Pain Management – Out With The New, In With The Old?

October 2, 2017 / Thomas Cohn, MD

Comprehensive chronic pain programs (CPP) have a long history, and they used to be the mainstay of treating pain. Up until the mid 1990’s, they were present across the country and there were several hundred present in the United States. With the widespread adoption of the use of opioids and the ratcheting down of medical expenses by insurance companies, many of these programs were eventually forced out of existence.

These programs cost between $5,000 and $20,000 and sometimes involved 2-4 weeks or more of inpatient care. In retrospect, considering the cost of surgeries and medications, these programs were probably a cheap investment for high quality proven outcomes. Today there are very few of these programs left – less than 100 nationwide – and we are suffering from a crisis of pain management and opioid addiction. In Minnesota, there only several left in the state.

Comprehensive Chronic Pain Programs

The typical chronic pain program is a behavioral based approach to pain with an emphasis on weaning off of all opioids. Nonaddictive medications are fine, and surgical or interventional approaches to pain are usually not a part of the program. Most of the emphasis is on changing behavior as it relates to pain. There is guided physical therapy, often aquatics, dietary advice and significant amounts of group and some individual psychological intervention toward the effects of pain on mood and activity level. The goal is to increase activity and function and show a person that their pain levels are often minimally impacted.

These programs are most successful for those whom have withdrawn from life and interactions. A typical patient in one of these programs is depressed, isolated, sedentary and not working. They often are very focused on taking medications and feel their pain prevents them from doing anything. However, to be successful in such a program, they must want to change their lifestyle.

Unfortunately, if you have chronic pain and are maintaining function in life, these programs often have little to offer. For a person who is well adjusted, with multiple outside of the home interests, working full-time, trying to exercise, doing meditation and not taking opioids, these programs have minimal things to offer that would be worthwhile. Pain management for many complex chronic pain patients is often much more difficult. Further, there are very few physicians in general who specialize in pain, and even fewer who have the interest, knowledge and experience to deal with many of these people.

Finding a chronic pain program is often not too difficult, and asking your insurance company or physician will probably get you pointed in the right direction. Finding a good pain physician that will meet your needs can be extremely challenging. A good place to start is a Physical Medicine and Rehabilitation Physician that is board certified in pain. After that, look for recommendations and then visit with the doctor to see if they can meet your needs. Finding the right physician is often difficult, and unfortunately there are no easy answers when it comes to pain management.

JAMA’s Approach To Chronic Pain Is Misguided

June 26, 2017June 26, 2017 / Thomas Cohn, MD

Every week, the prestigious Journal of the American Medical Association (JAMA) publishes short articles that address important topics in medicine. Last week one of the articles was on taking care of chronic pain patients in primary care medical practices.

In the era of opioid abuse, one would think educating primary care physicians on pain would be beneficial. This article unfortunately was a catastrophe. The information on addiction was wrong and the treatment of pain was overly simplistic.

Understanding Opioid Addiction

Opioid addiction is a significant issue today. Yearly over 30,000 people die due to opioid-related incidents. This is nearly as many people as those who die in automobile accidents. However, addiction is an illness in itself, and of all the people who use opioids, only a small percentage of about 5-7 percent at most ever become addicted. Addiction to opioids is no different then other addictions and requires psychological intervention and medical detoxification.

Chronic pain is a very complex disease, and has many causes. There often is not a single problem involved and finding solutions to improve the issues present takes a deep medical understanding of many different fields. One must be able to identify and understand all the medical problems contributing to pain. Having a solid knowledge of rheumatology, internal medicine, orthopedics, neurology, and musculoskeletal medicine are just a few of the skills needed in pain medicine. In reality, it does not matter how people progress to a chronic pain condition, what matters is that 1/3 of the adult population has problems with chronic pain.

The article in JAMA recommends that primary care physicians need to see the pain patients frequently, with shared decision making, compassionate care, promoting shared decision making, and use an interdisciplinary approach. They should work with motivational interviewing, and have physical therapists and psychologists in the office to work with them and the patients.

This article was written by physicians from the University of Michigan, and pardon my language, is crap. From experience, these physicians are in academics and they are tremendously sheltered from the pressures of most practice situations. Most primary care physicians have 15 minutes at the most to see a patient and they do not have any other support like psychologists in their practice or physical therapy. At the University of Michigan, pain patients are also referred out to the Physical Medicine physicians. The advice in this article is of extremely low use.

What We Should Be Doing

Primary care physicians need far more practical advice on management of chronic pain. First off, chronic pain is not a single medical condition but most commonly it is the response to multiple medical problems. The role of primary care medicine is, more importantly, to identify that there is a problem and help quarterback and guide a patient to the correct treating physicians. With limited time for each visit, send the patient to experts in pain management such as a physical medicine physician who actually has the appropriate training and resources to treat complex problems.

Secondly, avoid the quick fix by trying to hand out medication, especially opioids and many of the other drugs on the market since developing a comprehensive management strategy is necessary. Again this type of management is not really primary care and working with a specialist is more productive. Once a specialist has developed a successful treatment approach, be willing to take over and maintain the program. Third, realize pain is extremely complex, often with no cure, and the goal of treatment is to improve function and make the symptoms more manageable. The best advice for primary care physicians is to learn who are the knowledgeable and successful pain management experts in your area and use their expertise to help manage these complex patients.

Pain Catastrophizing and Chronic Pain Care

June 20, 2017June 20, 2017 / Thomas Cohn, MD

When it comes to managing chronic pain, it’s imperative to take as much care of your mental health as it is your physical health. Ignoring your mental health can lead to more negative attitudes towards your pain, which can lead to even more problems according to a new study.

A new report out of the Stanford University School of Medicine suggests that individuals who negatively fixate on their symptoms have been found to report greater pain intensity and are more likely to be prescribed opioids. Interestingly, the association was much higher in females than it was in men.

“When it comes to opioid prescriptions, pain catastrophizing has a greater effect on the likelihood for having a prescription in women than it does in men,” said medical student and lead researcher Yasamin Sharifzadeh.

Pain Catastrophizing

According to researchers, “pain catastrophizing” is defined as the cascade of negative thoughts and emotions in response to actual or anticipated pain. When you begin to let these negative thoughts continue to build and take hold over your pain, it can actually amplify the pain process and lead to greater pain and increased disability. Previous studies have shown that pain catastrophizing has been linked to increased pain sensations, but this is the first study to find a correlation between it and an increased likelihood of being prescribed opioids.

For their research, Sharifzadeh and her team analyzed clinical data from more than 1,800 patients with chronic pain. After analyzing the data and parsing out the results between genders, researchers came to an interesting conclusion.

“In men, it is pain intensity that dictates whether or not they are prescribed opioids,” Sharifzadeh said. “However, in women, there is a more nuanced issue where relatively low levels of both pain catastrophizing and pain intensity are associated with opioid prescription. Pain catastrophizing and pain intensity are working together in determining if a woman has an opioid prescription.”

This is especially problematic when you consider that women are more likely to suffer from chronic pain, be prescribed pain relievers and given higher doses for longer periods than men, according to the Centers for Disease Control and Prevention. However, by recognizing this correlation, doctors can help to mitigate this risk.

“If physicians are aware of these gender-specific differences, they can tailor their treatment,” Sharifzadeh said. “When treating chronic pain patients — especially women — they should analyze pain in its psychological aspect as well as its physical aspect.”

If you feel like your mental health is fighting a losing battle with chronic pain, reach out to your doctor. Contact Dr. Cohn today.

5 Pill-Less Treatment Options For Chronic Pain

September 23, 2016April 5, 2023 / Thomas Cohn, MD

Opioids and other pain medications can certainly help people cope with problems associated with chronic pain, but it should not be your only method of treating your pain. Pain pills are a passive treatment option that can be successful in controlling pain in the short term, but they lose their effectiveness and leave patients at risk for dependence and abuse in the long term. Today, we take a look at five pill-less treatment options for chronic pain that can be used on their own or in conjunction with other strategies to help keep your pain away.

Treating Pain Without Pills

We’ll offer a short blurb on five pill-less treatment strategies below. Click on the link in each article to learn more about each treatment option.

1. Exercise – Exercise is one of the best treatment options for chronic pain. It helps get healthy oxygenated blood flowing to painful areas of our body, helps us keep off excess weight, and it helps off push away the stress in our daily lives. Even if it’s low-intensity workouts, regular exercise is one of the best things you can do for your body, especially if you have chronic pain.

2. Yoga, Tai Chi or Meditation – These techniques also help get blood flowing and strengthen areas of our bodies that are in pain, but they also are great for the mind. Most people don’t recognize just how mentally and emotionally draining physical chronic pain is, but these treatments can help you keep your mind healthy while you’re battling your physical pain. If you have a healthy mindset, you’ll find that the physical pain is often less debilitating.

3. Massage Therapy or Acupuncture – These two techniques are similar in that they focus on the pain pathways in our body. These techniques haven’t been emphatically proven to be effective, but some people have found relief with these options. They should be used in conjunction with other strategies because they too are passive techniques, but both massage therapy and acupuncture have been shown to be successful for some patients with chronic pain.

4. Physical Therapy – Sometimes our chronic pain is caused by an easily identifiable problem, like a pinched nerve or bulging disc. When the pain pathways can be clearly identified, physical therapy to strengthen the areas or free damaged nerves can be a great option. Ask your doctor about what stretches you can do as part of your physical therapy, or better yet, see if they’ll refer you to a physical therapist that can assist you in person.

5. Daith Piercing – If your chronic pain is in the form of constant headaches or migraines, the daith piercing may help provide relief if other options have continually failed. Our blog on daith piercings has been far and away our most popular blog, and while there is no direct evidence that the piercing can provide full relief, numerous commenters have tried the technique and noticed a reduction in headache symptom and prevalence.

There Are No Magic Pills For Chronic Pain

June 10, 2016 / Thomas Cohn, MD

As we’ve said in a bunch of previous blogs, there’s no “magic pill” to cure all your symptoms associated with chronic pain. It takes hard work on the patient’s end and a medical team dedicated to finding the right solution. It’s not going to be easy, but it will be worth it.

Recently, I read a story about one family’s plight with chronic pain and felt compelled to share it. Originally posted in the New York Post, Michelle Makin pens a piece about how one family has battled through the troubles associated with chronic pain, learning the lesson we preach – that’s there’s no magic pill, but solutions are in reach.

A Daughter’s Battle Against Chronic Pain

As Veronica marks her 16th birthday this month, we are sharing an update in hopes of de-stigmatizing and demystifying life with chronic pain, fatigue and other undiagnosed chronic illnesses.

It’s been a year since Veronica lay bedridden, unable to breathe normally, felled by a mysterious combination of neurological and physiological complications that dozens of doctors couldn’t quite pinpoint. We thought we had a definitive answer when she was diagnosed with Tourette syndrome last July. But it turned out to be the tip of a medical iceberg.

Though her alarming bout with ‘‘air hunger” dissipated and she willed herself back to school part-time, she could still barely make it through each day. Despite normal blood tests, her exhaustion, brain fog, migraines and weight loss made it nearly impossible to function.

If you’ve suffered from chronic illness, you know the social ostracism that comes with it. ‘‘It’s all in your head,” ‘‘Stop being so dramatic” and ‘‘You don’t look sick” are some common responses from armchair doctors.

For teens, the isolation is wrenching. Veronica lost almost all of her ‘‘friends” last summer — too shallow or self-absorbed to care or comprehend her condition. Depression set in. We were losing her to an abyss of hopelessness.

Then came the Mayo Clinic. The renowned Rochester, Minn., practice runs a Pediatric Pain Rehabilitation Center for adolescents and young adults with chronic illnesses. It’s basically a three-week boot camp to equip young patients and their families with skills to get their lives back through cognitive-behavioral therapy, physical therapy, occupational therapy and recreational therapy.

We learned that Veronica’s basket of seemingly random co-morbidities is common among those diagnosed with dysautonomia, postural orthostatic tachycardia syndrome, hypermobility and pain-amplification syndrome. Her brain and body are wired differently; the triggers are unpredictable. We learned that the ‘‘what” of Veronica’s symptoms didn’t matter as much as the ‘‘how” to help her cope day to day.

There are no magic pills. It’s a tough-love crash course in hard work, personal responsibility and mind over matter. I’m not exaggerating when I say some patients enter the program in wheelchairs or on crutches — and leave on their own two feet with the ability to walk or even run after months or years of inactivity. The goal isn’t to eliminate pain or cure sickness, but to restore functionality.

For Veronica, exposure to and bonding with other teens saddled with similar conditions — and in some cases, much worse — was life-changing. It’s one thing to be told by a specialist ‘‘you’re not alone.” It’s another to join a family of survivors riding the chronic-illness roller coaster together.

Since completing PPRC last fall, Veronica has had more good days than bad. She didn’t let her migraines, second shoulder surgery for subluxation, severe joint pain or OCD stop her from finishing her sophomore year of high school. She has remained close to several of her fellow PPRC grads and made new friends at home.

She received a lot of help along the way. A caring counselor helped her become an athletic trainer at her school, which enabled her to rebuild her social life.

Mental-health professionals successfully treated her OCD and depression using a combination of medication and exposure therapy — an agonizing but effective treatment that required her to confront her fears. Gifted physical therapists continue to treat her joint pain and train her to manage it.

One of the most intriguing aspects of PPRC is the mandate to stop dwelling on symptoms. Talking and thinking about pain or fatigue all the time reinforces the neural pathways for pain and fatigue.

Instead, we focus on the small triumphs each day. We measure life, to borrow blogger Christine Miserandino’s famous analogy, by the spoonful: getting up on time, being able to walk on the treadmill for 10 minutes, completing simple chores, eating well, having a good laugh, breathing free and easy.

So, how’s Veronica doing? The short answer is that she’s doing — and that’s a gift we never take for granted. Happy birthday, my sweet 16 badass. Per aspera ad astra.