pain

Opioids and the Pain Recovery Process

/ Thomas Cohn, MD

Pain stagesPatients who deal with pain can be stratified into a three general categories: acute, sub-acute and chronic in terms of the length of symptoms. This is not an absolute, but a general system. Acute pain is the time immediately associated with an injury or surgery and during the first three months of treatment. Sub-acute is the period of time roughly three to six months after the initial injury. The most difficult time is the chronic period after six months when injuries may be permanent and long-term strategies will need to be determined. Determining treatment options during each period is challenging.

Acute Pain

The acute pain phase is hopefully the only time a person will have problems. It is the period right after injury or surgery, and for most people this is a very short period of time, lasting several days to a week. Many people are able to pass through this period with minimal problems and are on to healing and recovery without the use of any significant medications. With more major problems, symptoms are more prolonged, and more extensive use of treatments are necessary from therapy or long-term medications. Furthermore, everybody has a different need for management and finding the correct strategy may be quite complex.

This also is a period where a person with a tendency toward addiction psychologically or physically can develop a problem. Up to 15-20 percent of the population may be at risk for addiction to opioids. For those people, even within a few doses, the brain starts abnormally seeking the dopamine release stimulated by these drugs. The injury may heal, but the brain continues to desire opioids. This is one of the main times when people develop addiction and start a downward spiral. It is extremely difficult to predict who will develop an addiction and that is the reason for medical practitioners to try to limit exposure. The crisis in drug abuse has pushed the need to reduce the exposure and risk for everyone.

Sub-Acute Pain

The sub-acute phase of pain management is the period of time between three and six months after a medical problem. A management strategy needs to be developed at this point to determine what the diagnosis and prognosis is for the condition. At this point, a specialist is often appropriate so that the best strategy can be determined. Finding the correct person to treat a problem that is not resolving is often the most difficult issue. Physicians are often lacking knowledge and experience to solve the more difficult medical problems.

Fortunately, 90 percent of physicians can guide you through the medical maze. If you are one of those with a particularly difficult problem, you will need one of the best physicians in that field. These physicians are often not in prestigious places like universities or major medical centers, but are the hardworking private practitioners. They often have been in practice for a number of years and they have enough experience to determine what is the best path forward for the complex issues and are not constrained by a single strategy. During this time, hopefully a patient can be transitioned away from opioid-type medications and toward a comprehensive strategy.

Chronic Pain

The last phase is when a problem turns chronic. That time period is after six months. Sometimes, if the initial treatment has not been successful, this is the period when a skilled physician needs to be found to fully diagnose the issues and develop a new strategy. These skilled experts can clarify and define issues others have not seen. They are also the ones who will act as a guide through the maze of medical issues and not give up. If you listen and work with them, it is likely that a positive outcome will be achieved.

Chronic pain problems may or may not be well served with opioid medications. There are far more down sides to these medications than positives. They may seem helpful, but often are treating the anxiety associated with pain more than the pain itself. Opioids increase the sensitivity in the nervous system to painful stimuli and suppress the body’s own pain fighting ability. Everyone will become tolerant to opioids and up to 20 percent of the population will develop an addiction. With over 140 deaths/day and over 60,000 deaths/year associated with opioid addiction, it is a very limited treatment option. Most pain physicians therefore are reluctant to use these medications and push every other option. If they are used, then strict compliance rules are mandated for safety. Break any of the established rules and the option disappears, possibly permanently. If these medications are maintaining high levels of function such as full-time gainful employment, then they may be reasonable.

If you use opioids either short-term or for a long span of time, expect strict rules. These drugs are notoriously dangerous, and they often have a narrow range of safe dosage. Any improper usage can lead a provider to stop prescribing. Addiction, death and damage to the patient or others are always a concern. Further, if there is a better treatment available, then prescribing opioids may be a poor choice for both the patient and prescriber.

If you are told this is not the best treatment for you, there is probably a good reason and you should try every other option offered. Often a person in pain has poor insight into their own behavior and listening to others is necessary. Pain can be extremely complex, and often there is no solution but only management options.  For chronic pain, sometimes one needs to look at your own situation and determine a different path to follow in life such that life can be more enjoyable.

Understanding Chronic Pain in Children

/ Thomas Cohn, MD

chronic pain childrenPreventing chronic pain is a daily battle for many adults, and the symptoms can be even tougher to control in children and teens. Interestingly, new research published in Health Psychology suggests that adolescent pain may be linked to previous experiences with pain, and if we can improve these initial experiences, children may be less likely to experience future pain.

It may sound complicated, but the research wanted to see if there was a link between a previous pain experience and how pain is felt and managed in the future. To do this, researchers examined children who had undergone a major surgery, as these experiences, even if they go as expected, may be traumatic to the child and are likely accompanied with some pain or discomfort.

“This is not to say that every child who has chronic pain had a surgery that led to it,” said study author Melanie Noel. “Rather, it’s that surgery is the only context where we can catch these kids before they develop chronic pain. We know that 15 to 20 per cent of children who undergo these major surgeries will develop chronic pain. So, if we can catch them early and begin to understand the factors leading to their chronic pain, maybe we can prevent it from happening in the first place.”

At the conclusion of the study, researchers found that a child’s memories of pain following major surgery actually influenced their recovery and was associated with an increased risk of the development of chronic pain down the road.

“We’ve discovered that the way children are remembering their pain is an underlying factor in the development of chronic pain,” Noel explained. “It’s not the pain they actually experience so much as the way they process those memories of the pain which is driving whether or not they’re improving, right around the time that pain can transition into chronic pain. At a certain point, these children should be feeling better but those who develop chronic pain are not.”

Managing Adolescent Chronic Pain

The study, which was conducted in Canada, suggests that anywhere from 15-40 percent of Canadian children experience chronic pain at some point during their childhood. Moreover, 60 percent of these children eventually develop chronic pain in adulthood, so it’s important to control chronic pain while kids are young to prevent it from becoming a problem when they’re older.

Researchers believe the findings can help point doctors and parents towards solutions. They believe that psychological and language-based interventions may be able to help kids better cope with post-surgical pain, which will help re-frame their memories of the pain and in turn decrease their likelihood of developing chronic pain in adulthood.

“We can teach kids how to reminisce and talk about their pain experiences in a way that emphasizes anything positive about it,” said Noel. “Maybe the child coped with something well, maybe there was a really friendly nurse. It’s getting them to talk about things that aren’t just focused on the awful after effects of the surgery. It’s a way of catching it, a talk-based intervention that can possibly re-frame the memories. This may actually alter the pain trajectory. It’s one thing we can do to make the recovery and future experiences of pain better.”

This is fascinating research, and I hope the findings are considered by pain professionals when helping children get to the bottom of their chronic pain.

September Is Pain Awareness Month

/ Thomas Cohn, MD

pain management awarenessIf you don’t deal with pain on a regular basis, odds are you don’t realize how big of a problem pain is in our society. That being said, there’s a good chance you do deal with pain, because roughly one in three adults is the United States is battling a pain condition. Whether it’s from arthritis of the hips, carpal tunnel in the wrist or another painful conditional, pain is very prevalent here in America.

To help bring awareness to the pain problem, September has officially been declared Pain Awareness Month. Today, we hope to share some facts about pain and bring attention to the problem so that we can work towards a solution.

Everyone’s Pain Is Different

Pain is unique to the individual. Even though you may share a diagnosis with thousands of other people, your pain is going to be unique to you, so it should come as no surprise that treatments can differ greatly even if two people are diagnosed with the same pain condition. For some, physical therapy, exercise and a diet change can help keep pain at bay, while others will find relief with acupuncture, yoga and anti-inflammatory medications.

The key to treating pain is to treat the underlying condition, not the symptoms. Some passive treatment techniques like opioids or pain injections help to decrease pain levels in the short term, but they do nothing to treat the underlying problem, which means these patients will never truly be rid of pain. Pain specialists are great at finding the underlying cause and developing treatment strategies to fix the true source of pain. It’s not always going to be easy, but trust us when we say it will be worth it in the long run.

Treating pain also needs to be a two-way street. There is no magic pill to cure your of your pain, so while a doctor can help diagnose your pain and suggest treatment options, we can’t force you to take part in therapy or eat a healthier diet. The desire to get rid of daily pain needs to come from the patient. We will do everything possible to help you on your journey, but we can’t do it for you. Meeting with a pain specialist is a great way to set and manage expectation between doctor and patient.

Facts About Pain

To better explain just how prevalent chronic and acute pain is in today’s society, check out some of the facts about pain below.

  • Over 75 million Americans deal with a pain condition, more than those diagnosed with cancer and diabetes combined.
  • 30 percent of adults between the ages of 45-64 experience pain that lasts longer than 24 hours.
  • The estimated annual cost of chronic pain in the US is more than $100 billion.
  • 1 in 5 people experience pain that disrupts their ability to sleep.
  • Back pain is the leading cause of disability for people under the age of 45.
  • Less than half of pain sufferers feel like they have control over their pain.
  • More than 75 percent of individuals with chronic pain say they suffer from depressive thoughts or anxiety.
  • Headaches were the most common type of pain that led to lost productivity in the workplace.
  • Only 15 percent of people with a pain condition go to a pain specialist. Most prefer their primary care doctor.

If you are dealing with a pain condition, consider setting up an appointment with a pain specialist. Your doctor has a wide range of medical knowledge, but they lack the depth of knowledge about specific pain conditions that a specialist has. If you want to set up an appointment, reach out to Dr. Cohn’s office today.

Let’s Focus On The Pain Epidemic, Not The Opioid Epidemic

/ Thomas Cohn, MD

pain opioid epidemicA recent article in the Star-Tribune noted that every three weeks, the death toll from opioid overdoses matches the death toll from the attacks on the World Trade Center on September 11, 2001. Not only is this a concerning number, but trends show that the death toll from opioid overdoses is continuing to skyrocket. The government and even President Trump have stated that the opioid epidemic is a problem that needs to be solved, but are they looking at the problem in the right way?

The opioid crisis is a huge issue, but it’s only a symptom of a larger problem, which is the pain epidemic in America. More people are turning to opioids in the United States because more of them are fighting a losing battle against pain. We need to be finding solutions to the pain problem, because the opioid crisis is a symptom of the problem of pain.

Stopping Pain

Think of it this way. Let’s say you’re in your house and you see smoke. You run to the kitchen and notice a fire behind the stove. You quickly fill up some water from the sink and douse the flames with water, stopping the fire in its tracks. It’s great that you stopped the fire, but you wouldn’t just go back into your living room without investigating what caused the fire to start in the first place. If you don’t fix the faulty wiring that caused the fire, you’re prone to another fire in the future.

In the above instance, throwing water on the fire is like trying to treat the opioid epidemic. It is a problem that needs to be addressed, but unless we also focus on the root problem, which is pain (or faulty wiring in this case), then the problem is only going to continue to be cyclical. Eliminating opioids may reduce the number of overdose deaths, but it will also hurt patients who use them responsibly to manage their pain, and severely cutting back on opioids will do NOTHING to solve the pain problem.

What We Need To Do

Enough about what’s wrong with the current system – here’s a definitive list of what we as a nation need to do in order to fix the opioid crisis and the pain problem in America.

  • We need to educate both patients and doctors about how opioids work in conjunction with a multi-faceted approach to pain management.
  • Opioids can play a role in pain care, but they can’t be the only treatment option. They can help manage pain, but they are not a long term solution to treat pain. Anybody who is only taking pain medications for their condition is at a high risk for dependency and has a low chance of ever recovering from their pain.
  • We need to open up insurance coverage to other non-traditional methods of pain management. Let’s get creative with pain management, because what works for some will not work for others.
  • We have to pound home the message that there is no magic pill for pain, but tangible solutions are within your reach.
  • Doctors need to do a better job of pushing people towards tangible solutions instead of quick fixes. Things like physical therapy, aqua therapy, cognitive behavioral therapy, yoga, etc. over writing a quick prescription.
  • We need to invest research funding into pain treatments, whether it’s medical marijuana or new diagnostic tools, we need to spend money on solving the problem of pain. Invest in pain solutions like we’re investing in treating cancer or diabetes.

If we can check off all the items on this list, I’m confident we can find new ways to treat pain, and in turn combat the opioid crisis in America.

Two Reasons Why Smoking And Chronic Pain Don’t Mix

/ Thomas Cohn, MD

smoking chronic painAs someone who has dealt with both acute and chronic back pain, I understand why patients want to control certain aspects of their life. Chronic pain can lead to anxiety and stress, and oftentimes patients just want 5-10 minutes where they can turn their brains away from their pain and feel a little relief.

Unfortunately, some people turn to cigarettes for this relief, and while it may offer you short-term relief, it’s making it hard for you to achieve long-term relief from your chronic pain.

Smoking has been linked to cancer, but today we’re going to focus on its impact on your chronic pain. I understand where the smoker’s head is at, but here are two reasons why smoking is seriously jeopardizing your likelihood of ever solving your chronic pain problem.

Why Smoking Worsens Your Chronic Pain

Smoking does a number of different things to your body, but one specific side effect of smoking is the impairment of oxygen-rich blood to your bones and soft tissues. Think of it like watering your garden during a week-long drought. If you water your garden once during the middle of the week, the plants will get some nutrition, but they will also suffer because they need more water. If you watered your garden 3-4 times throughout the week, your plants would never be without nutrition and thus could grow and prosper.

The same thing happens when you smoke. Some oxygenated blood reaches the lower back, but more would help your body heal faster. Giving up smoking will ensure that more healthy blood reaches areas of pain, decreasing your likelihood of a flare up.

Along a similar vein, the second reason why smoking makes it harder to recover from a chronic pain situation is because smoking has been linked to fatigue and slower healing rates. Exercise is a great way to combat chronic pain, but if you are tired or unable to exercise for longer periods due to your smoking habits, your chronic pain is more likely to linger. Similarly, blood vessel restriction means that your body can’t always get the nutrients to heal as quickly. Chronic pain can easily become cyclical if smoking slows your body’s ability to heal, or if it contributes to the onset of other painful conditions, like arthritis or degenerative disc disease.

It’s easier said than done, but if you can kick the habit for a healthier one, odds are you’ll be amazed at the health improvements you’ll see. We understand the desire to find some control in what seems like an uncontrollable situation, but turning to cigarettes only makes the problem worse.