fact that the government does not place any control on these companies have led to the outrageous charges for medications. If one buys the same drug in Mexico, India, or Canada, the cost often is 10 percent of what is paid in the United States.

Data is the best way to improve our healthcare system. The best way to improve our system is actually quite simple; every person must have a unique medical identification code, and every medical record is kept electronically in the same way in one single system. If anyone sees a doctor, every other doctor who treats that person can see what has been done and will not need to duplicate tests or services. Statistics then can be data mined for any condition and treatment and soon it would become clear to see what works and what doesn’t work for any management option. The cost should plummet once we stop repeating tests and start seeing what really works for management of various problems.

Going backwards and throwing out the ACA is not viable option for anyone who needs to see a physician regularly or who has had a chronic medical issue. Vote for those who recognize the need to maintain the ability to obtain insurance. Also, vote for those who will stand up for changes to big businesses like the insurance and pharmaceutical industry. Lastly, get over the fear of the government having access to your personal health data, if they know everything about you financially since you pay taxes, what is the difference if they are actually trying to improve your health and make the system less costly? The United States ranks about number 40 in the world for the quality of healthcare, behind many third world countries. It is time people step up an vote for leaders who will improve the quality of our lives, not the politicians’ own pocket books.

The Politics Of Pain

October 31, 2016 / Thomas Cohn, MD

The problems with opioids have been all over the news. Now it is the political season, and the politics of pain have occasionally been making news. It’s generally about how awful the pharmaceutical companies have been and how they have been behind the current problems. Whenever we try to point blame, it is worth remembering that both the problems and solutions are complex. Drug companies may have recognized the market for pain medications but without a demand for the product, even with the best sales, the problems would not have developed. Further, doctors have also been blamed, always over prescribing pain medications.

The treatments for pain are as varied as the causes, as there is not a single treatment that works for all. Unfortunately, the culture in the U.S. often wants a quick fix, and if a pill helps, most want that solution. The harder solutions of modifying activity and exercise often have few takers. The easy solution is taking an opioid medication, and when people started to realize that it helps temporarily, many people have insisted on being prescribed these medications.

Patient rights and quality care have also been an issue in prescribing medications. Countless times patients have said it is their right to take certain medications and that if a patient has pain, it is the obligation of a healthcare provider to prescribe opioids to control their symptoms. Now with multiple sites providing online evaluations and ratings of care providers, patients dissatisfied with not being prescribed certain medications will rate a provider badly.

Prescribing Opioids

The politically correct position currently, at least for healthcare managers, politicians, and lawmakers, is to say opioids are always bad and doctors should not be prescribing these medications since they only cause addiction and death. The truth is obviously more complex, but these medications are appropriate for certain people, especially when all other treatments for pain have failed.

Years ago, the pharmaceutical companies were notably behind the push to have opioids more widely prescribed. Today, we have a better understanding of the problem with these medications, and we have some alternatives in management of pain. As cynical as it was for drug companies to push for prescribing medications, now the push for more addiction management due to opioid problems. One of the most important solutions to reducing opioid usage is to fund research for better treatment alternatives and to discover more about what causes ongoing pain.

The opioid crisis is real and it affects an alarming number. Yes, there is a need for stemming the crisis, but most of the money being proposed is to go for addiction treatment, and often people who directly profit are behind the treatment programs. Another group is pushing for legalizing marijuana for the treatment of pain, and many of those pushing the hardest will again directly profit if this is legalized. Those in the trenches trying to appropriately diagnose and treat pain, and those who are suffering from pain currently have little financial support. Even though a third of the population struggles with pain, very few resources are being targeted towards a better understanding of the mechanisms behind pain and new treatment alternatives. Pain is not glamorous, and there is no high profile celebrity pushing the cause for better treatments. Unfortunately, there are many people pushing causes related to pain for personal profit, from addiction treatment centers, pharmaceutical companies, to disingenuous entrepreneurs pushing for legalizing marijuana. When looking for solutions, they need to be based in the best interest of those in pain.

Chronic Pain Reaches The World Series

October 26, 2016February 7, 2023 / Thomas Cohn, MD

The World Series is under way, and after a Game 1 victory the Cleveland Indians are only three wins away from capturing their first championship since 1948. Their manager, Terry Francona, already has two World Series rings from his time in Boston, and while another championship would be ideal, he’s already winning another big battle in his life – his battle with chronic pain.

Francona played eight seasons in the majors before eventually transitioning to a coaching role, but his years in the big leagues took a significant toll on his body. He eventually needed a couple knee replacement operations, and complications left him in severe pain with blood clots and staph infections. He was in a great deal of chronic pain, and he eventually turned to opioids to help manage the pain. Unfortunately, like many others, what started as a technique to manage pain transitioned into a habit and later abuse.

Opening Up About Life On Painkillers

Francona opened up about his battle with painkiller abuse in a book by Dan Shaughnessy titled, “Francona: The Red Sox Years.” He said his descent into pain pills began after some complications from knee surgery.

“I think I probably should have died with all that happened,” said Francona, referencing an extended hospitalization in 2002 when he almost needed to have his leg amputated. “There were a couple of nights in the hospital where I was thinking, I can’t take this anymore. The nurses would come running in because I’d stop breathing. I was in bad shape. There were people around who did not think I was going to make it. I know I came real close to losing the leg.”

He turned to painkillers like oxycodone and Percocet to ease his discomfort as he recovered.

“I lived on it at that time,” Francona recalled in Shaugnessy’s book. “When I left the hospital, I was on heavy-duty drugs, and it was tough.”

He eventually recovered from the problemed surgery, but he still kept taking pain pills, and eventually started hoarding them because they were easier to obtain in the clubhouse. That was until one day when his daughter found a bottle at home with more than 100 Percocet pills, and she eventually convinced her father to seek professional help and to enter a confidential drug treatment program managed by Major League Baseball. That same year, after the Red Sox collapsed in the weeks leading up to the playoffs, the Boston Globe published a piece saying that “team sources expressed concern that Francona’s performance may have been affected by his use of pain medication.”

Francona was not hired back after his contract expired that year, but he’s found a home with the Indians and appears to have put his days of painkiller abuse behind him. He mentioned that he still takes a blood thinning medication, but he’s taken to other options, like exercises and compression sleeves, to improve his blood circulation so he’s not relying solely on pills.

Francona is a shining example of how easily someone can get sucked into the world of painkiller abuse, and it’s fantastic that he’s been able to get professional help and more forward with a healthier lifestyle. Win or lose in this World Series, he’s won his battle with painkiller abuse.

Pain Care – When Correlation Doesn’t Equal Causation

October 13, 2016 / Thomas Cohn, MD

It seems that there are new articles being published almost every day on the dangers of opioid pain medications. Unfortunately a lot of the studies are not very enlightening. Worse yet, some are just sensational, dumb correlations without causation.

For instance, saying obesity is correlated to eating is a great example of poor research. If you eat, of course could run the risk of being obese, but if you do not eat you could die, so obviously these findings are not very meaningful.

The latest was an article stating that a third of all adults in the United States in the last year received a prescription of opioid medication, and this is larger than the number of people who smoke cigarettes. The reason this is absolutely meaningless is this number has no real meaning. If you add up all the prescriptions for opioids written in one year and divide by the adult population, this is very likely.

Another interpretation would be that 1 in 3 people had a serious medical issue in the last year and were prescribed pain medication. Most people who have been in the hospital or emergency room for a surgery or injury may get a short-term prescription for pain medications. This is one of the very legitimate uses of these drugs, and should not be demonized. Treating acute pain aggressively at the outset has been shown to reduce the incidence of chronic pain problems. Several days of pain medications after a surgery or serious injury is appropriate but it should not be an ongoing use once the acute episode has healed.

Making Bad Connections

A third of the world population also suffers from chronic pain. A small percentage of those people are helped only by opioid medication and use these appropriately to maintain function and ability. There are many who use these medications extremely sparingly and thus continue to be highly productive in society since then they can control their symptoms. These people are dependent on these medications, they are not addicted, and oftentimes other conservative treatments have failed them. If there were better legal treatments available, many of these people would never use opioids.

Taking a prescription pain medication for a legitimate medical problem is not a significant issue or statistic. Smoking cigarettes for most is a daily addiction, affecting 25 percent of adults. It is voluntary, it causes multiple health problems, and has a huge cost to society. Comparing pain medication use to smoking is a useless correlation with no meaning.