chronic pain

The Connection Between Menopause and Chronic Pain

/ Thomas Cohn, MD

menopauseResearch has shown that middle-aged women are more likely to experience chronic pain than middle-aged men, and a new study suggests that menopause may play a role in that pain expression.

For the study, researchers with the Veterans Affairs took a closer look at the health data of more than 200,000 female veterans between the age of 45 and 64. In that group, researchers found that women with menopause symptoms were nearly twice as likely to have chronic pain and additional chronic pain diagnoses.

“Changing levels of hormones around menopause have complex interactions with pain modulation and pain sensitivity, which may be associated with vulnerability to either the development or exacerbation of pain conditions,” says JoAnn Pinkerton, MD, Executive Director of the North American Menopause Society (NAMS). “This study suggests that menopause symptom burden may also be related to chronic pain experience.”

Menopause and Chronic Pain

However, hormonal changes weren’t the only factor driving an increased likelihood of chronic pain conditions. Other factors include:

  • Being overweight or obese
  • Having a mental health diagnosis

Researchers found that 18 percent of women with chronic pain had been diagnosed with PTSD, 15 percent had anxiety and 13 percent suffered from depression. The above factors go hand in hand with menopause and aging, which often include weight gain, decreased physical activity, mood changes and impaired sleep, which can all also affect pain sensitivity and pain tolerance.

“Both chronic pain and menopause symptoms are strongly and consistently associated with psychosocial factors and health risk behaviors prevalent in and after the menopause transition,” said study lead author Carolyn Gibson, PhD, San Francisco VA Health Care System. “Consideration should be given to integrated approaches to comprehensive care for midlife and older women with chronic pain, such as targeted cognitive behavioral therapy coordinated with interdisciplinary care providers.”

This is not the first study to find a link between menopause and certain health conditions. A large study conducted last year found a strong association between the onset of menopause and rheumatoid arthritis. The study also found that menopause was associated with a worsening progression of rheumatoid arthritis, and post-menopausal women with RA had a significant increase in functional physical decline.

If you are getting nearly menopause or working through it, it’s more important than ever to focus on aspects of your health that can help reduce pain sensitivity. Make sure you are eating a healthy diet and getting plenty of regular exercise, and be sure to talk to your pain specialist if you have any questions or need assistance with an issue!

FDA Reexamining Opioids For Chronic Pain

/ Thomas Cohn, MD

FDA effectivenessThe Food and Drug Administration has announced that it will require drug companies to conduct studies to determine if prescription opioids are effective in treating chronic pain.

A number of studies have already suggested that pain controlling opioids are ineffective beyond 12 weeks, and many industry professionals say that continued opioid use after this period can increase a person’s likelihood of developing a dependence or addiction. The FDA wants to supervise the new studies to determine if certain changes, like the following, need to be made:

  • Changing the labeling on certain opioids
  • Imposing special rules for prescribing, dispensing and taking certain opioids
  • Prohibiting use of certain opioids in some cases

“We are going to impose a mandate on existing products . . . to answer the question that people have been posing for years: whether you have declining efficacy, and whether that declining efficacy can lead to addiction,” said FDA Commissioner Scott Gottlieb.

Some Don’t Agree

While it may seem like a good move that the FDA is appearing to take a step in the right direction of opioid abuse, others say the new measures are nothing more than a stall tactic for big pharma. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing, said the FDA ordered a similar measure in 2013 and that they already have all the research they need to make changes that could help protect the public.

“Here we go again,” Kolodny said in an interview. “That’s exactly what the FDA said to us in 2013. . . . Five years later, we don’t have the studies and another FDA commissioner says, ‘We’re going to do the studies.’ ”

However, Gottlieb argued that the research would be aimed at immediate, extended-released and long-acting opioid tablets that are given for pain care outside the healthcare facility. The studies would also cover current medications on the market to examine if new applications of the pain reliever could be more effective. The FDA will also be conducting a second study that is out to determine if opioids can actually cause users to become more sensitive to pain.

A similar study was carried out back in 2013, but Gottlieb said those studies were difficult to carry out because the FDA could only ensure post-marketing studies on safety, not effectiveness. They now have the authority to demand effectiveness research as part of an act passed back in October.

The opioid crisis killed 47,600 people in 2017, but there’s hope that the new research can lead to effective changes. There’s still plenty of work to be done, but with more control over effectiveness research, there’s hope on the horizon.

Why We Choose Not To Exercise

/ Thomas Cohn, MD

not exerciseExercise for healthy individuals is often challenging, and if you have chronic pain, even the thought of exercise can leave you riddled with anxiety and the worry of more pain. In an article recently published in the New York Times, it describes a new neurologic study that finds our brains are wired to tell our bodies to be mostly sedentary. It may be that we are suppose to be less active to conserve our energy.

The study was interesting, examining what motivates us to be active. Most people want to be active but find excuses not to be active. Common excuses we all know, like it takes too much time or that one is tired. Exercise takes commitment and often is at an inconvenient time either early in the morning or after work. Neither time seems enjoyable, especially when you could be doing more enjoyable things, like eating or sleeping.

Exercise Motivations

The New York Times study took healthy young people and then monitored how their brains reacted to visual representations of either physical activity or sedentary things like resting on the couch. The study looked at the brain activity while watching a variety of these images. While watching physical activity, the brain needed to use multiple areas to process the information. When sedentary types of activity, appeared the brain waves were much calmer. The implication was that the brain prefers the calm activities like laying on a couch or in a hammock. The conclusion the authors propose based on monitoring 29 people is that we are hard wired to be sedentary.

Exercise is clearly more work than just sitting around and not being active. The benefits are rarely seen right away and usually are difficult to decipher until time has passed. It is much easier to sit and watch television, sleep or enjoy a big meal. To benefit from exercise one must take a long look at the advantages. For those with chronic pain, exercise keeps the muscles loose and strong, and gives the person the endurance to get through the day. For many, exercise decreases the pain one has overall and keeps them functional in daily activities. The most common response for those who consistently exercise is that I am going to hurt regardless if I do or do not exercise, and without it I would likely not be able to move well at all, so I might as well exercise.

Maybe we have brains that are wired to enjoy restful activity over physical activity. The body, however, is designed for being active. The most appropriate saying that applies is “use it or lose it”.  As a pain physician and someone who does have chronic pain, I can hurt and slowly lose function or choose to be active and maintain as much ability as I can. It is a choice to be active, it takes work, and it is not fun, but it pays off in the ability to maintain function.

Complementary Approaches Beneficial For Chronic Pain Patients

/ Thomas Cohn, MD

meditation painNew research out of the Hospital for Special Surgery in New York found that complementary treatment approaches can help curb pain and in some instances reduce the need for opioids in patients with chronic pain.

“Opioid misuse and addiction are a major public health issue in the United States, and approximately 70 percent of individuals who use opioids on a long-term basis have a musculoskeletal disorder, such as low back pain or arthritis,” said Maggie Wimmer, coordinator of Programs and Outcomes, Public and Patient Education at HSS. “To address this epidemic, Hospital for Special Surgery implemented a Pain and Stress Management program in its orthopedic clinic to enhance patient knowledge and encourage complementary practices as alternatives to medication.”

For the study, the center recruited 122 participants and asked them to participate in a couple different meditation techniques. Patients took part in a monthly in-person meditation workshop and a weekly meditation conference call where they practiced mindful breathing techniques and other meditation activities. Patients also completed a monthly survey on a number of factors, including pain and stress levels, their understanding of complementary medical approaches and how often they practiced the techniques in their own time.

Study Findings

After analyzing the data, researchers uncovered:

  • 98 percent of patients said they were satisfied with the program.
  • 95 percent said the program increased their understanding of complementary treatments and how they can help manage pain and stress.
  • 93 percent said they would recommend the program to others.
  • 1 in 3 patients reported using alternative techniques five or more times in the previous week in place of medication, and 11 percent used the techniques three or four times in place of medication.
  • More than 50 percent of participants reported that their mindful breathing techniques helped them manage their stress and chronic pain.
  • During monthly in-person sessions, many participants also reported an improvement in daily function, calmness and an improved state of mind.

“The results indicate that alternative approaches are effective in reducing pain and stress, and in improving self-management and general well-being,” said Robyn Wiesel, associate director, Public and Patient Education at HSS.

This is something that we’ve been preaching on the blog for years now. You need to have more than one way to treat your pain condition, and these complementary approaches can work wonders. Whether it’s yoga, balance training, mindful meditation, cycling or swimming, find an activity that allows you to de-stress and strengthen your body. Not only will you have physical and psychological benefits, but it may reduce your reliance on opioids!

Drug Screening In Chronic Pain Clinics

/ Thomas Cohn, MD

drug testing Most pain practices have the occasional patient who they suspect are on controlled substances. Since drug abuse has always been a major problem in society, and because clinics prescribe medications, most practices also screen patients for appropriate drug use and abuse.

At the clinical level, drug screening is done in a number of ways, including testing blood, urine, or saliva samples for the presence of drugs. Some tests only show that a narcotic is present in the body, while others can tell how much of a drug is present. Depending on the circumstance, a provider may choose anyone of the different types of tests. Now a breathalyzer-type test is being developed to test for drugs of abuse.

Breath Tests For Drugs

A breath analyzer test has been done for decades for alcohol and now is being developed for marijuana, cocaine, fentanyl, PCP, and methamphetamine. These use a chemistry technique known as mass spectrometry so the test can identify the presence of certain chemicals and also help determine the level in the breath and possibly in the blood. Unfortunately for many of the compounds tested, there is not a standard for which these chemicals may cause impairment.

With marijuana, for example, we have no idea what level in the body correlates to any level of impairment compared to alcohol. The nice thing about this technique is that it is quick with the analysis being done in about 15 seconds. Currently the technology is very new and thus costly, but in the future it should be about $10,000 for a unit and be very portable.

For places looking to detect a very limited number of drugs of abuse, the breath analyzer will be good. For the pain practitioner, drug testing is more comprehensive. Usually a semi-quantitative screen of either urine or blood is used for drug screening. Most pain physicians want to know if the drugs a patient is supposed to be taking are in their systems and whether there are drugs that are present like street drugs that should not be in their system.

Most doctors also want to know if there are drugs not declared by the patient that may also be dangerous if taken with drugs they have prescribed. For the honest patient, drug screening should not be a worry. For those patients that are using street drugs or misusing their drugs, random testing often finds the problem. The patients who are misusing drugs often make mistakes and doctors discover them sooner or later.

In the midst of the opioid crisis and the high rate of misuse of prescription medicines, safe prescribing of any treatment for a pain patient always becomes a concern. There are many treatments for pain with medications being only a limited modality in the overall scheme of options. The use of addictive medications such as opioids is even less attractive since it often worsens pain and becomes ineffective over very short period of time for many people. Drug testing is one of the tools toward safe prescribing that needs to be implemented in pain clinics throughout the country.