Why Doctors Should Be Listening To Their Patients, Not Relying On Scans

March 13, 2017 / Thomas Cohn, MD

The world is a fast-paced environment. No one has time for anything anymore. In medicine, there is constant pressure to see more patients and do more electronic paperwork, and productivity is a key guidepost to life. However, slowing down and spending a few minutes listening to the world around you and to patients may actually be more rewarding, and solve more problems.

Listening To Your Patients

Being an older physician, technology was just beginning to influence medicine when I began training. CT scans were just starting to become available at the beginning of my training, and MRI scans were not available until I was in practice for a few years. The hallmark of a good physician was their ability to make a diagnosis based on a patient’s history, a physical exam, and some basic testing. The patient encounter was the critical event, as was at getting the story.

Most of the time, if one listens to the complaint of a patient closely, the diagnosis of the problem becomes much more clear. The physical exam is also critical; this is especially important since high technology studies like MRI scans often find problems that are not the cause of a patient’s symptoms. Going old school and using the technology as an assistant and not depending on it often leads to a better treatment plan for a patient.

Treatment and Listening

There are many different styles of physician practice. Being in the field of pain management, one can use multiple approaches to the same problem. One common approach for low back pain is that everyone needs to have every structure in the low back injected with steroid. Another style is that the only treatment that is needed is a course of extreme physical therapy. The approach that seems to be the most effective is take a good history, do an exam of the patient and then decide what is wrong and needed. Most of the time, it will yield a more precise course of action.

Multiple times I have found that an MRI may show multiple significant looking issues, but the history and exam show no correlated problems that would warrant treatment. The body can adapt to multiple things seen on a scan and not have any problems. Treating a scan versus treating a person can be the absolute wrong thing. Furthermore, most problems can be treated in a number of ways, and the choice is often dependent on the approach the patient wants once they understand the options available.

Listening and examining a patient may be considered old fashioned. As a new physician it is often hard to understand the subtle things a patient is trying to convey. Sending a patient for tests and treating the tests is far easier. As an older physician, a lot of the stories become very classic, as is the exam. For example, spinal stenosis in the elderly has a unique story of pain when walking a few feet and being just fine when sitting or lying down. The story tells more in a few words then the MRI and then the treatment is absolutely defined by what the patient desires. Being old fashioned and listening is not glamorous, but it often is a more effective way to get the job done right.

Shared Reading Helpful For Chronic Pain Patients

March 9, 2017 / Thomas Cohn, MD

New research suggests that shared reading may help ease discomfort and provide cognitive benefits for individuals battling chronic pain.

Shared reading, as the researchers defined, was the act of of gathering with others and reading short stories, poetry or other literature out loud. Researchers said by reading literature that triggers memories of experiences throughout life, like happy childhood memories or relationships, patients can experience benefits similar to or that outweigh the effectiveness of cognitive behavioral therapy for chronic pain.

Shared Reading And Chronic Pain

There are hundreds of different treatment options for chronic pain, because chronic pain is unique to the individual. Some people experience pulsing pain in their lower back, others battle waves and waves of headaches, while others have nerve damage that sends pain signals to the brain when their is no painful stimulus present. What works for one person will not always work for another, and unfortunately that’s the problem that many pain sufferers are running in to. In turn, they are looking into alternative options, one of which is shared reading.

For their study, researchers compared the benefits of shared reading to cognitive behavioral therapy, which is a technique that aims to change the way people think and behave in order to better manage physical and mental issues related to chronic pain. To do this, patients with severe chronic pain were asked to participate in either five weeks of CBT or 22 weeks of shared reading. At the conclusion of the five weeks of CBT, individuals in that group joined the shared reading group for the remainder of the 22 weeks. The shared reading sessions incorporated literature that was designed to prompt memories of family, relationship, work experiences or other happy memories throughout their lifetime. Participants were required to report their pain severity and emotions before and after each session, and they were asked to record their pain and emotions twice a day in a personal journal.

Study Results

At the end of the study, researchers wrote:

While CBT helped to manage a person’s emotions, shared reading appeared to help patients address the painful emotions that might be contributing to chronic pain.

Pain severity and mood improved for up to two days after shared reading sessions.

“Our study indicated that shared reading could potentially be an alternative to CBT in bringing into conscious awareness areas of emotional pain otherwise passively suffered by chronic pain patients,” researchers wrote. “The encouragement of greater confrontation and tolerance of emotional difficulty that sharing reading provides makes it valuable as a longer-term follow-up or adjunct to CBT’s concentration on short-term management of emotion.”

Researchers want to conduct future studies with larger sample sizes, but it’s an interesting approach to treating chronic pain. We’ll certainly keep tabs on shared reading as a potential treatment option.

Why Difficulty Sleeping Is Like Living With Chronic Pain

March 6, 2017April 20, 2017 / Thomas Cohn, MD

Chronic and acute pain often interferes with sleep. Since a third of our lives are spent sleeping or trying to sleep, having an issue getting good sleep can be a major issue. There are many problems that interfere with sleep, and many pain patients have difficulty sleeping. Sleep is similar to pain, in that it is a complex process, and many things can affect our sleep. Sometimes the solution to better sleep is simple, but more often the problem and solutions are complex.

Why Recent Guidelines on Sleep Fall Short

The latest issue of JAMA came in the mail today and had two articles related to sleep. The first was on chronic insomnia and the new guidelines for its management. The second article was on restless leg syndrome (RLS). The “guidelines” were put out by the American College of Physicians (ACP) and written by primary care physicians and health care administrators. To be valuable, guidelines really need to be written by experts in the field of the guideline, and sleep specialists can be credentialed in Neurology and Internal Medicine with a specialty of Respiratory Medicine. These experts were not the ones to write these guidelines. If a patient wants only entry level advice on sleep, these may be okay, but for those suffering from chronic sleep issues, consulting an expert would serve most patients significantly better. It is shame that leading national organizations like the ACP and JAMA publish minimally useful information.

Since I have been in practice for a number of years, learning some some of the basic treatment options to improve sleep is not difficult. If a patient is having difficulty sleeping, always start with a good history and physical exam. The history often tells significant information with regards to the nature of the sleep problem. Treating sleep is usually more complex than guessing the right medications. The most important first step is good habits prior to going to sleep. The easy things involve reducing caffeine intake, especially in the afternoons and do not drink it at night. Alcohol also does not help with sleep; it often will wake one up in the middle of the night. Technology is also a horrible actor; the blue light of cellphones and computers as well as television will stimulate people and prevent sleep. Lastly, do not exercise vigorously in the evenings; this also wakes up most people.

Solving Sleep Problems

If a person has addressed the simple sleep issues and they are still having sleep problems, then finding a solution will often require some expert intervention. Since there are many problems that affect sleep, obtaining a medical sleep consult by a specialist is worthwhile. Problems like sleep apnea are often an issue. Finding medical problems that need management can reduce interference with sleep. If nothing is found to be a problem by an expert, then solutions to what seems to be reducing sleep can be initiated. Many people cannot relax enough to go to sleep, and psychological based treatments like mindfulness or cognitive behavioral therapy are indicated. Few patients may need some sort of medications, but these need to be closely monitored for side effects.

Most experts have not found that a particular type of bed or pillow makes any significant difference. If I am asked about whether a person should buy a new bed, it is probably only necessary if the current one is totally broken. Pillows are really a matter of personal preference, but they need to keep the neck in a neutral spine position. Usually spending lots of money on beds and pillows is not a good solution for improved sleep.

The patient with chronic pain is often no different from any other patient with sleep difficulties. Correct the simple things with regards to sleep hygiene first. If a person continues to have sleep problems, they should see a sleep specialist who can often help find the most appropriate intervention. Expensive beds and pillows are not usually a good investment. If you need a new bed, buy either a bed with a memory foam type top, or an air adjustable bed so the firmness can be adjusted depending on how you feel. Beds with adjustable frames that raise the head are sometimes good for those with breathing problems at night. Most importantly, good sleep hygiene is the first issue to solve, and if the problems persist, ask to see a sleep expert.

New Low Back Pain Guidelines From The ACP

February 27, 2017 / Thomas Cohn, MD

In the last week, the American College of Physicians (ACP) published new guidelines for the care of low back pain. The guidelines are their recommendations based on the available research on the subject. The most important thing to remember is this information is designed for physicians to assist with the management of particular problems.

However, the recommendations are only as good as the knowledge and ability of those who put together the data. These guidelines provide some reasonable information, but they do not contain significant information from board certified pain practitioners who are treating the problem every day. The reason why we need to highlight this issue is because the guidelines attack back pain as if it has one single cause, which we know is not always the case.

Where The Guidelines Fall Short

For the pain practitioner and as it should be for every doctor, pain is one symptom, and the low back region covers a large number of structures that can cause problems. A diagnosis is based on a history of symptoms, a physical exam, and then the application of medical knowledge to determine the causes related to the problem.

The new guidelines move away from coming up with a specific diagnosis of the pain problem. They also recommend any number of treatments that have a limited scientific basis, like acupuncture and spine manipulation, and they did not address medications very well. Muscle relaxants are recommended as well as duloxetine (Cymbalta), while many more common medications like Celebrex were not studied. The guidelines also recommend many psychological therapies and exercises that are not readily available or not covered by insurance.

Treating Back Pain

Guidelines are meant to serve as a road map to help practitioners establish appropriate treatment for patients. The new ACP guidelines lack instruction on establishing appropriate diagnoses and true evidence-based treatment alternatives. The guidelines appear to be the answer to what is the cheapest way to get a complex problem patient out of an office. They recommend everything but appropriate diagnostic testing, referrals to experts in pain, or advice on all the non-opioid options available and when to use them. These guidelines made headlines in the national news, but they surely are not truly newsworthy.

Acute, subacute, and chronic low back pain all have different meanings and can be quite well treated with a variety of interventions. It is true that most acute back pain is short lived, but primary care physicians should learn much more about all the causes and treatments available. For the patient, telling them “No matter what you do, it usually gets better in a month,” as these guidelines suggest, is poor quality care. No patient wants to be sidelined for a month, and they want to have a definitive diagnosis and treatment plan. These guidelines fall short of offering the best care for each patient with back pain.

Would Mandatory Opioid Registry Checks Solve Painkiller Abuse?

February 22, 2017 / Thomas Cohn, MD

The Minnesota legislature has a proposed law to make checking the Minnesota Prescription Monitoring Program database (PMP) mandatory prior to prescribing any opioid medication. The purpose of the law is to help identify people abusing medications and to prevent the explosion of overdose-related deaths.

Unfortunately, this is another oversimplification of the opioid problem in our country. Abuse of opioids is a very real problem. The solution is much more complex then checking a database for the number of prescriptions being taken. Mandating this step will only have a very minor effect on the problem of opioid abuse.

Opioids Abuse And The Database

Opioid abuse is a very complex problem. There are many people who have very difficult to treat pain problems that are dependent on these medications, and they take them on a very reliable basis without abuse. Currently, most pain physicians, including my practice, have a variety of steps they take to reduce the potential for abuse. One of the easiest is to look at the PMP database. We sometimes find abnormalities of behavior there, but it is not that common. Most often we find the patient is using both an opioid and a drug for anxiety that can cause a significant interaction. Then we need to advise a patient on these issues.

Other steps taken include a comprehensive medical exam for appropriate problems to be treated and finding alternative treatment plans. Believe it or not, the worst problem is obtaining insurance company approval for more expensive options with better outcomes and less risks to the patient. Other steps taken include drug testing, checking state criminal databases and evaluating psychological stability before prescribing. For those wondering, our practice does check the PMP for everyone for each refill.

Mandatory Checks?

Mandatory checking of the PMP does not significantly help solve the opioid abuse problem. It is only a feel good step for politicians to say they are doing something. The problem runs much deeper. First off, a lot of people who are abusing opioids should probably never have been placed on the medication. The next step is that they should not be on them for any length of time – they may be okay for a very acute problem – but then they need to be stopped. Addiction is a medical condition. It is tough to treat and programs to help with addiction need funding and staff, and this needs to be promoted.

If the legislature wants to have a positive role in the addiction crisis, then they should be mandating insurance coverage for alternative treatments for pain besides opioids. Alternative treatments include everything from prolonged physical therapy, massage, chiropractic, and different medications, to comprehensive pain programs and implantable pain control devices. Obtaining insurance approval, especially from Medicaid or Medicare, is time consuming and often almost impossible. Physicians are extremely frustrated by the obstacles put up by insurance companies when better and cheaper alternatives are routinely denied in managing pain.

The last difficulty in understanding pain and the opioid crisis goes beyond the problems of addiction. Pain is extremely complex and one of the main tools to control symptoms is opioid medication. This is the same tool we have used for over 150 years. A third of the world population struggles with pain problems. Virtually no dedicated funding goes to research on pain compared to other medical problems. Our knowledge level in regards to pain as a disease is at the level where cancer was in about 1950. If the world wants to tackle the problem of opioid abuse, it really needs to fund research on all aspects of pain to solve the issues suffered by a third of the world population.