The Complexity Of Pain Management

February 1, 2017 / Thomas Cohn, MD

Back pain patients often state if they just lost some weight, maybe their low back would feel better. It would be nice if it were that easy, but it is often much more complex. Usually someone who has back pain has multiple causes of the pain, from simple lack of strength in the muscles, to nerve irritation, degeneration of the joints and discs in the spine and problems with body mechanics. Yes, weight can stress every structure in the back and make things harder and more painful, but oftentimes all the other things causing pain may be more important in order to control back problems.

Controlling Back Pain

Asking most doctors about how to lose weight is often not very helpful. About 75 percent of medical schools do not provide the recommended 25 hours of nutrition training, and many older physicians have had minimal to no training in nutrition. Complicating everything is the fact that older research was often sponsored by major manufactures of food and conclusions of the studies were not scientifically sound. Current research is showing that every person often responds differently to a diet, and what is helpful for one person will not always work for another. The more one reads, the more complex the human digestive system becomes and our understanding is really limited. Everything affects us, from our genetics, to what our mother’s ate during pregnancy, to the bacteria in our gut.

Eating a healthy diet is probably the most sound advice, and then pay attention to the amount you eat as well as when you eat. Healthy eating means eating less processed substances like pre-made foods. Some people equate this to eating from the fringes of the grocery store, where the fresh fruit, vegetables, salads, lean meats, and diary if often kept. Limiting simple carbohydrates like bread, potatoes, pasta, sugar and white rice can help many people as well. Protein sources from poultry, fish, beans, nuts and diary, and not from red meat are recommended in many diets. If you have gastrointestinal problems like inflammatory bowel disease or celiac disease with gluten intolerance, diets change play an even bigger role in solve the pain equation. In general, a plant-based diet is often the healthiest.

Managing Weight and Back Pain

Since low back pain is caused by many factors, it is rare that the most important issue is weight. The most common factor is usually the lack of exercise. Often a patient will go to physical therapy and learn what to do but after the formal sessions, they do nothing on their own. Those who are overweight are no different than most patients; they are not actively exercising and taking care of their health. Every patient must find their own internal motivating factor to take care of themselves and exercise. Staying healthy takes a lot of work. There is no quick fix and those who actually do the best take care of their physical and mental health. Those who do the best follow through with the three components of exercise – stretching, strengthening and aerobic conditioning. If you are doing the work of exercising appropriately and eating a healthy diet, it is likely that weight will not be an issue.

Those who do have back pain and who are significantly obese often can improve their back pain with weight loss. However, the improvement is relatively minor with the loss of weight. The patients who notice the most improvement in pain are those who adopt a healthier lifestyle. Despite being obese, they start consistently exercising, often finding a way to participate in a pool exercise program so they do not stress their joints. They also have changed their eating habits, and the combined efforts usually lead to a sustained weight loss of 1-2 pounds per week. Believe it or not, it becomes obvious who actually is exercising, as they start feeling better and have markedly less pain. Low back pain affects millions of people nationwide, the simplest solutions often are the best – exercise and a healthy diet.

The Politics Of Pain

October 31, 2016 / Thomas Cohn, MD

The 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.

Opioids – Why Patients and Physicians Are Frustrated

May 25, 2016May 25, 2016 / Thomas Cohn, MD

Every week there is a new article on the opioid epidemic. The focus is all on the number of people addicted to pain medications and how people are dying every day. Today an article appeared in the paper on how one of the drug companies is making a long acting opioid and how it can make people become addicted. Other stories are focusing on those who already have addiction problems. The real problem is the need for better treatment for pain, for both acute and chronic.

Chronic pain affects 30 percent of the worldwide population. Until the last several decades, many people did not survive long enough such that pain was a problem for decades of their lifetime. Now, life expectancy is often into the 80’s and many have chronic, painful conditions for nearly half of their life. The range of treatments is limited, and there is often no full cure for a lot of conditions that result in pain, despite the fact that western society expects the physician to have a miracle cure. Even the most knowledgeable patients often have unrealistic expectations to be pain free with the next treatment option.

Patient and Physician Need To Work Together

Yes, the United States of America has an opioid addiction problem. The real problem, however, is a lack of education for the patient and physician on how pain can be treated. On top of this is the focus on treatment of addiction versus the better treatment of pain. One of the main problems leading to opioid addiction is the lack of medications to treat pain. Other treatments for pain are not as easy as taking a pill. Physical therapy, behavioral interventions and injections may be better, but they are more difficult for the patient and definitely more costly.

The most frustrating problem for physicians is insurance coverage for newer medications, maintenance physical therapy, psychological therapies, alternative therapies, comprehensive pain programs and sophisticated interventions. It is easier to get coverage for an opioid for pain than get psychology to prevent the need for opioids. The same is true for allowing a trial of a spinal cord stimulator versus allowing for a back surgery. An intervention that has a cheaper overall cost and is safer within a year or two will not be covered by insurance. Further, the insurance companies often will say a treatment is experimental, such as a radiofrequency neurotomy or the use of Lidoderm patches, refusing to cover the expense while gladly paying for highly addictive opioids.

Pain patients and physicians are equally frustrated by the lack of coverage for alternatives to opioids. Instead of focusing so much on the bad outcomes of opioids and treating addicts, investments need to be placed on using alternative treatments and funding research to develop better pain treatments. One third of the population suffers from pain. It is about time the pharmaceutical industry, government, and even insurance companies invest in better pain management strategies.

Could Dad Be To Blame For Chronic Pain Woes?

August 31, 2015 / Thomas Cohn, MD

A study out of Japan suggests that how parents bond with their children during adolescence could impact the child’s likelihood of developing chronic pain later in life.

Furthermore, the study suggests that children who had a poor bond with their father were the only group to show a significant increase in chronic pain likelihood.

The goal of the study was to better understand chronic pain as a complex biopsychosocial condition and how outside psychosocial factors like pain, pain-related fear, self-efficacy, anxiety, depression and psychological distress feed into that perception of pain.

For their study, researchers polled nearly 800 adults about their relationship with their parents and their overall health. Participants completed the Parental Bonding Instrument, a self-administered questionnaire that assessed perceived parental bonding, as well as a health assessment. The PBI test asked respondents several questions about their relationship with their parents growing up, including questions about the perceived level of bonding, over/underparenting, affection and discipline as well as control and understanding. Participants took the survey twice, once while contemplating their relationship with their father and the next while answering questions about their mother.

After comparing the PBI results with the results from the health exam, researchers uncovered:

Compared to the optimal bonding group, the odds ratio for having chronic pain was much higher in the affectionless control group for paternal bonding and for maternal bonding.

When adjusting for other factors, significance remained only for parental bonding.

“The fact that fathers have been shown to be much more likely to use physical punishment and abuse than mothers in several epidemiological studies may also be related to these findings,” the study authors wrote. “Clearly, further studies are needed to elucidate the mechanism(s) whereby parental care affects the development of chronic pain in a gender-dependent fashion.”

Researchers concluded by saying that mass-education on parenting behaviors for optimal bonding may be one of the most promising chronic pain prevention techniques that few are pursuing.

Pain Care: The Benefits of Pain Management

July 9, 2014February 17, 2016 / Thomas Cohn, MD

Pain is a complex problem with physical and emotional components. It can affect all aspects of a person’s life. When pain is treated early and aggressively, often it can be cured. Sometimes the injury that has caused the pain cannot be completely reversed and the damage needs to be managed on a long-term basis. Medically, we are always looking to find a diagnosis and treatment for every problem. Pain Care is aimed at finding the individualized, comprehensive diagnosis and management plan for a patient’s symptoms and problems.

Pain Care

Pain Care has been developed to take the next step in managing a patient’s symptoms. A new patient will undergo a comprehensive evaluation by a Board Certified specialist in Physical Medicine and Rehabilitation with a subspecialty in Pain Care. These physicians are medical doctors with extensive special training in the musculoskeletal, medical and neurologic systems, which allows them to better diagnose and treat almost any painful condition. As Physical Medicine doctors, they are the “Family “ physicians coordinating and delivering care to those with pain.

Since pain often is a complex problem, Pain Care is designed to help the patient move forward with management. Every patient is unique with their own set of important problems. If all the answers were obvious, there would be no need for our services. Unfortunately, pain is the most common problem bringing a patient to the doctor’s office. When it does not resolve in short period of time, consulting a specialist is often extremely beneficial. There is not one solution, one medication, one shot, or one specific intervention that is right for every patient. Pain Care is designed to integrate and coordinate our skills into the community to treat these challenging patients with their current care team.

Pain management is not a new medical field, however there are not many providers with the Physical Medicine and Pain specialty skills. Pain is complex and Pain Care is designed to address these issues and bring a solution to the patient and community.