Tag Archives: treatments

Marijuana Policy Discussion

Douglas Hiatt, Seattle criminal defense attorney and co-author of I-1068, joined several other local experts to discuss marijuana legal reform at Seattle Town Hall. The community discussion aired live on Seattle Channel and featured audience participation. Several I-1068 volunteers spoke up and made their voices heard. Watch:



NY – Beth Israel Medical Center

Russell Portenoy, MD
Pain Medicine Specialist
Chairman, Department of Pain Medicine and Palliative Care, Beth Israel

Depression and Chronic Pain Is Extremely Common

In some patients, depression follows the pain, and if you can effectively treat the pain, the depression would get better. And in some patients the depression seems to drive the pain, says Dr. Portenoy. He explains that when these two conditions coexist, patients need carefully coordinated treatment.

Dr. Portenoy is among New York Magazine’s “Best Doctors” for 2008, as listed in the June 16, 2008 edition of the magazine. The New York Magazine list is excerpted from Castle Connolly’s annual guidebook, “Top Doctors: New York Metro Area.”

Address

First Avenue at 16th Street
New York NY 10003
Telephone:(212) 844-1505

Questions About Using Opioids for Chronic Pain

Q: Would you say that opioids are a last resort?

A: No. Opioids should be considered for every patient with chronic, moderate to severe pain, but in every case, you would only prescribe the opioid after carefully considering the responses to several questions.

Q: What are those questions?

A: First, what is typical treatment with respect to this pain? Second, is there some other therapy that has as good or better efficacy and safety? Third, is this person at relatively high risk of opioid side effects for whatever reason? And fourth, is this patient likely to be a responsible drug taker, or is there a history of substance use problems?

So in some cases, for example a patient with severe pain who has not done well with several steroid or other drug injections and physical therapy, and who presents to the doctor with back pain so severe that he can’t walk—that patient might be considered a candidate right then for a trial.

Q: What is an example of that review process with a typical patient who has arthritis of the knees and hips.

A: Everybody would agree that the first-line therapies typically would include acetaminophen, physical therapy, or a TENS unit, or maybe—if there’s a single joint that has some swelling—an injection.

The next-line therapy would be an NSAID. But if that person has a history of an ulcer or a history of bad heart disease, the NSAID risk gets to be relatively high. So that patient might be considered for a trial of an opioid at that point.

Q: If I’m that patient and I’m put on a trial, how will I use the drugs?

A: Almost everyone with chronic pain appears to benefit more from regular, fixed, scheduled use as opposed to PRN [when needed] use. There is a general perception, two decades old, that patients do better if they have pain medicine in their blood 24/7. It’s done in a sustained way, so that the blood levels don’t fluctuate much.

Q: In the whole range of treatments for chronic pain, where do opioids fit in?

A: The chronic use of opioid therapy to treat noncancer pain syndromes, such as headache and low-back pain, and arthritis, continues to be controversial. Most pain specialists nowadays would say that opioids might be considered in any patient who has chronic, moderate to severe pain, but generally should only be implemented if there are no other treatment options that have a favorable and safe effect. The shortest way of saying this is that most pain specialists would not consider opioids first-line treatment for chronic noncancer pain except in highly selected patients.

But we have accumulated clinical experience that suggests the following: There is a sub-population of patients with chronic pain, who can be given access to long-term opioid therapy, and they will experience sustained and meaningful control of pain in the absence of intolerable side effects and without the development of tolerance or the need for dose escalation. And they will not develop any aberrant drug-related behaviors consistent with abuse, diversion, or addiction.

Q: What about the use of opioids for breakthrough pain?

A: It looks like about 60% of patients with chronic pain have flairs that can be called breakthrough pain, and in the cancer population, the use of a short-acting opioid co-administered with a long-acting drug is the standard of care.

With noncancer pain, it’s a moving target. People are trying to figure out if it should be the standard of care or not. I think it should not. I think it should be a case-by-case decision.

Q: What are some of the risk factors when opioids are being considered? Do they all relate to addiction?

A: No. Suppose you have a patient with very bad lung disease who might be at risk for the respiratory effects. (Opioids can suppress breathing.) Or you have a patient who has severe gastrointestinal problems—where the constipation induced by the opioid might become very problematic. Or you have an elderly person with arthritis who has a mild dementia: In that case, the bias would be to try an NSAID because the opioid has a higher likelihood of causing cognitive impairment.

Q: Is the ultimate concern, though, addiction?

A: No, it’s broader than that. It’s responsible drug use, a term I use purposely because for clinicians, addiction is an uncommon problem—a very, very serious problem, but it’s an uncommon problem.

Q: So there are irresponsible uses that do not involve addiction?

A: What’s much more common for clinicians than addiction is what has been called aberrant drug-related behavior. Behaviors like doctor shopping or frequent visits to the ED [emergency department], or increasing the dose during pain flare-ups without permission. Or taking an opioid to help you get to sleep at night, or taking it when you’re feeling anxious. Or in some cases using an illicit drug, like smoking marijuana on the weekend, without telling you.

A clinician who is trying to prescribe these drugs safely ought to be monitoring all of those behaviors and trying to work with the patient so that the behavior regarding these drugs is responsible—meaning take the drugs as prescribed.

Q: It’s not as simple as saying that opioids deliver a “high,” is it? What “benefits” do abusers get from the drugs?

A: There are studies that have been done that show that in the usual person—with no history, and no family history of addiction—the typical mood response produced by opioids is dysphoria, not euphoria. But in some cases, they might be driven by co-morbid psychiatric disease—they may have anxiety disorder and realize that these drugs produce some reduction in anxiety. Or they have a depressive disorder—these drugs were used in the 1950s as antidepressants before we had any real antidepressants.

Or the patient may have a co-morbid psychiatric disorder associated with impulsive drug use—they would take any centrally-acting drug, any drug that alters their consciousness, impulsively.

There are also people who have an addiction biology, and it’s profound. I talked to a physician who became addicted to opioids, and he told me that the first time he took an opioid, it was like he had discovered something very magical about life. He said, “I knew this was my substance, this was something that I needed.” With a single dose.

Q: What is the risk of actual addiction?

A: Most scientists who work in this area think that about 10% of the population in developed countries have the biological predisposition, the genetic predisposition, to potentially become addicted. Truly addicted. Which is a huge number, 10%.

Q: If a chronic pain patient passes your various tests and is a good candidate for an opioid, what happens then?

A: At the present time the professional community is telling doctors that they have two obligations whenever they prescribe a controlled prescription drug.
Number 1: To know the pharmacology so that the patient’s outcomes—meaning the pain relief they get, and the side effects they experience—those outcomes are optimal.
Number 2: They need to do risk assessment and management to ensure that the patient takes the drugs in a responsible way, and there is minimal risk of abuse, diversion, and addiction.

Q: What does that mean for the patient’s experience?

A: Every patient should undergo a comprehensive assessment and risk stratification. The doctor takes a history and then makes a decision: Is this person at high risk or at low risk of developing problematic drug-related behaviors?

The most accepted factors that put a person into a high-risk category is a personal history of substance abuse now or in the past, a family history of substance abuse now or in the past, or a history of major psychiatric disorder. And there are many, many other factors: Current smoking, history of physical or sexual abuse.

Q: Give an example of a high-risk patient.

A: A young man who injures his back at work and has pain for six months, sees a doctor, and the history reveals that the patient binge drinks on the weekend, uses marijuana three nights a week, and has a brother who has been through detox. If an opioid is being considered for that patient, then the structure of the therapy should be very defined and very rigid, it might include any or all of the following.
An opioid agreement that is used to educate the patient about responsibilities and consequences of bad behavior
A small number of pills prescribed
The requirement that the patient returns with the pill bottle so that a pill count can be done
The requirement that the patient gets urine drug screens periodically
A requirement that the patient gets a consultation with an addiction-medicine specialist
The requirement that the patient uses only one pharmacy, so that you can track what has been dispensed

Q: What about a low-risk example?

A: A patient 70 years old develops bad knee and hip pain from arthritis, and the history reveals no personal history of substance abuse, including no use of alcohol, no family history, and no known psychiatric disease—that patient has very, very low risk of developing problematic behaviors. For that patient, a structure might be to come back in a month and provide a phone call in the middle.

Q: Sounds complicated. Should chronic pain patients seek out a specialist?

A: Only about 5% of people with chronic pain ever see a specialist. This is a type of therapy that, for 20 years, people like myself had been promoting as needing to be done by primary care doctors.

Q: What advice do you give patients who are looking for possible opioid treatment?

A: I would like patients to think, “Opioids may or may not be appropriate. But I need to see a physician who’s comfortable with prescribing opioids and also knows how to do it in a way that’s safe and effective for me. When I go into that physician, I know that I’m going to have to be honest and let that person do a good assessment. And I’m going to have to provide my records to that person. If that means that I have to have urine drug screens, so be it. If I have to sign an opioid agreement, if it’s reasonable and educational, I’ll sign it. If I have to go and get treated by a psychologist at the same time and I can afford it, I’ll do it.”

There has to be a recognition that this is a controversial therapy that takes a lot of effort on the part of the clinician, and the patient has to not only adhere to the therapy, but also has to communicate and be willing to be monitored.

Q: Given all that, do you believe that opioids are underused in the treatment of chronic pain?

A: Absolutely. I’ve seen this controversy in the U.S. going back and forth for about 25 years. This is a pendulum that swings back and forth depending on how frightened people are of addiction and abuse, and depending on how much the advocacy community gets the word out about undertreatment.

There’s a whole political and social context here that is not based on any known science. And in the 2000s we seem to have the pendulum shifting toward more denial that the therapy can be useful, more reluctance to prescribe, more concern about regulation.

Q: That’s an unfortunate swing for those people who would benefit from these drugs.

A: No question. But I want to acknowledge what my colleagues would say, many of them—that 25 years of research has yet to show the evidence that long-term opioid use is effective for chronic pain.

There have been a large number of good clinical trials, but they’ve all been either short-term or in very selected populations, or didn’t measure all the issues.

But the bottom line is that we have about 9,000 years of clinical experience showing that they can work. And you also have a consensus in the professional community of pain specialists—not just in the U.S., but also in Canada and England and other countries in Europe. You have a consensus that has evolved based on the data that do exist and the observations that exist.

The real issue is, let’s stop arguing about should patients ever get opioids and start arguing about who should get them and how you prescribe in a way to optimize the outcomes.

Q: Of course, even when drugs work, patients don’t always take them.

A: In the past 20 years, there’s been all of these new modified-release formulations, so now there are once-a-day drugs, twice-a-day drugs, patches that last three days, all for the treatment of chronic pain.

So you would think that compliance would be easier because it’s more convenient, and in some respects that’s true. But we just did a little study here, which we haven’t fully analyzed yet or published, and what we discovered in our group was this: In almost 100 patients, about 50% were non-adherent, and the vast majority of that group was undertreating.

It raises questions: Why are they undertreating? Are they afraid? Or do they have side effects? Is it money?

The bottom line is, most patients are not out there acting like [drug addicts], most patients are pushing you to give less, or not taking everything you prescribe. They’re not interested in abuse, they’re interested in getting off this stuff!

Headaches, Headaches, Headaches 24/7

I have survived cancer! I can not be happier and I fought with ALL I had inside me to beat cancer. I had only been engaged to the love of my life for four weeks and I had two children ages 7 and 10. There was no way I was leaving any of them.

My parents moved in as I was a single mom at the time and took care of me 24/7. They were the best they cooked and cleaned and got me to every single doctor’s appointment I had.

After two years I am cancer free and life should be perfect right? Well due to my tumor in my sinuses and right eye orbit I have been left with headaches 24/7. I look soooo much better then I have in the past two years!

I try to be perfect for everyone. But inside I am breaking. My headaches that I try to hide from everyone are killing my very being. I am on pain medicine and it really does not see to help it too much. While it does decrease the pain sometimes the majority of the time I have a headache. I my temple, forehead, neck and face….

I seem to snap quickly as it is always there then the littlest things set me off. I typically can not control it, as again, inside I am in knots from the pain and then something aggravates me and off I go.

I do not want to complain about my headaches to my husband as he has heard it! I do not want to complain to my parents as I do not want them to worry any more then they have to. I have to be a strong mom for my kids so most of the time I just put a smile on and not let anyone see what I am going through inside.

Who can help? This pain has to go away as I can not continue to live like this. It is not fair it is debilitating and is ruining my happiness and who I am as a person.

I want my “old” self back, the one before cancer who was happy and fun to be around. The one that was silly and loved to be outside doing just about anything.

Pleas help me find my relief!

LPHS and Acupuncture

Hello everyone,

I was wondering if any of you have tried acupuncture for the treatment of pain and bleeding in regards to LPHS. If you have, I would like to hear from you on whether you had success or not. I have had 5 treatments where is she trying to focus on the kidney itself. It is still hard to tell if it is working or not. Any help would be greatly appreciated.

Hoping to hear from someone who could be helpful.

Helene

Phantom limb pain

Phantom Pain is a form of nerve pain appearing to arise from an area of the body that has been removed or amputated. This pain can affect mastectomy patients as well as patients with simple tooth extractions. Phantom sensations of some kind are almost universal in patients that have undergone limb amputations. Significant pain occurs in as much as 80% of these patients, but seems to improve over time in at least half of these patients.

The cause of phantom pain is not fully understood. It is important to emphasize that the pain is not imagined, and is not the result of a psychological or emotional disturbance.

Phantom pain is the prime example of neuropathic pain; i.e., pain that is caused by a damaged or malfunctioning nervous system. Therefore, all the medications that are used for neuropathic pain can be useful for phantom pain. This includes anti-convulsant and antidepressant medications. Transcutaneous electrical nerve stimulation (TENS) of the stump can occasionally provide relief. Interestingly, stimulation of the intact, opposite limb is often more effective. In some patients, rehabilitation with active exercise and use of the stump and a prosthesis can be the most beneficial treatment. Placement of spinal electrical stimulators has had mixed results, but if the pain has been refractory to all prior treatments then this should be considered.

It may be most appropriate to target the initial injury that precipitates the enduring neuropathic pain. In fact, this is already done by the use of pre-emptive anesthesia during surgery. The surgeon uses a local anesthetic to deaden the nerves as well as a general anesthetic to immobilize the patent for surgery. Another possibility may be to suppress the immune system for the initial five days after injury. This may curtail the inflammation associated with peripheral nerves that appears to trigger many aspects of neuropathic pain.

A recent article in Psychiatric Times by Steven A. King reported that while the “apparent neuropathic nature of phantom limb pain (PLP) would suggest that antidepressants, anticonvulsants and similar medications would be most efficacious. Most (PLP) patients are treated with acetaminophen, nonsteroidal antiinflammatories and opioids.” A survey article by M.A. Hanley and associates found that just over half of PLP patients, and over one-third of severe PLSP patients, “had never been treated” at all for their pain.

from The Richeimer Pain Institute

At Sea

Unique Pain, Headache, and Migraine Education Series Setting Sail

Dr. John Claude Krusz, Helen Dearman, and Teri Robert have joined forces to form Pain Tamers(TM) At Sea to provide opportunities for chronic pain, headache, and Migraine patients to learn about their conditions and management techniques. In the setting of an ocean cruise, the goal of Pain Tamers(TM) At Sea is to provide a peaceful, relaxing setting for educational seminars combined with a short vacation.

Dr. John Claude Krusz, Helen Dearman, and Teri Robert have joined forces to form Pain Tamers(TM) At Sea to provide opportunities for chronic pain, headache, and Migraine patients to learn about their conditions and management techniques. In the setting of an ocean cruise, the goal of Pain Tamers(TM) At Sea is to provide a peaceful, relaxing setting for educational seminars combined with a short vacation.

ìBy offering people a chance to learn in a relaxing atmosphere, away from the stresses of everyday life, we will be providing them with tools to go home and do more to take control of their pain issues, whatever they are. For the few days theyíre with us, they wonít have to worry about answering their phone, taking care of their house, going to work, preparing meals, or even making the bed. They can enjoy some quality relaxation time, learn, and have special time to meet and talk with other people who fully understand their situation,î Robert said.

Dearman commented, ìYou donít have to let pain stand in your way. Iíve learned how to ëtameí it and want to tell others they can too.î

The first Pain Tamers(TM) At Sea cruise is scheduled for October 12 through 16, 2006, departing from Galveston, Texas, aboard the Carnival ìFun Shipî Ecstasy. Each of the three days will include three hours of seminars on the treatment of chronic pain, headaches, and Migraine disease; coping skills; building support systems, and more.

Krusz, Dearman, and Robert will each conduct a one-hour seminar each day. Printed materials will accompany the lectures. Topics include:

Krusz:
– Introduction to Headache and Chronic Pain. What are the Numbers?
– Co-morbidities for Headaches, Migraines and Chronic Pain
– Pain Treatments for Different Pain Syndromes

Dearman:
– Pain 101
– Medications and Definitions
– Goal Setting & Monitoring

Robert:
– Headaches and Migraine Disease 101
– Management and Treatment of Headaches and Migraines
– Empowerment, Disease Awareness

This Pain Tamers(TM) At Sea event is limited to the first 100 people to register to ensure the best experience for all participants. Early registration is suggested. Detailed information is available at the Pain Tamers(TM) At Sea Web site, www.PainTamersAtSea.com. Reservations may be made through Dianne at Academy Travel by calling 805-781-2630.

About Dr. John Claude Krusz
JOHN CLAUDE KRUSZ, MD, PhD is a prominently recognized expert in the fields of headache and Migraine treatment and pain treatment. In addition to being an outstanding clinician, he is also a researcher and author. Dr. Krusz practices at the Anodyne Headache and PainCare center in Dallas. He also offers his expertise and talents to assist with the ìAsk the Clinicianî column on About.comís Headaches and Migraine site.

About Helen Dearman
HELEN DEAERMAN knows what chronic pain feels like…she has been battling chronic pain for 27 years. Her fight against pain began in 1975 when she fell four stories from a ski lift. She broke her lumbar spine in three places; however, her spinal injury was NOT discovered or treated for 17 years. However, she did not let her pain keep her from doing the activities that she loved to do…and you don’t have to let pain stand in your way either! Helen is the founder of the National Chronic Pain Society (http://www.ncps-cpr.org), an advocacy group that helps people to deal with chronic pain. She also hosts a weekly international Internet radio show PainTamers(TM) on www.VoiceAmerica.com.

About Teri Robert
TERI ROBERT is a health writer and patient advocate. In 2004, she received the National Headache Foundationís (http://www.headaches.org) ìPatient Partner Award.î The About.com ìGuideî for Headaches and Migraine (http://headaches.about.com), she also serves as the support advisor for MAGNUM, the National Migraine Association (http://www.migraines.org), and serves on the education committee for O.U.C.H., the Organization for Understanding Cluster Headaches (http://www.ouch-us.org). She is also the author of ìLiving Well with Migraine Disease and Headaches: What Your Doctor Doesnít Tell YouÖ That You Need To Know,î published by HarperCollins.

Prolotherapy

Nonsurgical reconstructive therapy ó also referred to as “prolotherapy” or “proliferative therapy” ó evolved out of a treatment pioneered by H. I. Biegeleisen called “sclerotherapy,” which was originally (and still is) used to treat varicose veins. Prolotherapy involves the injection of an “irritant” solution into the area where ligaments are weak and/or damaged. Over the next few days, cells called “macrophages,” literally big eaters, are attracted into the area by the presence of this irritant solution. Once they arrive, these macrophages pick up the irritant solution and carry it away for disposal (they are the garbage men of the body). As the macrophages are finishing their job, the body sends in “fibroblasts,” literally connective tissue builders, to lay down fibrous tissue wherever they detect damage to connective tissue such as ligaments.

Of course, prolotherapy can be used on any weakened ligament or tendon in the body. The determining factor is the doctor’s skill in introducing the needle to exactly the right locaiton. Knees, hips, elbows, shoulders, in fact every joint in the body can develop problems which can be addressed with prolotherapy.

The doctor’s job is to introduce the irritant solution into the places where ligaments are weak or damaged. If properly placed, this causes the repair of ligaments. This new supporting structure pulls the vertebrae back into close relationship with each other correcting instability and therefore putting an end to inflammation. When inflammation disappears, so does pain! Stability is restored along with mobility.

A single treatment with prolotherapy will cost around $200. Usually not more than ten to fifteen treatments are necessary to bring a typical back pain or neck pain syndrome under control.

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The term “prolotherapy” is a derivation of “proliferative injection therapy” and is also known as sclerotherapy. The practice of prolotherapy is used by doctors of osteopathy and other physicians to treat a number of different types of chronic pain. Prolotherapy consists of a series of intraligamentous and intratendinous injections of solutions in trigger points near the pained area to induce the proliferation of new cells.

Proponents of this treatment suggest that looseness in the supporting ligaments and tendons around the joints causes the pain, inducing the muscles to contract against the ligament and irritate the nerve endings. The physicians using this treatment method for low back pain believe the ligament laxity to be concentrated in the sacroiliac joint. During a physical examination a physician will identify trigger points generally in the muscles overlying the sacroiliac joint. The physician then may inject proliferant substances into the supporting ligament and tendon tissue.

The practice of sclerotherapy or prolotherapy to produce dense fibrous tissue in an effort to strengthen the attachment of ligaments and tendons is not new. Forms of this therapy apparently date back to Hippocrates, however, prolotherapy recently found favor with osteopaths following the teachings of George Hackett, MD, who in 1939 began using a local injectable irritant to initiate the healing process. It was Dr. Hackett who coined the term “prolotherapy” because sclerotherapy implied scar formation, which, according to Dr. Hackett, did not occur with prolotherapy. Nevertheless, both processes use trigger point injections to form new cells in an effort to support weakened muscles. Although the method has been in use for some time, to date there is no strong clinical evidence to support the efficacy of the treatment.

Prolotherapy injections are intended to mimic the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue. The newly produced collagen is intended to support the injured or loosened ligaments, creating a more stable and strong muscle base, in the process, alleviating pain.

There are three classes of proliferant solutions used to initiate inflammation: chemical irritants (e.g. phenol), osmotic shock agents (e.g. hypertonic dextrose and glycerin), and chemotactic agents (e.g. morrhuate sodium, a fatty acid derivative of cod liver oil). The two studies supplied by the requestor used a dextrose-glycerine-phenol solution.

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What is known about prolotherapy outcomes for back pain?
Reported success rates range from 80%-90% when performed by a physician trained in the prolotherapy procedure. Many of these reports are based on anecdotal evidence from the physicians themselves. Studies have not yet connected positive outcomes for back pain and healing to prolotherapy.

The anecdotal reports suggest improvements such as:

* Reduction or elimination of back pain
* Increased strength of the ligament, tendon or joint capsule
* Reduced recurrence of injury to the treated site
* Improved or return to normal function

Factors that may be key for a successful outcome include:

* Proper diagnosis of the location of the sprain or strain
* Willingness of the patient to complete follow-up therapy
* Clinical skill of the physician in performing the injection

Finally, it is important to note that nobody knows exactly what happens in prolotherapy. There is no objective medical evidence, and no histology has been published as to what goes on when injection is placed into the painful soft tissues.