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.

Can Pain be all in your Head?

/ Thomas Cohn, MD

pain in the headMany patients wonder if their pain is all imagined and in their head.  Pain is a very complex problem.  Often the source is hard to determine and treatment is not totally effective.  The definition of pain also gives us a clue of the complexity.  The IASP, an international medical group that studies pain, defines pain as:

“An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Emotions are from the brain – therefore pain can be “all in your head” at times.

The Brain & Pain

The brain is the master of all sensory signals.  The role of the brain is to receive, interpret, and then provide a response to signals received.  Some sensory signals are from pain fibers in the periphery of the body, they travel to the brain, and the signals are then decoded in several different regions of the brain.  Acute pain sensory signals are often interpreted correctly and the body and brain can handle an appropriate response.  The body handles chronic pain signals differently.

There are multiple areas in the brain that respond to pain sensory signals.  When pain is chronic, there is an actual increase in pain sensory signals going to the brain and an increase in brain sensitivity to these signals.  Furthermore, areas of the brain that are near pain responders become stimulated, including emotional areas of the brain responsible for depression.  A short circuit occurs and emotions are often perceived as pain.  Treatment of pain that is it stimulated by emotions (such as depression) centers on successful treatment of the depression.

A Short Circuit in the Brain

There are also a few central pain syndrome triggered by damage to the spine or brain causing the brain to perceive pain, sometimes whole body pain, when there is no other injury.  The pain is very real, but the source is basically a short circuit in the wiring to the brain or within the brain.  Treatment of these problems is extremely difficult. Minimal pain medications help and central neuropathic medications like drugs for seizures are often the most helpful.

When pain is all “in the head,” there is likely an emotional component to the pain signals.  Chronic pain often stimulates this problem.  Treatments of the emotional components of pain are often as important or more important than medications for the pain itself.  Pain is complex, and treating all components is necessary, and since pain entails emotions, these must be treated equally.

Neck Pain – Nerve Irritation, Whiplash, & Muscle Spasms

/ Thomas Cohn, MD

neck pain x-rayThis is part two of our blog mini-series on Neck Pain. You can find the first installment here. Our first post focused on chronic neck pain causes and treatments at a general level. c

Nerve Irritation

Cervical discs in the neck that cause nerve irritation can have both axial pain or pain in the arms.  MRI or CT scans are necessary to see these structures and determine the severity of the changes.  If the changes have been slow degeneration, the body can often adapt to them even if there is severe narrowing where the nerves travel.  Treatment often includes cervical epidural steroid injections to calm spine irritation and inflammation.  Controlling nerve sensitivity can be helped by medications known as neuropathics that include some seizure drugs and antidepressants.  Physical therapy and behavioral health interventions are also beneficial.

Whiplash

Whiplash and cervical facets cause pain from abnormal movement or sensitivity of the joints between each of the cervical vertebra.  Patterns of pain from these joints are fairly specific, and are mostly along the spine from the base of the skull, out to the shoulders, and down through the shoulder blades.  Treatment ranges from heat and ice, massage, manipulation, acupuncture, anti-inflammatory medications, traction and physical therapy, to injections.  Most pain responds to simple things, about 5-10 percent need the more complex treatment such as steroid injections, nerve blocks, and radiofrequency lesioning to prevent pain feedback from the joints.

Muscle Spasms

Muscle spasms of the neck can be primary problems, or secondary to a deeper problem in the spine.  If the spasms are chronic, it is more likely they are due to a deeper structure like the facets or discs, and treating those problems will significantly improve the spasms.  At times, spasms continue despite treating all other problems and pain is chronic. For this type of problem, chronic use of muscle relaxers along with therapy is often necessary.  Botox, which is a medication that is injected into the muscle to partly paralyze it for several months, is also helpful.

Neck pain that is chronic and ongoing is a difficult problem to treat due to its many causes.  A Physical Medicine pain specialist can be especially helpful in the diagnosis and management of the problem.  They often can determine all the factors that are contributing to ongoing issues and develop a comprehensive strategy to manage the symptoms.  Treatment often is not simple, but working with an experienced specialist can help with a successful long-term solution to a frustrating problem.

Neck Pain Causes & Treatment Options

/ Thomas Cohn, MD

chronic neck painThe cervical spine and neck can often cause pain, especially as the body ages. There are seven cervical vertebras with multiple joints contributing to the core structure.  The spine and multiple nerves traverse the region.  Multiple muscles and ligaments contribute to motion and stability.

On top of the neck is the head with all its structures and below are the torso, shoulders and arms.  Pain perceived as from the neck may come from any of the structures in the region.  All pain fibers from the mid shoulder blade and chest level on up travel through the same area of the brain. As a result, the brain can have difficulties in determining the exact location that is generating the pain signals.

Acute Neck Pain

Neck pain may be described as headaches that originate in the neck or it may be specific pain in the neck.  Acute pain may be as simple as a muscle strain if there was no significant trauma.  More chronic pain often comes from a deeper structure in the neck, such as:

  • Cervical facet joints
  • Cervical discs
  • Cervical nerve irritation
  • Degenerative changes irritating the nerves

Shoulder problems can also be misinterpreted as neck pain.

Chronic Neck Pain Causes

The most common causes of chronic neck pain are cervical facets joints, cervical degenerative changes, discs irritating nerves in the neck, and secondary muscle spasms in the neck.  Trauma over time often contributes to the changes that have caused pain.  The result is felt as neck pain, muscle tightness, and decreased range of motion of the neck.  Determining the cause starts with a good history and physical exam.  If simple solutions such as exercise, massage, heat and ice, and over the counter medications have not worked, then a physical medicine pain physician would be extremely helpful in coordinating future care.

Chronic neck pain that is limiting function warrants help from an expert.  Muscle spasms and pain are the symptoms most commonly reported by patients.  The cause is often a combination of problems such as:

  • Degeneration of discs, bones, and joints
  • Nerve irritation
  • Muscles tightening to prevent further pain and movement of the head

After age 30, almost everyone will show a degree of degeneration of the cervical spine and these normal changes can also contribute to pain.

Treatment Options for Chronic Neck Pain

Treatment of neck pain starts with determining the causes, and often requires a complex plan that addresses each of the contributing factors that are maintaining the symptoms.  Chronic pain often involves multiple causes and a simple treatment is often not available.  Patient frustration is common since we all want a simple treatment.  If there are multiple structures involved and pain is chronic, expect that more than one thing will be necessary to manage the symptoms.

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.