Fibromyalgia: A Real Disease

August 26, 2016 / Thomas Cohn, MD

Fibromyalgia is a syndrome that causes diffuse pain throughout the body. Unfortunately, many practitioners still believe it is strictly a psychological disorder and many of the patients are faking symptoms. New research has now been finding objective changes that correlate to the symptoms in fibromyalgia. These findings however are not leading to tests to prove whether a person does or does not have the syndrome.

Diffuse whole body pain with muscle tenderness, abdominal complaints, headaches, fatigue, and sleep issues all are prominent characteristics of fibromyalgia. Currently, the diagnosis is made by history and exam of a patient, then by excluding other diseases such as diabetes, thyroid dysfunction and rheumatoid arthritis. The disease is much more common in females and first becomes symptomatic in the mid- to late-twenties but sometimes as late as the fifties to early sixties. The severity can be highly variable, from mild to disabling. Treatment is basically symptomatic at this time.

New Fibromyalgia Research

Dr. Anne Louise Oaklander of Massachusetts General Hospital studied 27 patients with fibromyalgia as diagnosed with the American College of Rheumatology criteria of the disease, and used a group of 30 matched control subjects. Skin biopsies were taken of the lower leg and 41% of the patients met the criteria of small fiber polyneuropathy. Her team also studied a group of 41 patients who had fibromyalgia begining as a juvenile, and 59% of those had small fiber polyneuropathy as diagnosed with a skin biopsy. Further study of these same patients indicate some of them appeared to have an immune component, like those with rheumatoid or lupus arthritis, and when treated similarly they improved in symptoms. Small fiber polyneuropathy is also seen in diabetes and vascular disease and is associated with the pain these patients experience. Unfortunately, the definitive test for this type of neuropathy is a biopsy (which is a removal of a small patch of skin) and microscopically examining it for nerve fiber endings, which is quite complex.

The importance of this study is that these findings indicate that there is real pathology behind fibromyalgia. It is not psychosomatic or imaginary. It also makes the disease more understandable. The small nerve fibers are those that carry pain sensations. If these fibers are abnormal, the result is pain. These fibers exist throughout the body, in the limbs one would have muscle pain, in the head one would get headaches, and in the trunk one might have stomach problems.

Small fiber neuropathy and peripheral neuropathy are currently best treated with medications that affect nerve cell function. The common medications, know as neuropathics, including gabapentin, Lyrica, Cymbalta, some other antidepressants, and a few miscellaneous medications are helpful. Opioids are very poor medications for this and help very little if at all. Fibromyalgia seems to respond in a similar way, and if it is a small fiber neuropathy, the same treatments would be beneficial.

Improving the understanding of the cause of fibromyalgia and the changes that exist in the body hopefully will lead to better treatment. Not all patients with fibromyalgia have these findings of small fiber neuropathy on biopsy. This syndrome may have different causes, and the treatment may vary due to these differences. Knowing that about half of the patients at least probably have small fiber neuropathy allows physicians to focus treatments that are effective for these problems. Further, the youngest patients with fibromyalgia commonly have immune system dysfunction and treatment for these disorders has also been showing promise. Fibromyalgia is slowly moving from a “psychological” problem to an objective medical syndrome with definitive findings.

Chronic Pain and Depression

August 17, 2016 / Thomas Cohn, MD

The majority of people will deal with chronic or nagging pain at some point in their life, and new estimates suggest that 1 in 10 adults will be diagnosed with chronic pain every year. Even though these numbers are really high, as a society, we’re not doing a very good job of solving the problem of chronic pain.

Even when chronic pain is managed and controlled, it can lead to other issues. When you’re constantly dealing with physical pain, it can be mentally and emotionally exhausting, and the same can be said in the inverse. If you aren’t in the right mindset, it can be difficult to stay active and really work towards preventing chronic pain.

Recently, a new study decided to take a closer look at the connection between chronic pain and mental health – more specifically, depression and chronic pain. For their study, researchers out of the University of Edinburgh in the United Kingdom examined physical and mental health assessments of more than 100,000 individuals.

Depression and Pain

After looking at the findings, researchers uncovered:

People who have partners with depression were more likely to experience chronic pain.

A person whose spouse was depressed had an 18.7 percent increased risk of suffering from chronic pain.

Also of note, having a parent with chronic pain increased a person’s likelihood of developing chronic pain by 38.4 percent.

“We hope our research will encourage people to think about the relationship between chronic pain and depression and whether physical and mental illnesses are as separate as some believe,” researchers wrote.

At the end of the day, this research shines a little more light on another potential avenue for chronic pain management. Sometimes we need to go beyond the root source of the pain and look at environmental and other contributing factors. If we can improve our mental health and the mental mindset of those around us, we might be able to reduce the number of people who have to battle chronic pain on a daily basis.

Clinical Trials For Chronic Pain Management

May 16, 2016 / Thomas Cohn, MD

Many patients who have chronic pain are interested in the latest research and want to be a participant in order to get the newest form of treatment. Unfortunately there are not a lot of recent trials that have advanced to the human level for pain medication. Research is also limited in novel approaches to pain. The total funding for pain research related topics is about two percent compared to the total amount of research on all medical areas, even though 30 percent of the population is dealing with pain related issues.

The truth about research is that it is very tedious. For new drugs, it usually starts with trying to find a compound that may have some modifying affect on a part of the pain pathways that we currently understand. Current studies are trying to find new pathways that impact the perception of pain in the nervous system. In reality, much of the research is still at the basic level. We can’t treat pain until we fully understand what is going on in the body when we perceive pain. From the basic science, at some point we hope to be able to find new ways and compounds to manage pain.

Chronic Pain Research Trials

When a new treatment is found, research begins on the computer with complex models to try to predict what is going to happen in living systems. If the basic research is positive, then the study of living systems can begin. Initial studies may be just in cell cultures to see if a compound is toxic. The next level may then be to try a compound out on a lab animal such as a mouse and observe if it’s safe and if it changes the animal’s response to a disease or problem. The initial process of exploration can take years, and most compounds wash out and are found to be ineffective or toxic.

If a compound finally clears all the initial hurdles, and may appear to be beneficial for humans, then clinical trials may begin. Human trials have multiple phases. Initially, they are looking at a small group of very clear cases of a problem and whether a drug is safe and is helpful over a control group. The statistics at this stage are that 1 in 30 people have a serious side effect and 1 in 10,000 dies. If the drug is found safe, trials are enlarged, and the safe and effective dose is sought out. The third phase involves an even larger group to further determine safety and make sure it actually does what it is supposed to do. In all these human trials, the subjects are usually highly selected. Subjects must only have the very specific condition and not have other medical problems.

Many patients who have chronic pain have multiple medical issues. Often, chronic pain involves multiple stimuli and causes. Pain is not a simple problem and those who have ongoing pain need to alter their manage strategies, as there is no magical solution. Expecting to join a research study as a chronic pain patient is a very limited option. Very few studies are being performed, and most have very strict criteria to become a subject.

Chronic pain is a very tough medical problem to manage. At this time there are no magic options to control pain. Often pain takes multiple strategies to manage. Constantly looking for that one pill, shot or intervention is often futile. The best solution is usually working with an experienced pain physician and developing an individualized plan that addresses your needs. It usually will not rid you of pain, but it can make life more enjoyable.

Smoking Worsens Chronic Back Pain

February 22, 2016October 25, 2017 / Thomas Cohn, MD

New findings out of the Association of Academic Physiatrists Annual Meeting revealed another reason why you shouldn’t take up smoking if you want to have a healthy body. Researchers say smoking has been linked to worsening of degenerative disc disease in the cervical spine.

Degenerative disc disease is a natural process that occurs as we age, but that doesn’t mean everyone will suffer from painful symptoms. The condition occurs as the cervical discs between our vertebrae slowly break down over decades of use. If the condition worsens too much, the jelly-like central portion of the disc can rupture, causing pain and irritating local nerves. Living a healthy lifestyle can help prevent a speedy degeneration of your discs.

Smoking, on the other hand, has the opposite effect. Lead researcher Dr. Mitchel Leavitt said smoking can harm the small blood vessels in your back, which can make it difficult for oxygenated blood to flow in your back, exacerbating degenerative disc disease.

“Smoking is not healthy for a person’s intervertebral discs given the risk of developing microvascular disease – a disease of the small blood vessels – due to nicotine abuse,” Dr. Leavitt said. “Intervertebral discs receive their nourishment from the microvasculature that line the endplates on either side of each disc; when these blood vessels are damaged, the discs do not receive nourishment and this may speed up the degenerative process.”

Chronic Back Pain and Smoking

To understand how smoking contributed to chronic back pain, researchers evaluated CT scans of 182 patients who did not necessarily have back pain. 34 percent of individuals identified as smokers, and five cervical discs were given a grade on a 0-3 point scale with a 3 score denoting severe disc height loss. A five-disc total score between 0-15 was assigned to each individual.

After looking at the available data, researchers found that on average, smokers scored 1-point higher on the degeneration scale compared to non-smokers.

“This is another example of the detrimental effects of smoking. Tobacco abuse is associated with a variety of diseases and death, and there are lifestyle factors associated with chronic neck pain,” said Dr. Leavitt. “Pain and spine clinics are filled with patients who suffer chronic neck and back pain, and this study provides the physician with more ammunition to use when educating them about their need to quit smoking.”

So if you want to give your lower back the best chance to avoid chronic pain from degenerative discs, give up your smoking habit.

How To Properly Dispose of Pain Pills and Opioids

February 8, 2016October 25, 2017 / Thomas Cohn, MD

Opioid abuse has become a huge problem in the United States. After many minor procedures and trauma people are prescribed pain medication. Oftentimes people have leftover pills that end up sitting around the home. This is one source of pills that may be misused or abused by others, or the patient themselves and can lead to addiction. No one usually wants to waste their medicine, but with the abuse potential and danger of these opioids, disposal then becomes an issue.

Leftover pain medications that are opioids need to be handled properly. When storing them at home, due to the street value and abusive potential, they should be kept hidden and locked away securely. One does not want these medications to ever be lost or stolen. Furthermore, easy access may allow another household member or friend the ability to take the opioids and use or abuse them. Your safety and others is dependent on keeping all your medications secure and used only according to the directions of the prescriber.

Proper Disposal

Disposal of medications has become a major problem. Most drugs, no matter the category, are considered hazardous substances. Drugs can be toxic to other people, animals and the environment. Studies of wastewater have often showed traces of a wide variety of substances from birth control hormones, to antidepressants and narcotics. The most common recommendation for drug disposal has been to flush them down the toilet. Unfortunately this has led to the spread of many compounds into the water system and the environment. A better solution for personal disposal is to crush and mix the pills with dirt or cat litter making the drug unusable and disposing with the trash.

Currently, the best option for disposal is burning the medication in a commercial incinerator. This actually destroys and fairly safely vaporizes most medications. Minnesota does have a program coordinated by local law enforcement offices to take unused prescription medications, and these are sent for hazardous waste incineration. Unfortunately this is not the most convenient system for a lot of people. Physician offices usually do not have the ability to do this but often they can add prescription medications to other drugs and materials that are sent out as hazardous waste on a very limited basis. Pharmacies and drugstores do not generally have the ability to accept returned medications.

Hopefully in the near future, Minnesota will develop a system to encourage medication return to pharmacies for disposal in a secure and proper way. A wide spread system of pharmacy return and transfer for incineration would be ideal. For this to occur, Minnesota would need to change its law and assist with the coordination of collection and proper disposal. This would be a major step forward in reducing medication available for abuse and it would lessen the toxic effects on the environment.