Pain Management for Senior Citizens

November 3, 2014 / Thomas Cohn, MD

A recent article in the latest edition of the Journal of the American Medical Association discusses the problems with opioids and the elderly. The article discusses the fact that there has been a large increase in hospitalizations tied to the usage of these medications. The problems are multifaceted, as overuse, over reliance and lack of understanding all lead to health problems in the elderly.

Chronic pain is a major health issue, especially as we grow older. Recent studies have shown that about a third of the population suffers from some sort of medical problem that causes chronic pain. Unfortunately, the science of treating pain has not kept up with the recognition of it as a problem. Furthermore, we have recognized the risks of acetaminophen with liver toxicity and the dangers of anti-inflammatories like ibuprofen with the kidneys. With the dangers of those drugs, opioid use has been pushed.

The practice guidelines for the management of pain from the American Geriatric Society has actually promoted the use of opioids for moderate to severe pain. They have discouraged the use of stand-by drugs like acetaminophen and anti-inflammatories. Unfortunately, in the elderly, opioids are very difficult to use safely, especially if one is not an experienced clinician. Senior citizens tend to be much more sensitive to medications, and “regular” doses can cause falls, liver toxicity, cardiac toxicity and cognitive impairment. Furthermore, half of the authors of the guidelines had significant financial ties to manufactures of opioids.

Careful Management

Chronic pain in the elderly, as it is in any other group of patients, is not one size fits all solution. Pain is a complex entity and needs to be treated as such. The multiple causes of the pain need to be diagnosed and each contributing factor should be treated with the most appropriate management option. Joint related pain may be best treated with an anti-inflammatory medication while neuropathic pain may need a seizure type drug. Furthermore, depression may be a factor and that may also need separate treatment since pain and depression centers in the brain are closely situated.

Management of pain is complex. Careful determination of all the causes and selective treatment by a skilled and knowledgeable practitioner is beneficial. More research on pain and treatment is necessary since the problem is so large. Pain specialists are often the experts needed to find the best management options.

Pain Prevalence in America

October 29, 2014 / Thomas Cohn, MD

A recent report from the Institute of Medicine described in an article in the Journal of the American Medical Association has discussed the magnitude of the prevalence of pain in the US. The article states that about 100 million Americans suffer from chronic pain. This is pain that lasts weeks or months; Not bumps and bruises that resolve quickly.

The data used to determine this number is based on a number of techniques to review medical information and was assembled at least in part by the National Center for Health Statistics. If you have chronic pain, you are not alone. These numbers are also consistent with research from the World Health Organization that estimates that 37% of the population in developed countries has chronic pain.

The prevalence estimates of adults for selected pain conditions were also listed in the report. Moderate pain affected 10% of the population, or 21.3 million people. Another 11% had severe pain, effecting about 22.5 million. Joint pain affects about 33% of the population. Arthritis of all types affects 25% of the population. Functional disability affects 12% of the population. The authors also noted that the study did not include children, military personnel, people in prison, and those in long-term care facilities.

The report mainly concentrates on the fact that there is a huge number of people who deal with chronic pain on a daily basis. However, we do not have good information of the impact of pain on employment, disability, functional abilities and the direct and indirect costs. In general, there is minimal information available on the cost of pain, in terms of medical expenditures and secondary costs to society.

The report makes a strong recommendation for a national, population-level prevention and management strategy. A public health approach to pain management is necessary, including prevention, care, education and research. It also recognized the serious problems associated with opioid use and diversion, and the need to develop a better approach to pain care that is beyond the use of such addictive medication.

As noted in this article, reducing the effects of pain and its associated morbidities with regards to the quality of life will require a cultural transformation. Chronic pain itself may need to be considered as disease. The extent of this disease affects about 4 out of every 10 adults in developed nations worldwide. Patients and healthcare providers need to recognize the problem and develop improved treatment and management solutions for the complex condition.

Is Chronic Pain Inherited?

October 22, 2014 / Thomas Cohn, MD

A new study out of Norway suggests that children of parents who have chronic musculoskeletal pain have a higher risk for developing similar pain. The study started in 1984 and used health surveys to determine if age, sex or other factors contributed to musculoskeletal pain. The findings suggest that children of parents with pain had a 20-40 percent increased risk of developing similar pain. Specific genetic variables and environmental factors were not isolated, but the important conclusion is there is a relationship between parents with pain and a subsequent occurrence in their children.

As a practitioner in pain, this study has several implications. Pain and the subsequent behaviors often do run in families. Parents can easily model behavior such that children learn the same strategies in coping with adverse events. The behaviors learned are sometimes good, but also can be maladaptive. If parents tend to complain and do not take responsibility for their actions, children often show the same behavior. Genetics also play a role, and psychological problems such as depression, which has a high correlation to pain, also has a high genetic component. Many diseases correlated to pain like rheumatoid arthritis and some aspects of osteoarthritis have genetic components.

Parents often have an influence on good and bad health habits in their children, such as diet, exercise or if the child becomes a smoker. A lack of exercise often contributes to pain and increased incident of injuries due to a lack of muscle condition. Obesity is positively linked to chronic pain, and the eating habits of parents are often taught to their children and they are at an increased risk of becoming obese. Smoking is also positively linked to pain, and parents who smoke often have children who smoke.

Whether the link between parents and children and both having pain is due to genetic or environmental factors is unclear. Both genetic and environmental factors likely play a role, but to what extent is unknown. Some pain is probably genetic, but a lot of pain could be a result of negative learned health behaviors. The long and short of it is, make healthy choices for yourself and for your children.

The Risks of Complications From Pain Injections

October 20, 2014 / Thomas Cohn, MD

Every action has risks and benefits. In the medical world, every medication has risks, and sometimes the risk of doing nothing is worse than treating the issue. This is especially true in many medical conditions such as hypertension or diabetes. The same goes for pain medicine. There are risks and benefits for everything that is done, but there are also many alternatives to treat any particular problem. Choosing the right treatment plan is an individualized decision between the patient and the physician.

Interventional pain treatment has risks and benefits, and there are well known complications from most procedures. The main risks are fairly clear, but there are four complications that arise more often than others. They are:

Infection. Whenever the skin is broken, this is a possibility, and is prevented usually by cleansing the skin with alcohol or special antibacterial soap.

Bleeding. Most procedures are done with a fairly small needle. If a patient is not on a blood thinner or does not have a bleeding disorder, this complication is uncommon.

Allergic reaction. This is rare, but if it does occur, it can be treated.

Damage to another critical structure with the interventional equipment. This can usually be avoided by taking routine precautions and by having a skilled physician preform the procedure.

Complication Likelihood

Recently, a study was done recording complications from many of the common injection type procedures preformed by pain physicians. Almost 20,000 procedures were done, and the rate of anything abnormal was found to be less than two percent. The most common minor problem was a vasovagal reaction (Feeling like one is going to faint). The next most common issue was an increase in pain, which resulted in the procedure being stopped prior to completion. Other notable problems included one serious allergic reaction (1 in 20,000), and 10 dural punctures (1 in 2000). There were no major complications resulting in any serious injury or permanent neurologic damage.

Treating pain is a complex problem. For every problem, there are often multiple options and pathways to improvement. Sometimes, the pain physician may suggest an interventional procedure to help one improve function and decrease pain. As noted above, the risks of most of these procedures are extremely small. The most common issues are feeling faint or light headed and having increased pain during the procedure and temporary increased symptoms. An experienced interventionalist will make the procedure beneficial and minimize risk to the patient.

Theramine and Chronic Pain Prevention

October 15, 2014 / Thomas Cohn, MD

Thermaine is a relatively new drug that is being used to treat chronic pain, typically in individuals suffering from low back pain. Theramine is a proprietary formulation of neurotransmitters, amino acids, antioxidants, neuromodulators, anti-inflammatory and immunomodulatory peptides, whey protein, and adenosinsine antagonists.

It is a trademarked formulation of compounds and considered a food supplement. It was designed to be used to treat a variety of pain syndromes, including acute and chronic pain. Each ingredient in the capsule was determined based on its ability to modulate an aspect of the sensory processes involved with pain signals. It is meant to moderate the effects of inflammation on the pain response. All of the ingredients that make up the compound have been approved by the Food and Drug Administration.

A recent article in the American Journal of Therapeutics suggested that Theramine was more effective than low dose ibuprofen for chronic low back pain. It was found to effective in decreasing both pain and inflammation in chronic low back pain sufferers. Part of the theory about why this supplement is helpful because it is thought that the chemicals present help restore certain compounds that are depleted or not present in individuals suffering form chronic pain.

It’s effectiveness means that the product is not cheap. A simple online search reveals that a one month supply costs over $300. If one has money to spare, it may be a safe consideration. It appears to be safe, with reasonable science behind its development. For a greater look into Theramine and its inner workings, check out this website.