There Are No Magic Pills For Chronic Pain

June 10, 2016 / Thomas Cohn, MD

As we’ve said in a bunch of previous blogs, there’s no “magic pill” to cure all your symptoms associated with chronic pain. It takes hard work on the patient’s end and a medical team dedicated to finding the right solution. It’s not going to be easy, but it will be worth it.

Recently, I read a story about one family’s plight with chronic pain and felt compelled to share it. Originally posted in the New York Post, Michelle Makin pens a piece about how one family has battled through the troubles associated with chronic pain, learning the lesson we preach – that’s there’s no magic pill, but solutions are in reach.

A Daughter’s Battle Against Chronic Pain

As Veronica marks her 16th birthday this month, we are sharing an update in hopes of de-stigmatizing and demystifying life with chronic pain, fatigue and other undiagnosed chronic illnesses.

It’s been a year since Veronica lay bedridden, unable to breathe normally, felled by a mysterious combination of neurological and physiological complications that dozens of doctors couldn’t quite pinpoint. We thought we had a definitive answer when she was diagnosed with Tourette syndrome last July. But it turned out to be the tip of a medical iceberg.

Though her alarming bout with ‘‘air hunger” dissipated and she willed herself back to school part-time, she could still barely make it through each day. Despite normal blood tests, her exhaustion, brain fog, migraines and weight loss made it nearly impossible to function.

If you’ve suffered from chronic illness, you know the social ostracism that comes with it. ‘‘It’s all in your head,” ‘‘Stop being so dramatic” and ‘‘You don’t look sick” are some common responses from armchair doctors.

For teens, the isolation is wrenching. Veronica lost almost all of her ‘‘friends” last summer — too shallow or self-absorbed to care or comprehend her condition. Depression set in. We were losing her to an abyss of hopelessness.

Then came the Mayo Clinic. The renowned Rochester, Minn., practice runs a Pediatric Pain Rehabilitation Center for adolescents and young adults with chronic illnesses. It’s basically a three-week boot camp to equip young patients and their families with skills to get their lives back through cognitive-behavioral therapy, physical therapy, occupational therapy and recreational therapy.

We learned that Veronica’s basket of seemingly random co-morbidities is common among those diagnosed with dysautonomia, postural orthostatic tachycardia syndrome, hypermobility and pain-amplification syndrome. Her brain and body are wired differently; the triggers are unpredictable. We learned that the ‘‘what” of Veronica’s symptoms didn’t matter as much as the ‘‘how” to help her cope day to day.

There are no magic pills. It’s a tough-love crash course in hard work, personal responsibility and mind over matter. I’m not exaggerating when I say some patients enter the program in wheelchairs or on crutches — and leave on their own two feet with the ability to walk or even run after months or years of inactivity. The goal isn’t to eliminate pain or cure sickness, but to restore functionality.

For Veronica, exposure to and bonding with other teens saddled with similar conditions — and in some cases, much worse — was life-changing. It’s one thing to be told by a specialist ‘‘you’re not alone.” It’s another to join a family of survivors riding the chronic-illness roller coaster together.

Since completing PPRC last fall, Veronica has had more good days than bad. She didn’t let her migraines, second shoulder surgery for subluxation, severe joint pain or OCD stop her from finishing her sophomore year of high school. She has remained close to several of her fellow PPRC grads and made new friends at home.

She received a lot of help along the way. A caring counselor helped her become an athletic trainer at her school, which enabled her to rebuild her social life.

Mental-health professionals successfully treated her OCD and depression using a combination of medication and exposure therapy — an agonizing but effective treatment that required her to confront her fears. Gifted physical therapists continue to treat her joint pain and train her to manage it.

One of the most intriguing aspects of PPRC is the mandate to stop dwelling on symptoms. Talking and thinking about pain or fatigue all the time reinforces the neural pathways for pain and fatigue.

Instead, we focus on the small triumphs each day. We measure life, to borrow blogger Christine Miserandino’s famous analogy, by the spoonful: getting up on time, being able to walk on the treadmill for 10 minutes, completing simple chores, eating well, having a good laugh, breathing free and easy.

So, how’s Veronica doing? The short answer is that she’s doing — and that’s a gift we never take for granted. Happy birthday, my sweet 16 badass. Per aspera ad astra.

Applying Pain Lessons To Our Every Day Life

June 1, 2016 / Thomas Cohn, MD

I try to skim the medical news every couple of days to see what’s making waves in the field of pain management. Most of what I see has to do with a variety of topics related to musculoskeletal medicine and pain.

A lot of articles I see have limited value to my current practice, but some topics have interest because there is science that may be important if it is applied in a more broad way. Other things are interesting because they are rooted in obvious facts.

Last week, the Star Tribune had an item on cancer prevention. JAMA Oncology had an article that 63 percent of men’s cancer and 41 percent of women’s cancer was preventable. The interesting thing was that if we just lived a healthy lifestyle, a lot of cancers would not occur. The obvious is the simple stuff, like not smoking and wearing sunscreen. The other aspects are a bit tougher, like eating healthier foods, not being obese, exercising, and sleeping adequately. It is a potent reminder of how we live life significantly impacts our overall health. The best way to cure cancer is to prevent cancer in the first place.

Another article in the paper was on baby powder causing cancer. The most common cancer was ovarian, but lung cancer may also be linked. The connection to cancer is that baby powder is a very fine particulate. It is also very similar to asbestos. If these fine particles get inside the body, they can cause immune reactions and stimulate abnormal tissue growth as well as cancer. So a supposedly harmless substance we use can cause deadly problems.

Take Away Points

There is a message here from these news pieces about cancer that applies to all of us. The first is that if we work at keeping ourselves healthy, we will have less illness and medical problems. Secondly, keeping compounds that naturally do not belong in our bodies out helps prevent cancer.

Applying this logic to pain management is natural. Let’s first look at the ideology of keeping ourselves healthy to prevent chronic pain. Exercises including stretching, strengthening and aerobically conditioning the body all help prevent pain. I used to be able to do parts of a program sporadically and function fairly well. As I have aged, consistency with a well-rounded program of exercise has been essential, as skipping days does not work well for me. Getting enough quality sleep is a problem; I have not yet focused on how I will try to improve my sleep. Eating healthy has been issue, but I am slowly changing my diet, lowering my carbohydrate intake, and concentrating on protein, vegetables, fruit and some cheese. I am trying to find a diet plan that makes sense and is sustainable.

The second point of focus is not adding things into my body that may not be healthy. That means keeping my medicine intake to what is necessary to prevent illness, such as taking cholesterol medicine (I have a familial variety of high cholesterol), and asthma medicine when needed. I keep away from addictive medicines. Overall, the most important aspect of health and pain control comes down to eating right, exercise, and good sleep. There is very little magic and a lot of personal work put in on my end, and my body thanks me for it.

Stop Telling These 3 Lies To Your Doctor

May 23, 2016 / Thomas Cohn, MD

If you’re like most Americans, odds are you bend the truth a little once you enter the doctor’s office. While it may seem harmless, lying to your doctor can have serious consequences. We all have unhealthy habits, and none of us are perfect, so we don’t expect you to eat healthy all the time and get 90 minutes of exercise each day. It’s perfectly normal to have some flaws, but when you lie to your doctor about your health habits, it only makes it harder for us to provide you with the utmost care. Here’s a look at three subjects people often lie about, and why that can be problematic.

Falsehoods in the Doctor’s Office

Here are three subjects that people often lie or bend the truth about when the topic is broached by the doctor:

1. Their Symptoms – This is especially true for chronic pain patients, but the reasons behind the lies may be different than you expect. For starters, some people with chronic pain overstate their symptoms because they are fed up with failed treatments and hope the doctor will take their concerns more seriously. Unfortunately, sometimes this leads to over-prescribing or giving harmful doses, which can lead to health issues or dependency. On the flip side, many patients don’t want to be defined by their chronic pain, so they play off symptoms like they are no big deal. This too makes it difficult for your physician to give you the best care. Great doctors will believe what you say and won’t judge you for saying them, so be open and honest about everything you’re experiencing.

2. Their Food Choices – As we alluded to above, nobody sticks to the perfect diet each and every day, and that’s fine. However, you need to be honest with your doctor about your dietary choices. Oftentimes the food we eat can affect how our bodies perceive pain. If you eat a lot of junk food or a heaping helping of spicy options, it can lead to inflammation in our joints, which may make pain worse. If your doctor can pinpoint some food choices that may be impacting your pain, this can help you get a better grip on your chronic condition. However, your doctor is not going to be able to help if you don’t open up about your regular diet.

3. Liquid Intake – Fluids are very important if you want to combat your chronic pain, but only the right ones will do the trick. Dehydration can make pain worse, so you want to make sure you’re getting plenty of water throughout the day. Most people are pretty honest about their water intake, but a liquid they often lie about is their alcohol intake. Alcohol may serve to “numb” the pain in the short-term, but it’s damaging other structures and making pain worse in the long run. Whether it’s out of embarrassment or the idea that their doctor may think less of them if they knew the extent of their drinking, many people skirt the truth when talking about alcohol intake. Your doctor isn’t going to judge you – he just wants to help get your condition under control. If you’re grossly underestimating your alcohol intake, your doctor may overlook that as a potential solution, or it could impact the effectiveness of your pain medication.

In the end, just be open and honest. We’re here to help, not to judge anyone for their lifestyle choices.

Here are the 12 Recommendations the CDC Should Have Made

May 19, 2016 / Thomas Cohn, MD

Opioids and the management of pain have been in the spotlight recently, and rightfully so. Many physicians felt like the recent CDC guidelines for doctors in regards to how they prescribe opioids for chronic pain fell short of addressing the real problem, mainly because CDC Director Tom Frieden placed the blame for the opioid addiction crisis on doctors, calling the problem “doctor driven.” Instead of a sweeping generalization saying that doctors are the problem, physicians feel that the new guidelines don’t address other complex challenges, like medical insurance coverage, legislative policies and clinical realities.

Dr. Lynn R. Webster, former president of the American Academy of Pain Medicine, opted to pen an op-ed that included 12 recommendations the CDC should have made instead of their current guidelines. Rooted in stronger evidence than many of the CDC guidelines, Webster believes these 12 recommendations would better address the problem of opioid addiction, and we tend to agree. You can see Dr. Webster’s entire piece by clicking here, or you can see the 12 recommendations below.

The following are 12 additional recommendations with a stronger evidence base than most of the CDC guidelines, and that would be far more likely to reverse the harm from opioids while not creating more suffering for people in pain. In Utah, a multipronged, state-funded program that included provider education (Pain Med 2011;12:S73-S76) with elements from the eight principles mentioned below was followed by a 28% reduction in the number of unintentional, opioid-related drug overdose deaths from 2007 to 2010, as reported by the Utah Department of Health:

1. Apply the “Eight Principles for Safer Opioid Prescribing” endorsed by the AAPM.

2. Use abuse-deterrent formulations when an extended-release opioid is indicated.

3. Remove the cap on the number of opioid-addicted people who can be treated for addiction with medications such as buprenorphine.

4. Allow nurse practitioners to prescribe medication agonist therapy for opioid addiction.

5. Recommend affordable, perhaps free, access to buprenorphine and methadone therapy in line with public policy that recognizes addiction as a disease.

6. Push U.S. and state legislatures to issue mandates to payors demanding a minimum level of benefits for patients in pain to increase coverage for evidence-based alternatives to opioids.

7. Remove methadone as a preferred opioid for pain from state formularies.

8. Ask that payors require prescribers to demonstrate methadone-specific knowledge before being allowed to prescribe methadone for chronic pain.

9. Encourage the U.S. Congress to increase funding to find safer and more-effective alternatives to opioids for the treatment of acute and chronic pain.

10. Recommend legislation for partial prescription filling for Schedule II controlled substances to reduce the quantity of unused prescription drugs.

11. Implement the National Pain Strategy as a top priority.

12. Consider prescribing naloxone with all extended-release opioid prescriptions.

Pacing Yourself With Chronic Pain

April 18, 2016 / Thomas Cohn, MD

If one has chronic pain issues, sometimes life requires compromise. Our bodies change as we age. Just like a car, when we are young, not much maintenance needs to be done. As we get older, the parts become worn and it takes more work to keep us running. We can no longer just add fuel and go, we have to do routine maintenance and do special work to keep the body moving. Going full speed ahead may not be the wisest move, and slowing down might be helpful.

3 Aspects of Health and Wellness

In order to keep going, one of the most important aspects of care is to exercise. There are three components to a good program; stretching, strengthening and aerobic conditioning. Like a three legged stool, all of these components are necessary to prevent one from collapsing. When one is young, doing only one aspect may be okay, but if you have chronic pain, without all three it may not work.

Stretching – Muscle tightness and “spasms” often cause pain, so stretching of these areas significantly reduces muscle tightness and pain. Stretching often needs to be done several times a day, once should be fairly extensive, but short 30-60 seconds of isolated stretches may be extremely helpful throughout the day.

Strengthening – Strengthening is essential to maintain the body’s power and ability to perform activity. To be able perform an activity, one needs to have the muscle strength. Performing strengthening of the muscles by using exercises that push the body against gravity, or using machines, weights or bands are simple ways. Simple exercise routines can be found easily in apps for your smart phone or by searching the internet especially for the neck and low back region.

Aerobic Conditioning – The last leg of the stool is aerobic conditioning. Aerobic exercise ranges from walking, to pool exercises, to workouts on treadmills, ellipticals, or bicycles. Conditioning should be for about 30 minutes and be 4-5 times a week.

If one has chronic pain, the intensity and speed that one went at life prior to injury often needs to be decreased. Going all out at any activity often will cause more problems. Despite doing the appropriate exercise, once injured the body is often not perfect thereafter. Expecting to be able to do everything the same as what one did 20 years ago is unrealistic. Spring cleanup or housework that was once done in a single day may now require splitting up the routine over several days and paced out. It may take just a bit longer, but the job will still get done. It often does not matter what route one takes, as long as one gets to the same endpoint.

Once a new car leaves the dealer, it is always deteriorating unless it is never used. Once we reach adulthood, the body is always slowly growing older. It will never be quite the same as it once was in the past. Maintenance is always needed. Pacing ourselves through life will give us longevity. Getting to the endpoint is what is important. Speeding will garnish a ticket; more pain and will not make the journey especially enjoyable.