pain medication

9 Tips for Communicating Effectively with your Doctor

/ Thomas Cohn, MD

doctor communicationEffectively communicating with your doctor is important whenever you have an appointment.  The time during a doctor visit is important and both the patient and doctor want it to be worthwhile.  Every person has a different style of communicating.  Most doctor visits today are too short (often because doctors are overscheduled).  Because of these time limits, it is necessary for the patient to be prepared for the visit. Below are some tips for effectively communicating with your physician.

Be Concise

Remember that all healthcare providers have limited be time to be with you.  Tell the provider about the problems you are experiencing. You can leave out the details about your most recent vacation that does not pertain to the visit.

Be Honest

Do not exaggerate or lie.  If you overused your medications, tell them why it happened.  Do not lie about losing your drugs. Most doctors will know if a story does not make sense.

Don’t Leave Anything Important Out

Do not leave out important details about your back pain. If you have had multiple back surgeries, tell that to your doctor.  Also keep track of the treatments that you have tried and what did or did not help.

If you have psychological problems, such as depression, these are also important issues to bring up.  Psychological problems are just as important as physical problems, so do not forget to include these in your history if you want successful treatment.

Medications

Medications are often an important aspect of treatment.  Keep track of what you are currently taking (including dose and frequency).  Nonprescription medications are equally important since many drugs may interact with each other negatively.

Be on Time

If you want your doctor to be on time, you must be on time.  If you are going to be late, notify the doctor’s office as soon as you can.

Ask Questions

If you have questions about your treatment or problem, ask them.  Doctors try to anticipate some of the questions and answer them when they explain the treatment plan, but we are not mind readers. We are trying to determine what is wrong and what needs treatment.  If you don’t tell us what you are concerned about, we cannot fully help.

Most Visits end with a Treatment Plan

This is a joint venture between the healthcare provider and the patient to solve the patient’s problems.  If you have questions about your treatment plan, ask them.  Please follow the advice given and the plan. Picking and choosing only parts of the plan will not lead to a good relationship or a successful resolution of your problems.

Respect the Office Staff

Everyone who has pain is uncomfortable at times, but do not be abusive or rude to the office staff when you are having a bad time. We understand you want to feel better, but everyone deserves a degree of respect.  In today’s world, both patient and doctor deserve respect, if the patient shows no respect to others, it is unlikely that you will receive ongoing treatment.

Remember that not all Problems are Curable

We are listening and trying to find an effective solution that is specific for your circumstances.  It is a team effort, and the patient is the most important member of the team.  You have to be involved, not passive, and need to participate in your treatment if you expect to improve.  In pain management, you need to be both physically and psychologically involved since the brain is an equal partner in pain.

How do Pain Medications Impact your Dreams?

/ Thomas Cohn, MD

weird dreamsMany medications used in pain management have been known to cause weird dreams. Medications that tend to have some effect on the brain can also have an effect on sleep and dreams.

Antidepressants & Muscle Relaxers

The most common medications that impact dreams and sleep are probably antidepressant drugs, followed by muscle relaxers.  These medications have direct actions on the brain and nervous system, and change the balance of brain chemicals that can lead to very odd cognition and disturbing dreams.

The older tricyclic antidepressants have a positive effect on pain but have had a significant reputation for bad dreams.  Newer antidepressants impact the neurotransmitter chemical balance in the brain, and can make emotions, depression, and sleep worse if they are not the right medication for the individual.  Muscle relaxers are compounds that have similar structures to drugs used for anxiety. They can cloud thinking and negatively impact sleep.

Neuropathic Medications

Neuropathic medications are drugs often used to treat pain.  These drugs include many different classes of chemical and all directly affect the central nervous system and the brain in a variety of different ways.  For most people, if prescribed with a degree of caution these drugs can be highly effective for pain.  However, as with any medication that acts on the brain, the side effects can include an alteration of cognition and weird dreams.

At this time, it is very difficult to know if a drug will cause bad dreams without trying it.  If you have had a problem with a medication, similar drugs may cause the same type of problem and should be monitored closely.  Sudden or rapid changes in drug levels can cause some of the problems tolerating certain medications.  Often, if a new drug is started at the lowest available dose, and slowly increased, side effects can be minimized.  It is also equally important to not suddenly stop these drugs to prevent side effects.  Working with an experienced physician with regards to medications is always advisable.  If a problem does occur, ask the prescribing physician to check if there are medications interacting with each other and causing problems.

Pain Medication Tolerance vs. Addiction

/ Thomas Cohn, MD

drug tolerancePain medications such as opioids and narcotics can be very helpful at relieving and managing pain. However, if these pain drugs are used in excess they can lead to tolerance and addiction. This article will investigate the similarities and differences of drug tolerance and addiction. Are they the same? Does one lead to the other? Read on to learn more.

Pain Medication Tolerance

Drug tolerance is a state that occurs when a medication dose ceases to be effective for a person who previously found the same dose to have a therapeutic effect.  A higher dose is then required to achieve the same previous effect.  Tolerance is a common phenomenon with many medications, especially opioids and narcotics.

Enzymes that metabolize a drug become more active over time as the presence of a drug becomes routine. These enzymes clear the drug out of the body faster and, as a result, it takes more of the drug to achieve the same previous therapeutic level.

Addiction to Pain Meds

Addiction to a drug is a physical and psychological state in which a person has a loss of control in their behavior and is unable to limit the intake of a drug despite negative consequences.  In addiction, the drug provides a positive, pleasurable reward to the brain.  An addict will seek out the drug even if it is ruining their health or involves illegal activity.

Addiction is a disease of the brain. It occurs with many drugs that stimulate the dopamine reward centers and is also seen with opioid medications and alcohol.

Dependence is usually coupled with addiction. When a person is dependent on a drug, they can function normally with the medication in their system, but experience a physical disturbance when the drug is removed. Opioid withdrawal can cause:

  • Nausea
  • Vomiting
  • Diarrhea

Dependence occurs with many medications, which is why many drugs have warnings not to suddenly stop taking the medication.

The Difference Between Tolerance & Addiction

The difference between tolerance and addiction is the psychological desire for the medication that occurs with addiction.  Many drugs can develop tolerance effects.  Sometimes changing the medication to a slightly different drug that is similar or changing the dose can overcome this issue.

Addiction is an abnormal craving for the drug since it gives the person some sort of psychological pleasure, and that the person will do anything to get the drug despite the consequences.  Those who are tolerant (and not addicted) can be withdrawn from the drug and do not crave it once it is no longer available.

Tolerance to a medication does not equate to addiction.  However, a person who is tolerant to a medication can also have addiction problems to the same medication.  If you have questions, you should talk directly with your physician and be evaluated.

Uncommon Pain Medications Used to Treat Pain

/ Thomas Cohn, MD

uncommon pain medicationMany medications are used in the treatment of pain. The most common pain medications include opioids, anti-inflammatories, simple analgesics, and others. Read our previous blog for more detailed information on these common pain medications.

For many patients, these common pain medications are not effective and specialized medications are often used. These uncommon medications include seizure medications, antidepressants, and a variety of others.  These drugs are often considered neuropathic medications and are used whenever abnormal nerve function is suspected in causing pain. Read on for more detailed information about these uncommon pain meds and how they’re used in the treatment of pain.

Antidepressant Medications

Antidepressant medications are used to control neuropathic pain. Two types of antidepressants are commonly used:

  • Tri-cyclic antidepressants (TCAs). Tricyclic antidepressants include amitriptyline, Nortriptyline, and desipramine, the later two are the best tolerated and used at very low dose.  The TCAs have many side affects including dry mouth, low blood pressure, sedation, and urinary problems.
  • Serotonin/noradrenaline reuptake inhibitors (SNRIs). The newer SNRIs include Cymbalta and Savella have very few side affects.  Cymbalta is very effective in a number of neuropathic pain situations including diabetes, radiculopathy and fibromyalgia, while Savella only is known to work in fibromyalgia.

Antidepressants such as Zoloft, Prozac, and Celexa along with Effexor have no affect on pain.  These medications decrease nerve transmission and nerve sensitivity.

Seizure Medications

Seizure medications were among the first neuropathic medications.  The originals were Dilantin and Depakote, but due to their significant side affects, these are now rarely used.  Tegretol is also used rarely for similar reasons, but has been found uniquely helpful with trigeminal neuralgia.

All seizure medications work by decreasing the ability of the nerves to be active and send signals.  They can be sedating and can cause mental clouding.  The newer ones include gabapentin (Neurontin) and Lyrica. For any pain nerve associated, these medications can be very effective, and if monitored and prescribed correctly have minimal side effects.

Lidocaine Skin Patches

Lidocaine skin patches use a local anesthetic to decrease nerve sensitivity at the skin.  These patches work on a variety of painful conditions including shingles (post-herpetic neuropathy), and diabetic neuropathy.  They may be helpful in headaches, neck and low back pain.  Myofascial pain and fibromyalgia sometimes respond to lidocaine skin patches as well.

Clonidine & Tizanidine (Zanaflex)

Clonidine and tizanidine (Zanaflex) are alpha-2 adrenergic agonists, blocking certain sensory interneurons important in pain transmission.  Clonidine is normally a potent blood pressure medication, but sometimes is very effective in neuropathic pain and is sometimes even used in intrathecal pumps.   Tizanidine has properties that help with analgesia in neuropathic pain and helps with muscle spasms, and was originally developed for controlling muscle spasm in quadriplegia.

Capsaicin & Baclofen

Capsaicin is a crème derived from chili peppers used in neuropathic diabetic pain and post-herpetic neuralgia. It activates certain pain fibers on the skin.

Baclofen is an unusual medication affecting nerve receptors in the spinal cord and brainstem.  Originally, it has been for spasticity, often in paraplegia, quadriplegia, cerebral palsy, and multiple sclerosis.  It is used orally as pills and sometimes by intrathecal pump.  It can help also with neuropathic pain.

NMDA Receptor Antagonists

A final group of adjuvant pain medications are NMDA receptor antagonists.  These medications also block a set of sensory fibers and pain transmission.  Ketamine is the main drug in this category.  It can only be given by IV or intrathecal pump, and has been used in CRPS, and cancer.  It is similar to the drug LSD, and can cause hallucinations.

Common Non-Opioid Pain Medications

/ Thomas Cohn, MD

pain medsThe most common medications prescribed by primary care physicians for pain are analgesics.  They can be divided into to two main categories: opioids/narcotics and non-opioid type medications. We have discussed opioids at length in previous blogs. This article will cover common non-opioid pain medications.

Acetaminophen/Tylenol

Acetaminophen/Tylenol works for mild to moderate pain, such as headaches. It works by enhancing the body’s inhibitory pain pathways.  The maximum safe dose was considered to be 4000 mg, but data now available is questioning that level.

Breakdown products of acetaminophen can be toxic to the liver, especially when the liver has other compounds to metabolize.  Alcohol can greatly interfere with acetaminophen breakdown, and when toxic it can kill the liver, and has been found to be the most lethal nonprescription medication sold. In short, be careful when taking this medication with alcohol.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most prescribed pain medications.  Common examples include:

  • Ibuprofen
  • Naproxen
  • Aspirin
  • Diclofenac
  • Celebrex

These medications inhibit enzymes that are released from cells when they are injured and inhibit inflammation and secondarily peripheral pain receptors.  These drugs act on the “COX” enzymes.

  • COX 1 enzymes protect the gut, maintain kidney function, and cause platelets to form clots.
  • COX 2 enzymes are involved in inflammation.

Most NSAIDs are nonselective, impacting both COX 1 and2 enzymes, and therefore can cause stomach damage, bleeding and kidney problems.  NSAIDs are used for joint pain and pain after injury.

Corticosteroids

Corticosteroids are medications that include:

  • Prednisone
  • Hydrocortisone
  • Injectable steroids

These medications only work on inflammation.  They are very powerful, and can be used in a number of ways.  Topically they are used for rashes.  Orally and via injection they can bring down local or diffuse inflammation.  They have been injected in joints to bring down joint pain, and often are used by pain physicians as epidural injections to treat spinal pain causing radiculopathy.  Unfortunately, if not used with caution, they can have numerous side affects due to affecting hormone balance.

Muscle relaxers and anti-spasm medications

Muscle relaxers and anti-spasm medications are used to reduce muscle tightness.  Most of these drugs have no impact on pain, and may act by sedating a person.  These medications may help pain that is due to muscle tightness beyond what is necessary.  Some of them are very addictive, since they include Valium and similar anxiety medications. In chronic pain, most of these medications are ineffective.  Other muscle relaxers commonly used include Robaxin, Skelaxin, and Norflex.  These medications are sedating and some may be addicting, but generally have very little affect in overall pain.