Mentoring and Support Crucial For Teens With Chronic Pain

March 24, 2016 / Thomas Cohn, MD

New research out of Canada suggests that doctors should ensure that teens who are battling chronic pain and illness should have a support system in place to address their mental health, as it can help manage physical symptoms.

The study was small, but the findings speak to a larger issue that oftentimes gets overlooked when it comes to helping adolescents with chronic pain. For their study, researchers conducted an eight-week study with 28 kids between the ages of 12 and 17 who had been diagnosed with various chronic pain conditions. The group was split in two, with one group participating in the iPeer2Peer program.

Those in the treatment program were partnered up with an adult between the age of 18 and 25 who had also been diagnosed with a chronic condition. The mentors needed to undergo a 20-hour training session prior to being paired up with a mentee. The pairs talked via Skype twice a week for at least 20 minutes a session for the first two weeks, then at least once a week for the remaining six weeks. Researchers noted than sessions routinely ran about twice as long as the minimum 20-minute scheduled session. Mentors shared advice, offered emotional support and addressed any concerns or questions the mentee had.

Mentoring Chronic Pain

At the conclusion of the eight weeks, researchers uncovered:

Mentees reported significantly higher self-management skills and more satisfaction with their ability to cope with pain after completing the program.

Mentees in the program said they were satisfied with the program and would recommend the treatment to a friend.

Mentors responded that they enjoyed the sessions as well.

Researchers believe that showing teenagers that they don’t have to fight their battles alone can be a significant step in helping them cope with their chronic condition.

“Young people with chronic pain can become socially isolated and many have never met another person with chronic pain,” said lead study author Sara Ahola Kohut, a pediatric health psychologist at The Hospital for Sick Children in Toronto. “By having trained mentors, young people who are only a couple years older than the teens, teach coping strategies, we believed the pain coping skills might be easier to learn and practice.”

Kohut concluded that anywhere from 11 to 38 percent of children and adolescents deal with chronic conditions at that stage of their life, so we need to start addressing the issue. This program may be the answer.

“The program is easily accessible, teenagers liked it, and it helped improve the teenagers’ ability to cope with pain.”

Guidelines For Prescribing Opioids For Chronic Pain

March 17, 2016February 7, 2023 / Thomas Cohn, MD

The Centers for Disease Control and Prevention recently announced some new guidelines for physicians in regards to prescribing opioids for chronic pain control. The official statement is a little wordy, but the CDC also published an infographic to explain the new guidelines. I plan on publishing my thoughts on the new recommendations, but for now, here’s a look at the recommendations as well as a statement from the American Academy of Pain Medicine.

AAPM Statement

“We know that doctors – primary care and pain medicine specialists – are integral in treating pain wisely and carefully monitoring for signs of substance abuse. Abuse and diversion of prescription opioids must be addressed. Opioids are not the usual first choice for treating chronic non-cancer pain, but they are an important option—as part of a comprehensive multidisciplinary approach— that must remain available to physicians and appropriately selected patients,” said Dan Carr, MD, President of the American Academy of Pain Medicine and Professor of Public Health and Community Medicine at Tufts University.

“We need to address both chronic pain and its treatment as public health challenges. This view is endorsed by the National Academy of Medicine and outlined in the draft National Pain Strategy from the NIH. Public health problems are typically complex; well-meaning, but narrowly targeted, interventions often provoke unanticipated consequences. We share concerns voiced by patient and professional groups, and other Federal agencies, that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence. It is incumbent upon us all to monitor the deployment of the guideline to ensure that it does not inadvertently encourage under-treatment, marginalization, and stigmatization of the many patients with chronic pain that are using opioids appropriately.”

The Next Generation of Fitness Trackers

March 15, 2016 / Thomas Cohn, MD

The next generation of fitness trackers and wearable wellness devices are coming, and with them are several new trends and capabilities. The most common feature is the ability to monitor more items related to your health. The second trend will be sharing your personal statistics with others, especially your health insurance carrier and if you meet various goals, insurance costs may be lowered.

The Future of Fitness

Fitness trackers all have miniature computer chips and circuits inside them. Currently, they can easily monitor steps taken, and relative changes in altitude to measure stairs climbed. Based on secondary data in an external program, they can estimate calories burned and distance traveled. The next level already performed in many trackers includes monitoring heart rate, and providing rough measures of sleep based on body motion. The increased level of monitoring provides a measure of fitness in most people. Some of the units are also including GPS receivers such that distance and time can be more closely estimated.

Future fitness trackers are looking at tracking other aspects of health. Other parameters that are likely to be added are blood oxygen saturation, possibly CO2 levels in the blood, and blood glucose. For runners and high level athletes, lactate levels in the body, and some are looking at measuring electrolytes in the sweat to improve performance. Other possible health monitors that may be incorporated somehow will be more sophisticated heart beat evaluation and brain wave analysis at night to check sleep patterns.

Although these devices are improving, they are not necessarily as accurate as those used in the medical office setting and likely will not be considered medical devices. They will be useful to give a person more immediate information about their overall health status, but they certainly shouldn’t replace regular checkups with your doctor.

Fitness Trackers and Insurance

Some employers and at least one major insurance carrier are now starting programs using fitness trackers to motivate employees to work on healthier lifestyles. One measure of health is the amount of activity a person performs, and this is measured by the number of steps taken during the day and the frequency during the day of increased activity. By meeting certain goals of activity, health insurance costs may be fractionally lowered. The one fact this all hinges upon is those who exercise regularly tend to be in better health and thus have lower health care costs.

Everyone knows the importance of exercise. For those with pain, it is even more important. Pain may limit what they can do for exercise but it is still essential and in most cases improves the quality of health and diminishes pain. Exercise needs to include overall activity for cardiovascular health and increase endorphins, and stretching and strengthening routines. All three components of exercise are necessary, and fitness trackers can help motivate a person to be consistent. The reward will be personal with better health and improved functional activity.

The Complexity of Chronic Pain

March 11, 2016 / Thomas Cohn, MD

Recently the Star Tribune published an opinion piece titled “How not to treat chronic pain” by Ellen Stern. The article was quite interesting, but seems to miss the mark in understanding pain and its management. The author suffers from chronic low back pain. She tried treating it conservatively with the traditional route of management from medications, to therapy, to injections – none were very successful. She eventually underwent lumbar fusion and this also did not relieve her pain. Despite all the treatment she continues to be in significant pain.

The Complexity of Pain

Chronic pain is very complex. All of my patients understand the nature of pain and how difficult it is to find a good management option. Furthermore, since I have chronic low back pain with significant spondylolisthesis and severe stenosis, and have close family with pain problems, I have a very deep understanding of all these issues.

Rule number one in pain management is that there is no magical treatment. Chronic pain is “managed” and not cured. Complaining about the medical community may feel good but does not move you forward. Adjust your attitude, if necessary get professional help, and concentrate on all the things that you can do and not on the negative. If the physicians you are seeing are not helpful, it may be necessary to find someone who works with you better.

Opioid Abuse

The issue with opioids and abuse is nationwide. It is now as much of a problem with accidental deaths as automobiles used to be and is ever increasing. As the country has become more aware of the problem, all prescribers of these medications have become more cautious. There are numerous ways to reduce abuse of opioids, and all patients who receive them are scrutinized. As a prescriber, we are constantly trying to determine if a patient is appropriate for opioids. Since our licenses and livelihoods are on the line when prescribing opioids, most of us are cautious when prescribing. We all can tell stories of success as well as ultimate disasters, so please understand close monitoring of the patient receiving opioids comes with a certain level of danger.

Medical Marijuana

Medical marijuana in general is another complex issue. As with all treatments for chronic pain, it is just another management tool. Like any other compound, it works only for certain people and definitely not for everyone. Further as noted in multiple previous writings, the science behind medical marijuana has been minimally studied. There is very little rigorous research similar to any other drug that has been approved for medical use. Many physicians are reluctant to recommend a compound that has not been adequately analyzed and has solid research behind it. Many compounds in medicine have come on the market and we later find significant serious dangers caused by the compound.

Treating chronic pain is extremely complex. There is no silver bullet of a cure. There is much more that the medical community does not understand about pain than what we really know in detail. The majority of the tools we use today are often quite crude and old. Surgery is often quite brutal, and changes the body often in the wrong way. Morphine and its opioid derivatives are the same concoctions that we used to treat pain over 150 years ago. Research is slowly bringing medicine better understanding of pain. Physicians are struggling with the problems of pain and its treatments and a lack of new and better solutions with good scientific basis. Hopefully more funding and research will lead to better solutions in time since chronic pain does affect over 30% of the population worldwide.

Sleep, Insomnia, and Pain

March 8, 2016 / Thomas Cohn, MD

Difficulty sleeping is a common problem with patients in pain. Good quality sleep throughout the night often reduces the intensity and perception of pain. There are many causes and not a single solution for poor sleep. Pain in the neck and low back regions can cause discomfort within a short amount of time while lying down. Chronic pain can also cause anxiety and depression and that can contribute to sleep issues. To make matters even more complicated, the medications used to control pain may have side effects that impair sleep. Patients with chronic pain may also have other medical conditions that cause difficulty with sleep.

Sleep Postitions

Treating sleep problems in patients with pain is often quite complex. The first step in treating sleep-related pain is to make sure the patient has good positioning of the body with regards to the spine in a neutral position. For neck pain this would be using a pillow that supports the head without having the neck bent if lying on the side, or a thin pillow with a slight neck roll if lying on the back. Low back patients need pillows to support their position if lying on the side between the knees and sometimes supporting the stomach or against the back. Having multiple pillows to maintain a good position is normal. If lying on the back, having a pillow under the knees improves the low back position reducing stress on those muscles. A bed that accommodates and maintains natural curvatures of the body, such as a memory foam mattress or an adjustable air bed also may be helpful to reduce stress and pain on either the neck or low back.

Pain, Anxiety, and Sleep

Pain itself can cause sleep difficulties related to anxiety and depression. The centers in the brain that interpret pain signals and those associated with anxiety and depression are in the same regions. Often as one develops chronic pain, anxiety also occurs and contributes to sleep problems. Not treating this problem adequately can worsen the pain since these areas of the brain tend to interact. Often anxiety has been treated with benzodiazepines like:

Valium
Ativan
Xanax
clonazepam

These medicines induce the first phases of sleep but not the deeper sleep that is needed. Anxiety in pain patients is often a symptom of depression, and is not well treated with the above medications. Using antidepressants actually treats the chemical imbalances that occur and with the right medications the symptoms improve as well as the sleep.

In pain patients, recent studies show that sleep problems are often mixed with significant concern about not being able to sleep. Patients tend to concentrate on not being able to sleep and this then becomes the reality. More drugs with side affects is typically not the best solution. More effective treatment is the use of cognitive behavioral therapy (CBT). This is a psychological method of retraining the brain to think in a constructive fashion and this reduces the anxiety about sleep and anxiety. Studies have found the use of CBT to be equally or more effective in managing sleep problems in pain patients than the use of medications.

Traditional pain medications like opioids also have negative effects on sleep. These drugs tend to reduce deep sleep and increase the shallow phase 2 sleep. Deep sleep phases are the periods that are necessary to feel rested. The more potent opioids also have a tendency to increase both obstructive sleep apnea and central sleep apnea. Both decrease oxygen levels in the body and lead to frequent awakening. Sleep apnea will markedly decrease deep sleep and the quality of sleep.

New Sleep Medications

Ease of falling asleep, being able to stay asleep, and having deep restorative sleep measure good quality sleep. With good sleep, one should feel well rested and have less pain. As noted above, one of the best management techniques for sleep is using cognitive behavioral therapy. Medications are starting to get better. The newer sleep medications over the last ten years like Ambien and Lunesta help induce sleep, they do not keep one asleep and may cause hangover and odd behaviors like sleep walking. Melatonin type medications also induce sleep, can be used safely long-term, but do not maintain prolonged deeper sleep. The newest medication is Belsomra and this appears to be inducing and maintaining sleep. One old time medication, doxepin at very low doses also seems to have similar properties.

If one has pain and sleep difficulties, it is important to discuss the problem with your pain physician. A trial of simple solutions, either CBT or melatonin type medications is reasonable. If the sleep problems are ongoing, being evaluated by sleep specialists and having a sleep study done is beneficial. Sleep apnea is common in pain patients and treating these problems is essential in managing sleep. Ongoing sleep problems may require a combination of solutions since multiple factors are probably present. Like managing pain, sleep is complex and often difficult to find a solution to improve the situation.