The Politics Of Pain

/ Thomas Cohn, MD

Politics PainkillerThe problems with opioids have been all over the news. Now it is the political season, and the politics of pain have occasionally been making news. It’s generally about how awful the pharmaceutical companies have been and how they have been behind the current problems. Whenever we try to point blame, it is worth remembering that both the problems and solutions are complex. Drug companies may have recognized the market for pain medications but without a demand for the product, even with the best sales, the problems would not have developed. Further, doctors have also been blamed, always over prescribing pain medications.

The treatments for pain are as varied as the causes, as there is not a single treatment that works for all. Unfortunately, the culture in the U.S. often wants a quick fix, and if a pill helps, most want that solution. The harder solutions of modifying activity and exercise often have few takers. The easy solution is taking an opioid medication, and when people started to realize that it helps temporarily, many people have insisted on being prescribed these medications.

Patient rights and quality care have also been an issue in prescribing medications. Countless times patients have said it is their right to take certain medications and that if a patient has pain, it is the obligation of a healthcare provider to prescribe opioids to control their symptoms. Now with multiple sites providing online evaluations and ratings of care providers, patients dissatisfied with not being prescribed certain medications will rate a provider badly.

Prescribing Opioids

The politically correct position currently, at least for healthcare managers, politicians, and lawmakers, is to say opioids are always bad and doctors should not be prescribing these medications since they only cause addiction and death. The truth is obviously more complex, but these medications are appropriate for certain people, especially when all other treatments for pain have failed.

Years ago, the pharmaceutical companies were notably behind the push to have opioids more widely prescribed. Today, we have a better understanding of the problem with these medications, and we have some alternatives in management of pain. As cynical as it was for drug companies to push for prescribing medications, now the push for more addiction management due to opioid problems. One of the most important solutions to reducing opioid usage is to fund research for better treatment alternatives and to discover more about what causes ongoing pain.

The opioid crisis is real and it affects an alarming number. Yes, there is a need for stemming the crisis, but most of the money being proposed is to go for addiction treatment, and often people who directly profit are behind the treatment programs. Another group is pushing for legalizing marijuana for the treatment of pain, and many of those pushing the hardest will again directly profit if this is legalized. Those in the trenches trying to appropriately diagnose and treat pain, and those who are suffering from pain currently have little financial support. Even though a third of the population struggles with pain, very few resources are being targeted towards a better understanding of the mechanisms behind pain and new treatment alternatives. Pain is not glamorous, and there is no high profile celebrity pushing the cause for better treatments. Unfortunately, there are many people pushing causes related to pain for personal profit, from addiction treatment centers, pharmaceutical companies, to disingenuous entrepreneurs pushing for legalizing marijuana. When looking for solutions, they need to be based in the best interest of those in pain.

How Placebo Pills Are Helping Patients With Chronic Pain

/ Thomas Cohn, MD

Placebo Pill StudyNew research suggests that knowingly taking placebo pills may help chronic pain sufferers find some pain relief.

Conventional wisdom suggests that the placebo effect should only work if the patient believes they are taking a medication with an active ingredient, but the new study suggests that may not be the case.

“These findings turn our understanding of the placebo effect on its head,” said joint senior author Ted Kaptchuk, director of the Program for Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center and an associate professor of medicine at Harvard Medical School. “This new research demonstrates that the placebo effect is not necessarily elicited by patients’ conscious expectation that they are getting an active medicine, as long thought. Taking a pill in the context of a patient-clinician relationship — even if you know it’s a placebo — is a ritual that changes symptoms and probably activates regions of the brain that modulate symptoms.”

Placebo Study

For the study, researchers recruited 97 individuals with chronic low back pain and split them into two groups. Both groups watched a 15-minute video explaining the placebo effect, then one group continued their normal treatment, while the other group took daily placebo pills that were stored in a container marked “placebo pills” that clearly stated that they had no active ingredient. Both groups continued their specific treatment options for three weeks.

At the end of the three week period, patients in the placebo pill group reported 30 percent reductions in typical and maximum pain, while those in the treatment as usual group experienced 9 and 16 percent reductions respectively. Individuals in the placebo group also reported a 29 percent drop in pain-related disability, while those in the treatment as usual group did not report improvement in that measure.

“Our findings demonstrate the placebo effect can be elicited without deception,” said lead author, Claudia Carvalho, PhD. “Patients were interested in what would happen and enjoyed this novel approach to their pain. They felt empowered.”

However, Dr. Carvalho cautioned that the placebo effect may only provide mild relief for patients with undiagnosed chronic back pain, and that patients with specific conditions like herniated discs or pinched nerves will not experience similar results.

“You’re never going to shrink a tumor or unclog an artery with placebo intervention,” he said. “It’s not a cure-all, but it makes people feel better, for sure. Our lab is saying you can’t throw the placebo into the trash can. It has clinical meaning, it’s statically significant, and it relieves patients. It’s essential to what medicine means.”

Chronic Pain Reaches The World Series

/ Thomas Cohn, MD

The World Series is under way, and after a Game 1 victory the Cleveland Indians are only three wins away from capturing their first championship since 1948. Their manager, Terry Francona, already has two World Series rings from his time in Boston, and while another championship would be ideal, he’s already winning another big battle in his life – his battle with chronic pain.

Francona played eight seasons in the majors before eventually transitioning to a coaching role, but his years in the big leagues took a significant toll on his body. He eventually needed a couple knee replacement operations, and complications left him in severe pain with blood clots and staph infections. He was in a great deal of chronic pain, and he eventually turned to opioids to help manage the pain. Unfortunately, like many others, what started as a technique to manage pain transitioned into a habit and later abuse.

Opening Up About Life On Painkillers

Francona opened up about his battle with painkiller abuse in a book by Dan Shaughnessy titled, “Francona: The Red Sox Years.” He said his descent into pain pills began after some complications from knee surgery.

“I think I probably should have died with all that happened,” said Francona, referencing an extended hospitalization in 2002 when he almost needed to have his leg amputated. “There were a couple of nights in the hospital where I was thinking, I can’t take this anymore. The nurses would come running in because I’d stop breathing. I was in bad shape. There were people around who did not think I was going to make it. I know I came real close to losing the leg.”

He turned to painkillers like oxycodone and Percocet to ease his discomfort as he recovered.

“I lived on it at that time,” Francona recalled in Shaugnessy’s book. “When I left the hospital, I was on heavy-duty drugs, and it was tough.”

He eventually recovered from the problemed surgery, but he still kept taking pain pills, and eventually started hoarding them because they were easier to obtain in the clubhouse. That was until one day when his daughter found a bottle at home with more than 100 Percocet pills, and she eventually convinced her father to seek professional help and to enter a confidential drug treatment program managed by Major League Baseball. That same year, after the Red Sox collapsed in the weeks leading up to the playoffs, the Boston Globe published a piece saying that “team sources expressed concern that Francona’s performance may have been affected by his use of pain medication.”

Francona was not hired back after his contract expired that year, but he’s found a home with the Indians and appears to have put his days of painkiller abuse behind him. He mentioned that he still takes a blood thinning medication, but he’s taken to other options, like exercises and compression sleeves, to improve his blood circulation so he’s not relying solely on pills.

Francona is a shining example of how easily someone can get sucked into the world of painkiller abuse, and it’s fantastic that he’s been able to get professional help and more forward with a healthier lifestyle. Win or lose in this World Series, he’s won his battle with painkiller abuse.

Tai Chi Beneficial For Chronic Neck Pain

/ Thomas Cohn, MD

Tai Chi Minnesota PainLast week we shared a story on how yoga may be helpful for individuals with low back pain. Today, we’re learning of new research out of Harvard that suggests another form of low-intensity exercise may be beneficial for people with chronic neck pain.

To better understand the benefits of the ancient martial arts technique, researchers gathered a group of 114 individuals who were at least 18 years old and who suffered from nonspecific chronic neck pain for at least three months. Half of the group was asked to participate in regular Tai Chi classes for a period of 12 weeks, while the other half acted as the control group.

It may not sound shocking that individuals in the Tai Chi group had better outcomes than individuals who did nothing to improve their condition, but that’s what researchers discovered.

“The study showed that 12 weeks of Tai Chi was more effective than no treatment to improve pain, disability, quality of life and postural control in persons with chronic neck pain,” said Peter M Wayne, assistant professor at Harvard Medical School in the US.

Something Better Than Nothing

The news about Tai Chi having benefits for neck pain isn’t revolutionary, but it speaks to the larger point we try to express to our patients – that you need to put in the work if you want to take control of your pain. Your pain isn’t going to resolve simply by sitting down and popping a pill, you’re going to need to take an active role in pain management.

The researchers went on to say that Tai Chi was no better or worse for chronic neck pain than targeted neck exercises, but it again stresses the importance of strengthening your body to fight back against pain. As we’ve said before, there is no magic pill for chronic pain, and that holds true here. Even low intensity workouts can have amazing physical and psychological benefits. Don’t just hope your neck pain resolves, attack it head on.

Pain Care – When Correlation Doesn’t Equal Causation

/ Thomas Cohn, MD

Opioid Abuse Smoking StudyIt seems that there are new articles being published almost every day on the dangers of opioid pain medications. Unfortunately a lot of the studies are not very enlightening. Worse yet, some are just sensational, dumb correlations without causation.

For instance, saying obesity is correlated to eating is a great example of poor research. If you eat, of course could run the risk of being obese, but if you do not eat you could die, so obviously these findings are not very meaningful.

The latest was an article stating that a third of all adults in the United States in the last year received a prescription of opioid medication, and this is larger than the number of people who smoke cigarettes. The reason this is absolutely meaningless is this number has no real meaning. If you add up all the prescriptions for opioids written in one year and divide by the adult population, this is very likely.

Another interpretation would be that 1 in 3 people had a serious medical issue in the last year and were prescribed pain medication. Most people who have been in the hospital or emergency room for a surgery or injury may get a short-term prescription for pain medications. This is one of the very legitimate uses of these drugs, and should not be demonized. Treating acute pain aggressively at the outset has been shown to reduce the incidence of chronic pain problems. Several days of pain medications after a surgery or serious injury is appropriate but it should not be an ongoing use once the acute episode has healed.

Making Bad Connections

A third of the world population also suffers from chronic pain. A small percentage of those people are helped only by opioid medication and use these appropriately to maintain function and ability. There are many who use these medications extremely sparingly and thus continue to be highly productive in society since then they can control their symptoms. These people are dependent on these medications, they are not addicted, and oftentimes other conservative treatments have failed them. If there were better legal treatments available, many of these people would never use opioids.

Taking a prescription pain medication for a legitimate medical problem is not a significant issue or statistic. Smoking cigarettes for most is a daily addiction, affecting 25 percent of adults. It is voluntary, it causes multiple health problems, and has a huge cost to society. Comparing pain medication use to smoking is a useless correlation with no meaning.