5 Tips for Sleeping Through Pain

/ Thomas Cohn, MD

sleep through painWhen you’re in pain as the result of an injury or other condition, oftentimes the best remedy is to get plenty of rest and sleep. But sleeping through pain is easier said than done. Rolling over onto a painful back, leg, or arm can wake you up (and keep you up) in the middle of the night. More pain equals less sleep, and less sleep slows your recovery. It’s a vicious (dare I say painful) cycle.

But there are a steps you can take to help sleep soundly through the pain. Here are a few tips:

  1. Take your pain relief medications as directed, and right before bed if possible.
  2. Reduce your caffeine intake. Coffee, soda, and energy drinks are jam packed with caffeine. They are designed to keep you awake and alert. This is great if you need a pick me up at work, but not when you’re trying to sleep. If you can’t cut out the caffeine completely, try to only drink it in the morning.
  3. Cut down alcohol consumption. Many people find that a “nightcap” helps put them to sleep. While it’s true that alcohol can induce drowsiness, the sugars in alcohol are more likely to wake your body up later in the night.
  4. Get into a sleep cycle. Try to go to bed and wake up at the same times every day. This will help your body get into an internal rhythm or groove.
  5. Relax and avoid physical activity before bed. Exercising is a great way to reduce your pain, but exercising too late in the evening can keep you up and make it difficult to fall asleep.

Whether you’re dealing with chronic pain from an illness, or acute pain following an injury or surgery, getting a good night’s sleep is essential for your overall health. Follow these tips and you’ll be off to dreamland in no time.

Facial Pain and Trigeminal Neuralgia: Pain Management Options

/ Thomas Cohn, MD

face painTrigeminal neuralgia is a condition that causes facial pain.  The trigeminal nerves or nucleus (their origin) send signals of severe pain to the brain.  The symptoms are often severe stabbing pain or electrical shocks.  Pain is on the side of the face, usually always one side, and comes in episodes.  The frequency and length of attacks is variable.  It can occur at any age, but is more common in those older than 50, and has multiple causes and treatments.

Causes of Trigeminal Neuralgia

Causes of trigeminal neuralgia are numerous.  It can be related to a variety of neuropathies, including multiple sclerosis and diabetes.  Vascular changes can cause pressure on the trigeminal nucleus and pain, and tumors can also affect the nerves.  In most cases, the cause is often not found, and may be a spontaneous problem, possibly due to a previous infection.

The main characteristic of trigeminal neuralgia is facial pain.  If a cause can be found, such as vascular compression or tumor, neurosurgical correction sometimes can lead to a cure.  However, in many cases, nothing can be found on diagnostic tests.  Treatment then is focused on management of pain symptoms and diminishing activities that irritate the region.

Facial Pain Management

Medication management is often the first line of treatment of trigeminal neuralgia.  Neuropathic medications are very effective for this condition.  The most common of these medications are drugs used for seizures.  It is often a trial and error method used to find the right medication and limit side affects.  Neurologists are often the first physicians managing the problems since they are experts in the diagnosis of nerve issues, and have extensive experience with prescribing these medications.

If the pain is not readily controlled with medications, a segment of those with trigeminal neuralgia are referred to a pain specialist.  The trigeminal nerve can be blocked and settled down with local anesthetic and steroid injections in some patients.  When injections work, relief can be almost instantaneous and put a patient in remission for months at a time.  If the relief is not prolonged but good, then ablation/destruction of the trigeminal nerve may also be effective.  The nerve can be abated several ways, including by a radiofrequency needle technique, special radiation, or surgery.

Good sources of additional reliable information on trigeminal neuralgia can be found through Mayo Clinic and the National Institutes of Health.

4ARVMK68BQQK

Spine Surgery Often Unnecessary in Treating Back Pain

/ Thomas Cohn, MD

spine surgeryA recent presentation at the North American Spine Society (NASS) meeting, points to the fact that a third of spine surgery patients are still using narcotic/opioid medications one year after surgery.

Further, the study indicates that of those patients using opioids before surgery, 51% continued a to use them a year later.  The article goes on to discuss the concern that too much opioid prescribing is occurring.  This is the wrong concern. The real concern should be whether spine surgery should have been done in the first place.

Reasons for Spine Surgery

The United States has one of the highest rates of spine surgery.  Compared to most other countries, the spine surgery being done is mostly unnecessary.  There are appropriate reasons for spine surgery, such as:

  • Trauma
  • Scoliosis
  • Changes in the spine causing nerve damage with loss of muscle or organ function

Pain alone is a poor reason for spine surgery.  Most spine pain is caused by degenerative discs and joints. Treating this surgically most often only changes the location of pain, and does not resolve pain.  Nonsurgical management of most spine conditions has been shown to be much more successful in numerous studies.  Ask a group of surgeons, the answer of course is that the surgery works.

Pain management experts will usually have a more conservative view with regards to surgery. Spinal fusion surgery has at most a 30% success rate for helping with pain.  Spinal surgery in general also has a 20% rate of significant surgical complication.  The above statistics highlight the real issues with spine surgery – that it often causes more problems than solutions.

Alternative Treatment Options

Treatment for spine pain involves many different options, including a variety of medications and possibly opioids.  Every person has different needs, and a Pain Medicine physician can evaluate you and help determine an appropriate treatment program.  Surgery should only be considered if neurologic compromise is occurring and without intervention, loss of motor control or organ function may result.

Opioid medication use in the United States may be out of control, but so is spine surgery.  Surgery and opioid use are truly independent problems.  Pain and opioid use after surgery is not a surprising issue.  The problem is too much surgery and not enough good pain management of spine problems by qualified experts.

Spinal Stenosis: Causes & Pain Management Options

/ Thomas Cohn, MD

spinal stenosisSpinal stenosis is a narrowing in the spinal canal where the spinal cord and nerves of the spine travel and exit the bony spine structure.  It most commonly occurs in the neck and low back regions.  It can be caused by normal changes relating to aging, such as:

  • Bony overgrowth
  • Trauma
  • Congenital changes

The body is highly adaptive, and if changes that lead to stenosis are slow, often no symptoms are present until the body can no longer compensate.

Causes & Symptoms

The symptoms of stenosis are signs of nerve damage at the spinal level that include:

  • Pain
  • Numbness
  • Muscle weakness
  • Bowel or bladder problems

Symptoms are dependent on the cause and location of the spinal narrowing.  Trauma, like car accidents, can cause sudden fracture of the spinal vertebrae. The bone pieces can damage the spinal cord causing immediate paralysis.  Congenital abnormalities may cause curvatures of the spine (scoliosis) and pinching of the nerves as they exit the spine.

Stenosis most commonly develops as one ages. The bone can become overgrown where the vertebral discs and joints are causing central and lateral spine narrowing.  In the neck, symptoms of pain, numbness, and weakness occur in the arms and head, but can also occur in the legs.  Low back stenosis causes symptoms in the low back and legs, and sometimes bowel and bladder control.  Symptoms in the low back may be very positional. Bending forward and sitting may significantly relieve the pain.  The most common symptoms that send a person to a doctor are pain or muscle weakness.

Diagnosis

Diagnosis of spinal stenosis is made based on symptoms, history, and physical examination.  Pain is often in the distribution of a particular spinal nerve level and muscle weakness corresponds to that level.  An exam shows sensation changes, weakness of muscles, and reflex changes.  If stenosis is suspected, CT or MRI scans of the spinal region can confirm the diagnosis.  Electrodiagnostic studies may also be useful to determine the extent of nerve damage, and are performed by Physical Medicine doctors or Neurologists.

Pain Management Options

Treatment for spinal stenosis needs to be individualized for every patient. Conservative care centers on physical therapy to strengthen spinal muscles and maintain proper posture, to medications for pain and spinal injections.  Many people can control symptoms for years with a variety of conservative care techniques.  If the conservative path is not controlling symptoms, then surgical care may be necessary to relieve spinal narrowing.

Spinal stenosis is a complex condition.  A good Physical Medicine pain specialist can lead one through the maze of diagnosis and treatment.  Most people do respond to conservative care.  Narrowing of the spine does occur in many people and often can be treated with PT, medications and other types of care.  Find a physician who can lead you through conservative care before you consider surgery.

Signs of a Pain Medicine Overdose

/ Thomas Cohn, MD

pain pill overdoseAll medications can cause problems when not taken correctly.  Pain medications, even those sold over-the-counter, can have deadly consequences when overdosed.  Having the right balance of medications for pain and not having significant side effects is the trick that a good pain physician will try to develop for a patient.  It is always necessary to keep track of the patient’s medications, even nonprescription to monitor for adverse reactions. This article will discuss the signs of overdose for opioids, over-the-counter meds, and neuropathic medication.

Opioid Overdose

Narcotic/opioid medications have had the most publicity concerning overdose.  These are the drugs like Percocet, Vicodin, Oxycodone, and Morphine. These drugs are powerful analgesics and are commonly given for severe pain.  Side effects are common and include:

  • Upset stomach
  • Constipation
  • Nausea
  • A tired or “drugged” feeling

Signs of an overdose of opioid medications include:

  • Excessive tiredness & sleeping
  • Low pulse and blood pressure
  • Decreased breathing

Significant overdose may be treated with a medication called Narcan to reverse these effects.  There is a push for all emergency responders to carry Narcan since overdose of these medications is becoming common due to drug abuse.

Neuropathic Medication Overdose

Neuropathic medications include many antidepressants (like amitriptyline, and Cymbalta), and seizure medications (such as gabapentin, Topamax, and Lyrica).  These medications often have annoying side effects such as:

  • Dry mouth
  • Short term tiredness

If they cause significant changes like memory problems or worsening depression, talk to the physician about problems.  Overdose with antidepressants such as amitriptyline can cause severe respiratory problems and needs to be treated with acute hospitalization.

Over the Counter Medication Overdose

Over-the-counter medications like acetaminophen and ibuprofen also have problems if overdosed.  Anti-inflammatories like ibuprofen can cause ulcers and stomach bleeds in some people, even at normal doses, but these affects can be treated.  Acetaminophen however is very dangerous if taken in to high of a dose.  Taking 1.5 times the recommended amount can lead to liver failure and even death.  If you have been taking too much acetaminophen the eyes and skin can turn yellow indicating liver damage, and must be treated promptly by a physician.

Pain medicines can be very helpful in managing symptoms.  Like all drugs, they need to be taken only as directed.  Make sure your physician knows all the medications that you are taking. Additionally, be sure to talk to your doctor about whether you can eat certain foods, or drink alcohol with your medication. If side effects of a medication are a problem, talk to the doctor before stopping the medication, sometimes these drugs need to be tapered off or just changed slightly to be helpful.