pain

The Devastating Consequences of Addiction

/ Thomas Cohn, MD

pain medication addictionAddiction is one of the leading concerns for physicians in the field of pain medicine. Pain management is a broad and complex field with a range of treatments crossing many different disciplines of medicine. When pain is chronic, there is often not a magical single solution or pill. Pain is managed – it may not be cured – and the patient will have to do a significant amount of individual work and treatment to keep the pain under control.

What is Addiction?

Addiction is a disease of the brain. It is often described in terms of the “4 C’s” of behaviors that are seen.  The four C’s are:

  • Loss of Control
  • Continued Use Despite Harmful Consequences
  • Compulsion
  • Craving

The first C is for loss of control over use. One pill is not enough, and the person will take more and more until they pass out. The behavior does not stop at one episode; it continues multiple times. The second C is continuing use despite harmful consequences. An addict may be hospitalized for repeated overdoses of medication. Some people steal medications of others, or sell their medications in order to be able to afford more drugs in the future. The third C is a compulsion to use a drug.  One may not have any pain, but continues to use the drugs because they want the “high”.  The fourth C is a physical craving for the substance. If they stop the drug, they will go into a withdrawal.  They will physically shake, become nauseated and have other symptoms.

Addiction is a bio-psycho-social issue. There are multiple circumstances that surround addiction, but a big influence is a person’s environment, which may stimulate addiction. If the people you associate with and the activities they participate in promote addiction, for instance hanging out at the bar drinking every evening, addiction can occur.

If a person has family members that have an addiction issue, genetically they are also prone to the same problem. Certain chemicals to the brain also stimulate addiction. Compounds that increase dopamine levels in the brain can cause a prone person to have problems. Opioids and some antidepressants affect dopamine and taking these medications can promote problems in an at-risk individual.

Addiction Prevention

Pain medicine physicians have many solutions to pain. Pain physicians are trained to recognize which medications may lead a person towards addiction, and to spot addiction symptoms at early stages. A physician will shy away from certain medications if they see that a patient has had a problem with medication abuse in the past. Prescribing drugs that are less likely to lead to addiction is one way to prevent addiction, but there are a lot of related prevention techniques that should be discussed and implemented by your physician.

If you have ever had a problem with addiction, a wise pain physician will help you find a solution to your problem and try to avoid a new issue. Pain is difficult to treat and it will take significant effort on the part of the patient and treatment team to develop a reasonable solution over time. New discoveries will also improve management. There is hope on the horizon.

Hand Pain & Carpal Tunnel Syndrome

/ Thomas Cohn, MD

Genetic Testing PainHand pain can be caused by a number of different ailments. There are a huge number of structures in the hand that allow it to have its functional ability. The bones, joints, muscles, ligaments, tendons, and nerves all may be sources of pain. Trauma can easily damage any of these specific structures.  However, one of the most common syndromes to affect the hands is carpal tunnel syndrome.

Pressure on the median nerve in the wrist may cause pain, numbness, tingling and weakness in the hand. The median nerve and several tendons of the hand travel through a narrow space in the wrist called the carpal tunnel. The median nerve provides sensation and motor function to the thumb and first two fingers. Difficulty with pain, tingling and weakness in these fingers is often from median nerve injury in the carpal tunnel region.

Causes

The cause of carpal tunnel syndrome is pressure on the median nerve in that confined space. Swelling in the region of the wrist can cause pressure. Medical conditions such as diabetes, hypothyroid, and rheumatoid arthritis may also be causes. Obesity, hypertension, and pregnancy with fluid retention can also bring about symptoms. Even more commonly, repetitive motions of the hands and wrists, such as typing or the use of a keyboard or mouse, can cause the injury.

The diagnosis can be made by a physician exam with several tests that may reproduce pressure on the nerve and symptoms in the distribution of the median nerve. Confirmation of the diagnosis is made with electrodiagnostic testing of the median nerve and comparing it to other nerves in the hand. If the study is abnormal, the diagnosis is confirmed.

Treatment Options

Treatment of carpal tunnel syndrome depends on the severity of symptoms. Mild symptoms and changes to the median nerve are treated by reducing the repetitive activities and causes. Rest and splints are great at alleviating mild CTS cases. Moderate cases may be helped by anti-inflammatory medications and steroids with hand physical therapy. Severe cases, where significant damage has occurred to the median nerve, usually require surgery to resolve damage or prevent further damage.

The Overdose Issue: Narcotics and Benzodiazepines

/ Thomas Cohn, MD

Pain Pills KillThe recent death of actor Philip Seymour Hoffman has brought to the forefront the issue of narcotic overdose. Many of the famous actors who have died of medication overdose have done so with a whole cocktail of drugs found in their system. Many have overdosed on a combination of multiple prescription medications, street drugs and alcohol. The mixture of drugs is especially lethal, since the effect of the mixture makes many drugs more toxic. A very common mixture found in overdose cases is the combination of opioid/narcotic and benzodiazepine. The source of these medications is most often the primary care provider.

Opioids and Benzodiazepines

Opioids have a very legitimate use for the management of pain. The prescription of these medications for acute pain on a very short-term basis by primary care providers is definitely appropriate. Once pain becomes chronic, pain management becomes much more complex, and the prescription of opioid medications should be in consultation with a trained pain physician. Since there are many advanced treatments for pain, the inclusion of a pain physician will reduce the over-prescribing of opioids. Furthermore, pain physicians will be able to better monitor appropriate medication use and determine early when the medications are not advisable.

Benzodiazepines are medications used for anxiety. Short-term use of these medications for anxiety is reasonable if prescribed by a pain physician. Anxiety and depression are closely related, and if the patient is depressed, treating the condition with an anxiety medication will not help resolve the feeling of depression. Ongoing anxiety is usually a sign that the patient is depressed, and a physician should prescribe a depression medication and not a benzodiazepine.

Pain and Depression

In the brain, the centers for pain and depression are next to each other and they interact with one another. Significant pain will cause stimulation in the area that controls your mood, thus, a patient with chronic pain will often be depressed. A primary care provider will often treat individual symptoms through a combination of opioids and benzodiazepines, which is safe as long as they are taken in the recommended amount. A patient may not realize the danger of these medications and may overdose if they take too much in a short period of time or in combination with other drugs.

The other main issue is that these medications are, for the most part, widely prescribed.  These medications are available in the public, and they are being traded and sold, which opens them up for abuse. A person with an addiction has easy access to these medications either legally or on the street. Better management of patients who actually need these medications will greatly reduce the amount of medication on the street. Better education of all medical providers on pain management will also help. Experts trained in recognizing pain and depression symptoms can help decrease the amount of excessive or unnecessary pills that flood the market.

The more we know, the more we can do to help keep people safe.

Pain Injection Risks and Safety Procedures

/ Thomas Cohn, MD

Pain InjectionsMany patients with pain can benefit from various types of injections. These pain injections are preformed by interventional pain physicians who specialize in managing pain and reducing chronic aches.

Training of interventional physicians is variable; they include those trained in Anesthesia, Radiology, and Physical Medicine and Rehabilitation. A good interventional pain physician will be board certified in their specialty and have years of experience.

Types of Pain Injections

The appropriate injection will be determined once the problematic area is assessed. Most injections can be performed with minimal discomfort and will take only a few minutes once the procedure begins.

Every injection has the same four risks. They are:

Risk of Infection – The first risk is infection. Cleaning off the skin, and using sterile techniques and medications reduces this risk.

Bleeding Risks – The second risk is bleeding. If the patient does not have a bleeding disorder or is not on anticoagulation medication, then this is not a problem.

Allergic Reaction – The third risk is an allergy to a compound used with the injection. The most common is an allergic reaction to the X-ray contrast, however this risk is very small, less than the risk of being hit by lightning, and can be treated.

Needle Damage –  The largest risk is the possibility of a needle causing damage to the structure that is being treated. Damage during a spine injection to the spinal cord or to a vascular structure that may cause damage to a nerve, spine or the brain is always a concern. Risk is minimized by using real time X-ray guidance known as fluoroscopy, and by having an experienced and knowledgeable physician administer the injection.

Post-Injection Safety

Some pain clinics require all patients to have a driver for any procedure, but it usually depends on which injection you’re receiving. In the vast majority of procedures, the patient will feel the same or better shortly after receiving the injection. If the patient is nervous, I usually recommend they have someone drive them to and from the clinic, as there is little reason to compound the injection with fear. This is also a good piece of advice for anyone who will be receiving an injection for the first time. If you feel fine on the ride home from your first appointment, feel free to drive yourself to any follow-ups.

If you need help to move or drive before the procedure, it is unlikely the injection will give you the ability to do so in the immediate aftermath. In these cases, you absolutely should plan on having a driver. If you are sedated for your procedure, you’ll be required to have a driver since this definitely impairs the ability to make safe decisions behind the wheel.

After the injection is complete, the physician will likely use a local anesthesia to reduce discomfort around the injection site. This will make your drive home more comfortable, especially if you received an injection on your lower back or hips.

A good pain physician should be able to make you comfortable during the procedure. They can answer your questions and describe the procedure so you know what to expect. You should always meet the physician before the procedure so you can ask any questions you might have ahead of time.

Can Marijuana Relieve Pain?

/ Thomas Cohn, MD

MarijuanaThere is currently a raging controversy about legalizing marijuana, especially for medicinal purposes.  A few states have recently legalized it, and several other states (including Minnesota) are considering it. This article will examine the potential benefits of marijuana for managing pain.

Marijuana Compounds & Ingredients

The active ingredients in marijuana are cannaboids, and there are at least 84 different ones present in the plant.  There are also 483 known compounds in marijuana.  The main compound is THC, which has psychoactive components.  For medical purposes, it has been used and approved for glaucoma and poor appetite related to chemotherapy and cancer.  Unfortunately, there are claims about the success of the plant for many other conditions, but very little scientific support to determine the reality of these claims.

Studies have shown that marijuana has psychoactive effects, some positive, and some negative. A few of the more common effects include:

  • Heightened mood
  • Relaxation, and euphoria
  • Decreased short-term memory
  • Impaired motor skills and judgment
  • Anxiety and paranoia

Marijuana & Pain

Marijuana has been known to have some impact on pain. Some studies show its effectiveness in managing nerve pain such as:

Why it works it not understood, but there are multiple areas in pain pathways that it may modulate.

The Need for Better Research

The problem with marijuana is that there are many compounds in the plant when taken as a whole.  Some of the chemicals may be beneficial, while others may cause problems.  On a scientific basis, most medical doctors want to know the specific compounds that are effective for any condition and use just that compound.  Marijuana has 483 different compounds and at least 84 cannaboids, and the whole plant is on the “Black List” – thought to be dangerous to society.  In the United States, research on marijuana is strictly controlled.  The variety of plants grown is extremely limited by the U.S. government and the restrictions on handling the plant make good research extremely difficult.

In reality, it is likely that there are beneficial cannaboids for a variety of painful conditions.  Good research is needed to determine which compounds are effective for what conditions.  The U.S. government needs to at least legalize marijuana for medical research, and get serious about determining the real safety issues with the various compounds.  Control of marijuana for safety versus making it illegal on all fronts is wise.