A Patient’s Guide to Pain Management Medications

Introduction

There are several types of medications that can be used to treat pain. No one drug works for everyone. The medications that work best for you will depend on the type of pain you have and your response to them. Your medication regimen will need to be designed just for you.

This guide will help you understand

• what medications are commonly prescribed
• why these drugs are prescribed
• what are the risks and benefits of this treatment

Rationale

If you have lived with pain for a long time, it is common to have other conditions as well. These may include depression, anxiety, and insomnia (trouble sleeping). These conditions can make pain worse. And it’s harder for you to cope with the stress of living with pain. In order to get control over the pain, these conditions usually need to be treated at the same time as the pain.

The goal of using medication, as part of your treatment plan, is to increase your activity level. This can be done by improving pain control with drugs that you can afford while avoiding side effects.

The medications most commonly used in pain management belong to the following groups

• Opioid (narcotic)
• Non-opioid (non-narcotic)
• Acetaminophen (Tylenol®)
• Non-steroidal antiinflammatory (NSAID)
• Steroidal anti-inflammatory
• Antiepileptic (anticonvulsant)
• Antidepressant and antianxiety agents (anxiolytics)
• Muscle relaxants (antispasmodics)
• Sleep aids (hypnotics)
• Topical agents

Opioid (Narcotic) Pain Medications

Pain management experts prefer the term opioid to describe narcotic medication. The word narcotic is a legal term that is often linked with the illegal use of drugs.

Rationale

Opioid medications are expected to improve your activity level. They do this by decreasing the pain you feel when you are active.

Expected Benefit

Opioids such as morphine (MSContin), fentanyl (Duragesic), and methadone reduce pain by binding to opioid receptors in the brain. Most pain is responsive to opioid medications. However, some types of pain respond better than others. Nociceptive pain refers to skeletal or muscular pain. This type of pain is usually more responsive than neuropathic (nerve) pain.

Some problems such as fibromyalgia with diffuse (widely spread) myofascial (inflamed muscle and fascia) pain may respond at first. But studies show that patients with fibromyalgia do not do better over time on these drugs. Pain caused by headache may be relieved by opioids, but they can cause worse headaches later. These are called rebound headaches.

Potential Risks

There are some possible risks associated with opioid use. Not everyone will have all of these problems. With the right management, you may not have any problems. Risks can include

• Addiction
• Physical dependence
• Tolerance
• Hyperalgesia
• Decreased hormone levels
• Change in mood
• Sleep apnea
• Theft
• Death

Addiction is defined by craving, uncontrolled or compulsive use, and continuing to use the substance despite harm. Addiction is a complicated chronic disease. Simply taking an opioid does not cause addiction. If you have no risk factors, it is rare to develop the disease of addiction.

However, addiction is a possibility if you have the right (or wrong) genetics. Psychological and social stressors are also important factors. Family history must be reviewed before taking an opioid. There are ways to lower the risk of addiction or relapse if you are at risk for this disease. If you have an active addiction, the risk may outweigh the benefit of taking an opioid. Other options for pain control should be explored.

Substance abuse is a term used for unusual or abnormal behavior that does not meet the definition of addiction. Pain experts watch closely for any signs of this kind of behavior. These behaviors include reports of lost or stolen medication or use of medication in ways other than directed. Not taking the medication according to the directions would also fall into this category. Requesting early refills or taking a medication despite serious side effects are red flag behaviors. Taking the drug to deal with stress such as after a heated argument with someone is also a warning sign. These behaviors are often a signal that you may be getting into trouble with your medication. Your treatment plan may need to be altered. The goal is to get the most benefit with the least risk of side effects.

Pseudo-addiction is the term used to describe what appears to be dangerous or unusual behavior but occurs when pain is not being fully treated. Think about this idea. You have constant pain. It lasts all day and night. You are given a pain medication and told to take one every eight hours. The pain medication that you are prescribed is effective and allows you to be active. But it only works for about four hours. Four hours before the next dose is due, you are in great pain again. How would you respond?

Some people take more drug than is prescribed. Then they run out of pills early. Others complain bitterly at every appointment. They demand a refill. To the doctor it seems as if the person is “drug seeking”. Some may go to more than one doctor to get what they think they need to relieve the pain. When these behaviors are caused by under-treatment of pain, an increase in the dose stops the behavior. If these behaviors start up shortly (within days to weeks) after the dose increase, then there may be other reasons for the behavior.

Physical dependence occurs in everyone on opioids. This happens when you take them regularly for more than two to three weeks. Physical dependence does not mean that you are addicted. Physical dependence means that your body has become used to the drug. You feel withdrawal symptoms if the medication is stopped suddenly.

Symptoms of withdrawal can range from mild irritability to sweating, diarrhea, vomiting, and muscle cramps. You may feel like you have a severe case of the flu. You may feel like you are dying. But withdrawal from opioids is not fatal. It can be avoided by slowly decreasing the amount of drug you take. This can be done over several days up to several weeks. The time it takes to get off the medication without having unpleasant symptoms depends on how much medication you are on and how long you have been on it.

Many opioids require a hand signed prescription every time you need it refilled. It is very important to plan ahead for holidays. You don’t want to run out.

Tolerance to a medication occurs when an individual requires more medication to achieve the same amount of pain relief. Tolerance is not the same as addiction. Not everyone develops tolerance to pain relief. If you should have tolerance to your pain medication, there are ways to deal with it. For example, your doctor may increase the amount you are taking. Or you may be switched to a different drug. Sometimes treating other conditions such as depression and anxiety is helpful. Adding a non-opioid drug can help, too. The best approach depends on your situation. You and your healthcare provider will decide together what’s best for you.

Hyperalgesia is an increase in painful sensation. If you become less functional and feel more pain after starting or increasing an opioid, you may be having hyperalgesia. If hyperalgesia develops, decreasing the opioid or stopping it will improve pain control. Other non-opioid medications and non-medication treatments can be useful should you experience hyperalgesia.

Decreased hormone (testosterone and estrogen) levels can develop over time. Let your healthcare provider know if you feel a decrease in energy, increased depression, or new sexual problems. Simple blood tests can be ordered to see if you are having a decrease in hormone levels. Treatment for this problem is possible. It might mean replacing the hormone or stopping the opioid medication.

A change in mood can occur with opioid medications. You may feel worse (depressed mood). Or you may feel better (elevated mood). If you have a mood disorder such as depression or anxiety, an opioid can make you feel better. This can be hard to sort out. You may not be able to tell if you feel better because of the mood elevation or because you are getting pain relief.

But opioids only improve mood for a short period of time such as several weeks to several months. It is not possible for this mood elevation to last very long without an increase in opioid dose on a regular basis. This complicates therapy. And it can be dangerous. If you have a mood disorder, it needs to be treated in order to get good pain relief from an opioid. Mood disorders or worsening of the spinal condition are more often behind dose increases than tolerance to the pain relief. Short-acting opioids such as hydrocodone found in Lortab® and oxycodone found in Percocet® are useful for pain that only lasts a short time (less than three to four hours). These drugs are good choices when pain doesn’t occur very often. The short-acting opioids are linked with mood changes. It is best to use long-acting opioids whenever possible. This will help you avoid the ups and downs of the short-acting medication. First it kicks in and then it wears off within hours.

Sleep apnea can get worse while taking opioids. If you think you have sleep apnea, you should have it checked before starting an opioid medication.

Theft. Opioid medications have value in the illegal drug market. People have been known to open medicine cabinets, go through drawers, and attend open houses just to look for these drugs. Family members have been known to do the same thing. They may go through your medicine cabinets and steal medications to either take for themselves or sell for profit. Be sure to keep your opioid medications safely locked away. This step is for your benefit and for the safety of others. Many healthcare providers will not replace stolen medications.

Death can be caused by taking more of the medication than prescribed. If you take too large of a dose, an opioid can stop your breathing. However, the benefits of the correct dose include the fact that they do not damage organs such as your liver or kidneys. Opioids must be started at a low dose and slowly increased as you become used to them. Methadone is unusual as it builds up in the body over three to seven days. As methadone builds up in the body, it becomes more effective. This means that the full effect of the current dose doesn’t occur for three to seven days. Methadone causes accidental overdoses and death when patients take extra doses. They do this while trying to get more pain relief now. It is extremely important to take opioids only as directed. Never take extra. Talk to your doctor if you aren’t getting the pain relief you need.

Potential Side Effects

The most common side effects from daily use of opioids are constipation, stomach upset, itching, and drowsiness. All of these side effects (except constipation) become milder. They can be treated if needed. They usually go away over five to10 days.

Exercise and eat a healthy diet to prevent constipation. Drink plenty of water and eat fiber-rich foods such as vegetables and fruits. Prunes are an excellent choice. Even with a good diet and exercise, you will most likely need a stimulant laxative while on an opioid.

Avoid bulk laxatives such as Metamucil® because excessive bulk can worsen constipation caused by opioids. A combination of senna (stimulant laxative) with docusate (stool softener) such as is found in Senokot S® (or any generic equivalent) is recommended. Start with two tablets at bedtime and increase as needed. This will help you have a bowel movement at least every other day. Do not take more than eight tablets per day. Tell your healthcare provider if this does not prevent constipation for you. You may need a more aggressive treatment approach.

Non-Opioid (non-narcotic) Pain Medications

Acetaminophen (Tylenol®)

Rationale

Acetaminophen improves your level of activity by decreasing the pain you feel while active.

Expected Benefit

Acetaminophen or Tylenol® inhibits pain-generating substances called prostaglandins. It blocks the pain pathway to the brain. Acetaminophen works well for mild-to-moderate pain by itself. When taken with other medications, it can improve your pain control.

Potential Risks

Liver failure is the main risk linked with acetaminophen. The overuse of acetaminophen is the most common reason for liver failure and the need for a liver transplant. Acetaminophen is in many prescription and non-prescription products. So be sure to read all labels to see if it is in any of your other medications. Never take more than four grams of acetaminophen per day. Four grams is equal to eight extra-strength 500 mg tablets or 12 regular strength 325 mg tablets. Tell your healthcare provider if you have any liver disease and/or a history of alcohol abuse. You may need to limit your use to less than two grams per day. Or you may have to avoid acetaminophen entirely. This depends on your risk factors for liver disease.

Potential Side Effects

Acetaminophen is well-tolerated and unlikely to cause any significant side effects when taken as prescribed.

Nonsteroidal anti-inflammatory Drugs (NSAIDs)

Rationale

NSAIDs can improve your level of activity by decreasing pain and swelling.

Expected Benefit

NSAIDs inhibit the production of inflammatory substances such as prostaglandins. NSAIDs are commonly used for acute painful conditions such as a sprained ankle or a flare-up in back pain. They are also used to decrease the pain and stiffness you might feel with arthritis.

Potential Risks

Let your healthcare provider know if you have any problems with your stomach, intestines, or kidneys. Any problem with bleeding should also be reported. Some NSAIDs have been shown to increase the risk of cardiovascular disease resulting in heart attack or stroke. These medications can be very helpful in the short-term ranging from several days to several weeks. The benefit of using them for months-to-years needs to be carefully weighed against your personal risk factors for cardiovascular disease, kidney disease, and stomach ulceration.

If you have kidney disease, you are at an increased risk for kidney failure. If you are diabetic, you have an increased risk of developing kidney disease and kidney failure.

Bleeding can be increased as a result of taking NSAIDs. Most NSAIDs such as ibuprofen (Advil®), naproxen (Naprosyn®, Aleve®), and piroxicam (Feldene®) can increase bleeding. These drugs should be stopped before surgery. Avoid taking them if you are taking a blood thinner. Celecoxib (Celebrex®) is the only NSAID on the market at this time that does not increase bleeding and is allowed to be taken prior to surgery.

Stomach ulcers can be caused by NSAIDs irritating the stomach or intestinal lining. You may decide to take an NSAID even if you are at risk for ulcers. If this is the case, there are products that can help protect the stomach and intestinal lining such as omeprazole (Prilosec®) and esomeprazole (Nexium®).

Potential Side Effects

Stomach upset is the most common side effect. Taking NSAIDs with food usually helps. If taking the medication with food doesn’t help enough, your healthcare provider may prescribe medication to protect your stomach. While on the NSAID, you may also be given famotidine (Pepcid®), omeprazole (Prilosec®), or esomeprazole (Nexium®).

Steroidal Antiinflammatory Medications

Rationale

Steroids decrease inflammation. They do this by decreasing the body’s immune response to injury or disease.

Expected Benefit

In an acute flare-up of pain, a short course of a steroidal anti-inflammatory may be helpful. Drugs such as methylprednisone (Medrol®) can decrease pain by decreasing swelling and inflammation. The effect takes place around the spinal nerves. With this treatment, you may be able to return to your activities sooner.

Potential Risks

Short-term use, such as several days to several weeks is usually safe. Long-term use (months to years) can cause major problems. Osteoporosis, diabetes, poor wound healing, and increased risk of infection are among the most common problems.

Potential Side Effects

There are some common side effects from taking steroids. These include mood changes (either feeling better or worse), increased appetite, indigestion, increased nervousness, and decreased sleep. If you have diabetes, you will need to check your blood sugar closely.

Antiepileptic Medications (Anticonvulsants)

Rationale

Anti-epileptic Drugs (AEDs) are expected to improve your activity level. They do this by decreasing the pain you feel. They also help you cope with the stresses of living with pain.

Expected Benefit

Anti-epileptic Drugs (AEDs) are used to treat epilepsy, stabilize moods, and manage neuropathic (nerve) pain. Nerves can become pain generators. AEDs quiet the nervous system. If you have lived with pain for very long, you most likely have some nerve pain. Pain described as streaking, lightening, burning, tingling, pins and needles, or pain radiating down legs or arms is most likely neuropathic pain. Many people get good pain relief when given a medication from this group such as gabapentin (Neurontin®) or pregabalin (Lyrica®.)

Potential Risks

Abruptly stopping the medication can bring on seizures. This can be avoided. Slowly decrease the medication before stopping. There are many different medications in this group. Some have specific risks associated with them. Topiramate (Topamax®) is linked with an increased risk of kidney stones. Lamotrigine (Lamictal®) can cause a severe skin rash. Carbamazepine (Tegretol®) has rare reports of blood disorders. Be sure to ask your healthcare provider about the specific risks of any AED you are thinking about taking.

Potential Side Effects

Most AEDs are well-tolerated if they are started at a low dose and slowly increased. Drowsiness, dizziness, tiredness, swelling, and stomach upset are the most common side effects. Tremor, blurred vision, dry mouth, constipation, anxiety, and weight gain are also common.

Antidepressant and Anti-anxiety Medications

Rationale

Antidepressants decrease pain while improving mood and your ability to cope with the pain. Some antidepressants also improve neuropathic pain.

Expected Benefit

Pain is very much affected by mood and mood is very much affected by pain. Both need to be taken care of in order to get good pain relief. Most antidepressants also treat anxiety. In addition to anxiety and depression, certain antidepressants are good at treating neuropathic pain. The antidepressants that are good at decreasing neuropathic pain are the ones that increase both serotonin and norepinephrine activity. These include the older tricyclic antidepressants (TCAs) such as amitriptyline (Elavil®) and nortriptyline (Pamelor®) and the newer serotonin norepinephrine reuptake inhibitors (SNRIs) duloxetine (Cymbalta®) and venlafaxine (Effexor®). The selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), paroxetine (Paxil®), and sertraline (Zoloft®) are good antidepressants and anti-anxiety medications. They do not specifically treat neuropathic pain.

Potential Risks

If you are bipolar, adding an antidepressant without a mood stabilizer can bring on mania. Most of these medications can cause withdrawal symptoms if stopped abruptly. Because of a few reports of liver failure, duloxetine (Cymbalta®) should be avoided in alcoholics and anyone with liver disease.

Benzodiazepines are not antidepressants but are very effective anti-anxiety agents. They have the additional risks of addiction and physical dependence. They are only used when other drugs fail. Examples of benzodiazepines used to treat anxiety are lorazepam (Ativan®) and clonazepam (Klonopin®). Be sure to ask your healthcare provider about the specific risks associated with any antidepressant or anti-anxiety agent that you are planning to take.

Potential Side Effects

The most common side effects are stomach upset, feeling wired, drowsiness, and tiredness. Sexual dysfunction, flat mood, insomnia, headache, and appetite changes can also occur. Some cause carbohydrate craving and weight gain. When first starting one of these medications, some people feel increased anxiety. But these medications are generally well-tolerated if started at a low dose and slowly increased. If you do not respond well to one of these drugs, changing to a different one may give you better results.

Muscle Relaxants (Antispasmodics)

Rationale

Muscle relaxants decrease the pain associated with muscle spasms. This should allow you to be more active such as being able to participate in physical therapy.

Expected Benefit

Surgery, injury, or increasing activity often causes muscle spasms. Pain caused by muscle spasms does not respond well to other pain medications. Use of a muscle relaxant helps keep pain from muscle spasms under control.

Potential Risks

The muscle spasm agents do not usually work well for long periods of time. After an initial injury, they often serve as tranquilizers rather than as effective treatment for muscle spasms. Methocarbamol (Robaxin®) and cyclobenzaprine (Flexeril®) are examples of commonly prescribed muscle relaxants. Physical dependence and addiction are risks with the benzodiazepine group of antispasmodics. Examples of benzodiazepines used to treat muscle spasms are diazepam (Valium®) and lorazepam (Ativan®).

Potential Side Effects

Drowsiness, dizziness, lightheadedness, upset stomach, blurred vision, insomnia, low blood pressure, and dry mouth are all potential side effects associated with muscle relaxants.

Sleeping Aids (Hypnotics)

Rationale

Many patients have trouble sleeping. Sleeping aides help you sleep. Improving sleep should help you cope with pain and the stresses that come with the pain.

Expected Benefit

Lack of sleep makes everything worse, including pain. You may have trouble falling asleep. Or you may wake up during the night unable to fall back asleep. Which sleep aid is best for you depends on your sleep pattern. Other factors such as pain and depression can make a difference. Short-term use of sleeping aids is very helpful for some people. However, learning good sleep habits and treating the pain properly are the preferred long-term solutions.

Potential Risks

The risks depend on the medication chosen to improve sleep. Diphenhydramine (Benadryl®) is in many products such as Tylenol PM®. Diphenhydramine is an antihistamine. Because its main side effect is drowsiness, it is also used for sleep. It causes more problems in elderly patients than in young patients. Urinary retention, low blood pressure resulting in falls, and confusion are risks for the elderly. You should not take products containing diphenhydramine if you are over 65 years old.

Some medications such as zolpidem (Ambien®) come with the risk of withdrawal or rebound insomnia when they are abruptly stopped.

Some medications can cause sleepwalking and amnesia. Or you may forget what you have done during the night. This has been associated with several medications including zolpidem (Ambien®) and triazolam (Halcion®).

Trazodone (Desyrel®) is an antidepressant that causes drowsiness. In low doses, it is used for sleep. It is considered safe for older patients to use. Young males are at risk for priapism. This is a painful erection that does not go away and can require a visit to the emergency room. Occasionally surgery is needed to resolve the problem.

Potential Side Effects

Daytime drowsiness, nightmares, and dry mouth are the most common side effects. Eszopiclone (Lunesta®) can cause such a severe bad after taste that patients refuse to take it. If you experience a bad taste with Lunesta®, try taking it with orange juice.

Topical Agents

Rationale

Topical medications can improve pain control without causing the side effects that result from taking an oral medication.

Expected Benefit

Some medications such as diclofenac (Voltaren®) can be absorbed through the skin allowing it to be mixed into a lotion or a cream and applied directly to the area that hurts. The drug acts locally and doesn’t have to be absorbed into the blood stream. If it doesn’t go throughout the body, side effects such as stomach ulcers can be avoided.

Capsaicin (Zostrix®) is made from hot peppers. Applying it for 4-6 weeks depletes substance P in the painful area. Substance P stimulates nerves to transmit the pain signal to the brain. By eliminating substance P, nerve pain can be drastically reduced. It has also been beneficial for pain caused by osteoarthritis in the joints such as in the knees. Lidocaine can be mixed into a lotion such as in Emla® or absorbed from a patch such as in Lidoderm®. Lidocaine can decrease the pain you feel by numbing the painful area.

Potential Risks

Most of these are considered safe when applied to the skin. The cost can go up if they have to be mixed by a pharmacist. Excessive use can result in too much absorption. When that happens you can get the same side effects as the oral medication. Be sure to follow the instructions as with any medication.

Potential Side Effects

Skin irritation is the most common side effect. Capsaicin works well but has to be used very carefully. Using too much at first can cause a severe burning sensation. You can avoid this by applying a tiny amount to a dime-sized area one to two times per day. Slowly increase the amount you use over several weeks. Do not give up too soon. It takes four to six weeks of daily use for it to work. The pain control is worth the patience it requires. It is doesn’t cost very much. It doesn’t need a prescription. And it delivers good neuropathic pain control without any other side effects.

A Patient’s Guide to Chronic Pain and Nutrition

Introduction

Your nutrition has a major role in how you feel pain. What you eat will give your body the chemistry it needs to make an inflammatory response. Inflammation is what your immune system creates when there is some kind of insult or damage to your tissue. Inflammation is not the only cause of pain but it can make your pain feel more intense and last longer.

This guide will help you understand

• how nutrition affects your pain
• what nutritional changes you should make
• types of supplements to consider
• the role of nutraceuticals

Basic Information

The amount of inflammation that occurs in your body can be affected by what you eat. This includes food and drinks as well as other chemical exposures. Environmental pollution and artificial colorings and preservatives can also cause painful inflammatory responses in your body. Eating foods that leave you low in many micronutrients (vitamins and minerals) can make it more likely that your body will produce pain chemistry.

Fat cells in particular are a source of inflammatory chemistry. And for those who are overweight, chronic low back and hip, knee, or foot pain may be caused by where and how the bones and joints are supporting that weight.

The chemistry that creates pain signals in your body is increased by starchy and sugary foods. It’s can be decreased by protein foods. Controlling inflammation and therefore pain is done best by avoiding carbohydrates you don’t need. This means sweets and many of the grain products. Meals that regularly include lean meat, fish, and eggs are essential for controlling pain chemistry. Portion control is also central in controlling inflammation, and to successful weight loss. Portion control means not eating more food than you are using for fuel on a daily basis.

Research suggests that losing as little as seven to 10 per cent of your current body weight can help. Such a weight loss can change your body chemistry for the better. These changes can help decrease physical pain. Diet and exercise are crucial. Medication, herbs, and nutritional supplements can help but won’t be enough without your efforts to improve your muscle tone and lose extra fat.

Weight Loss

There is a lot of mistaken information about how to lose weight. Ninety per cent of people regain fat once lost. Preventing re-gain is crucial to long-term health. Recent interest in the epidemic of obesity has resulted in new information about how you can successfully lose weight and keep it off long-term. It’s important that you lose fat in a healthy way. The goal is to keep it off the rest of your life.

Changing how you eat, drink, and exercise can be hard but the results are always very rewarding. All the changes you make to reduce your pain by losing weight will help every part of your life. This includes your ability to think clearly, your memory, and your moods. Eating to reduce pain can also help you avoid illnesses of all kinds, including heart disease, diabetes, and cancer. Avoiding foods with artificial colorings, preservatives, and other chemical pollution allows your body to put its energy toward healing.

There is no single diet that will work well for everyone who needs to lose weight. Food choices should be made to allow for your personal preferences. Try to limit foods that are high in fat. Get plenty of lean protein. Increase your intake of vegetables and fresh fruit. Drink plenty of of clear liquids. These are the basic rules of any healthy diet.

For some people using meal replacement products can be useful. However learning to eat the right amount of home-cooked meals will always be part of complete recovery from obesity. Following structured meal plans and regular contact with supportive professionals and friends or family will also make weight loss success more likely.

What nutritional changes should I make?

What To Do

• Lose excess fat
• Eat two or more cups of fresh vegetables daily
• Avoid sweets and reduce starchy foods
• Increase clean, lean meat, poultry, fish, and eggs
• Use olive oil and snack on fresh fruit, nuts, and seeds
• Avoid artificial colorings, preservatives, hormones, antibiotics, and herbicide and pesticide residues in your food
• Take a good quality multiple vitamin/mineral supplement every day
• Think about other specific nutraceuticals for your own specific needs

What nutritional supplements should I consider?

There are some nutritional supplements that can help with weight loss. They are safe and effective when used as recommended. None are a substitute for changing eating and exercise habits. Research is showing that quite a few herbs and nutritional supplements are good options for pain control. Comparing these nutraceuticals to non-steroidal anti-inflammatory drugs (NSAIDs) reveals that some of them are as effective at pain relief while having few-to-no side effects. These natural products often cost less than many drugs.

Anti-inflammatory Herbs

Willow bark (Salix spp) is the original source of the salicylic acid used to make aspirin. A study was done of 228 people with low back pain compared willow bark (standardized for 240 mg salicin) with an antiinflammatory drug (Vioxx). (Vioxx is no longer on the market due to dangerous side effects for some people.) However, the study showed these medicines were equally effective. But willow bark was safer and 40 per cent less expensive. The daily dose of willow bark products should not have more than 240 mg of salicin. The best products will include other parts of the whole plant.

Willow bark works in multiple, complex ways to relieve pain. It is an antioxidant. Antioxidants are molecules that slow down or prevent potentially harmful chemical reactions in the body. Willow bark slows the production of at least three pain-causing chemicals. Except for rare allergy, no adverse effects are known. It can be blood thinning so it is not advised for use during pregnancy or with anti-coagulant medication.

Boswellia (Boswellia serrata) is a well-researched plant medicine. It is an effective anti-inflammatory pain reliever. It also reduces fever and helps with muscle relaxation. It works on many tissues including joints, the digestive tract, the colon, and the airways. It reduces swelling in cases of brain cancer. It does not cause the sort of stomach irritation and ulcers that are common side effects of many NSAIDs. Studies show it is very safe even after many weeks of use. There are only rare side effects such as mild nausea, loose stools, or skin rash.

The usual dose is about 150 mg three times daily. The product should contain 37.5–65 per cent boswellic acids.

Ginger (Zingiber officinale) is familiar as a spice and food. It also has a long history of use as an anti-inflammatory and anti-nausea medicine. It reduces the production of three different kinds of chemicals that can lead to inflammation. Ginger has been shown to safely reduce the pain and disability associated with arthritis, muscle aches, and migraine headaches.

Ginger appears to have a protective benefit against stomach ulceration. This is different from over-the-counter or prescribed NSAIDs. Ginger doesn’t cause any major side effects. It has mild effects that may interfere with blood thinners and drugs used to treat gallstones.

The recommended doses for the treatment of body pain has ranged from one gram (one-half teaspoon) of powdered ginger to up to 50 grams per day of fresh or lightly cooked root.

Devil’s Claw (Harpagophytum procumbens) has a long history of use in the treatment of musculoskeletal complaints. Recent research has shown that it is useful for relief of mild to moderate pain. Twelve clinical trials found Devil’s claw to be both safe and effective. It has no more adverse effects than a placebo (sugar pill). These studies showed that people had at least as much pain relief from the plant medicine as they got from commonly used non-steroidal anti-inflammatory drugs (NSAIDs). And they had fewer uncomfortable side effects than with the NSAID. Less than 10 per cent of users reported mild diarrhea or GI upset. Even fewer had some dizziness. Devil’s claw may increase the blood thinning activity of drugs taken for anti-coagulant therapy.

Devil’s Claw usually costs less than NSAIDs. The most useful products will have standard amounts of harpagosides. The effective dose for most people is between 30 mg and 60 mg of harpagoside daily. Treatment should continue for at least four weeks. Many people will still improve eight or more weeks after starting treatment.

Bromelain is a mixture of digestive enzymes from the stem of the pineapple plant. It reduces pain and inflammation caused by surgery, arthritis, trauma, or sports injury. It helps to heal and regenerate the digestive lining of the stomach. The usual dose of bromelain is two or three 2,400 mcg capsules. This is taken two or three times daily on an empty stomach. Studies have shown that for larger people, the best pain relief comes with larger, more frequent doses.

Bromelain reduces edema and inflammation. A study of people with knee pain showed bromelain improved stiffness, physical function, and overall psychological well-being. Other studies show it increases healing as well.

Studies have shown that bromelain can
be as effective and a safe alternative to NSAIDs in the treatment of painful episodes of osteoarthritis of the knee. Results of these studies showed that people with sinusitis who took bromelain had better breathing and decreased mucosal inflammation.

Bromelain can cause an allergic response in some people. These are individuals who are also allergic to pineapple, honeybee venom, or olive tree pollen. No toxic effects have been seen using recommended doses for as long as six months. Not enough research has been done to know if bromelain is safe for pregnant or nursing mothers.

Bromelain may increase the action of anticoagulant drugs. It will also increase the action of certain antibiotics. Bromelain helps the cancer drugs 5-fluorouracil and vincristine to work better.

Curcumin (Curcuma longa) is the yellow-colored chemical of the turmeric root. Curcumin (or tumeric) acts as a powerful antioxidant. Curcumin also has antiinflammatory effects equal to some NSAIDs in acute injuries. It is also potent in chronic inflammation. Curcumin can stop a number of different inflammatory molecules. It assists with wound healing by helping to repair the lining of the colon.

People using up to 8,000 mg of curcumin per day for 3 months found no toxicity from it. Five other research studies showed people could use 1,125-2,500 mg of curcumin per day without problems. Turmeric is not advised if you have certain health problems. These include bile duct blockage, a blood-clotting disorder, a history of stomach ulcers, or gallbladder disease. Turmeric may increase the risk of bleeding or increase the effects of blood thinning drugs. It has been used for hundreds of years in East Indian and Asian cooking. Even so, there isn’t enough research yet to say whether turmeric or curcumin is safe to use by pregnant women or nursing mothers.

Quercetin is one of the most important plant medicines we have studied. It slows down the production of histamine and other inflammatory chemicals from white blood cells. It reduces acute inflammation and the swelling and pain of arthritis. There are currently no reported adverse reactions to quercetin. There is not yet enough safety data available to recommend the use of quercetin during pregnancy or while nursing a child.

Nutrients

Vitamin D (cholecalciferol): New research shows a big increase in the number of people in the United States who don’t have enough Vitamin D. Low levels of Vitamin D are especially likely in people with chronic musculoskeletal pain, limb pain, and low-back pain.

People with too little vitamin D can take an oral (by mouth) pill to supplement their vitamin D. This can have anti-inflammatory benefits. Treatment with vitamin D can safely lead to a big decrease in musculoskeletal pain for many people. It is best to have a yearly blood test to measure your vitamin D levels. Then it can be adjusted as needed with supplements. People taking moderate doses of vitamin D (adult range 4,000 – 10,000 IU per day), should have blood levels of calcium measured every six or so months. Too much blood calcium is the best indicator of vitamin D excess. High doses of vitamin D (up to 100,000 IU per day) have been safely used during pregnancy. Testing of calcium levels in the blood is needed to check for high blood calcium.

How much vitamin D each person requires differs depending on many things. Factors include sun exposure, skin color, food choices, and digestive health. Currently some medical authorities are saying that adult males need about 4,000 IU per day. This is a much higher dose than has been set in the recent past.

Most people would have to take a pill form of Vitamin D to get that much. Otherwise, you would have to have most of your skin exposed to the sun for hours every day. This would be how our ancestors lived. It explains why our bodies need this much vitamin D. In general, a safe dose for most people is 2,000 to 4,000 IU daily. Before and after testing of vitamin D and calcium blood levels is a good idea.

High doses of vitamin D should not be taken by people who are also taking thiazide diuretics. Likewise anyone who has a vitamin D hypersensitivity syndrome should avoid too much vitamin D. This includes people with primary hyperparathyroidism, adrenal insufficiency, hyperthyroidism, hypothyroidism, or granulomatous disease. Granulomatous diseases include sarcoidosis, Crohn’s disease, or tuberculosis.

Niacinamide is a form of vitamin B3. It was first shown to be highly effective in the treatment of osteoarthritis more than 50 years ago. A recent well-designed study found that niacinamide therapy improved joint mobility. It also reduced objective inflammation. This was measured by erythrocyte sedimentation rate (ESR). Therapy with this nutrient decreased the impact of the arthritis on the activities of daily living. It also allowed people to decrease their use of pain medication.

Side effects are rare when daily doses are kept below 3,000 mg per day. However it is a good idea to check liver enzymes after three months of treatment. After that, the liver can be tested once a year. People notice pain relief after two to six weeks of treatment. Many people notice a decrease in anxiety levels as well. This may be due to the binding of niacinamide to brain cells. The result is a calming effect. A dose of niacinamide 750 mg given orally four times per day works better than 1,000 mg three times per day.

MSM (Methylsulfonylmethane) is a fairly popular nutritional supplement. It is used to treat the symptoms of allergies, interstitial cystitis, and joint pain. Research supporting its use is very limited. MSM is fairly inexpensive. It appears safe, especially for short-term use. One clinical trial used 2,600 mg for 30 days with no major adverse effects.

Glucosamine and chondroitin sulfate are the building blocks used to make cartilage. Supplements will help slow the break down of joint cartilage that can occur with arthritis. Clinical trials with glucosamine and chondroitin sulfates have shown positive results for people with arthritis pain of the hands, hips, knees, jaw, and low-back.

Both treatments are safe for many years of use. The rare side effects include allergy and mild gastrointestinal upset. Most people see the change in their joint symptoms after four to six weeks. The effects last for as long as you keep taking it. Using glucosamine and chondroitin sulfate appears to safely reduce the pain and disability from osteoarthritis. At the same time, there is less risk of cardiovascular illness and death. This is in contrast to anti-inflammatory drugs that increase your risk of having serious, even fatal heart disease.

The adult dose of glucosamine sulfate is generally 1,500-2,000 mg per day. It is taken in divided doses. The dose of chondroitin sulfate is around 1,000 mg daily.

Nutraceuticals That Help You Lose Weight

The idea of taking a pill to solve our problems usually sounds good. This seems true no matter how many times we try them and they fail or even cause us harm. Many specific nutrients are very valuable, for many reasons, before, during, and after a weight loss effort. But there’s no pill that can cause weight loss if you do not also change how you eat and exercise.

The following are some safe and effective nutraceuticals. They can help you in your efforts to change your lifestyle habits. These supplements will help you make the most of your weight loss efforts.

Calcium

Studies have shown that people whose diets have the most calcium are least likely to be overweight. More research is needed to understand the links between calcium intake and body fat. For now, these findings remind us how important it is to get enough calcium every day, especially while eating to lose weight.

The dairy industry has turned these observations into an advertising campaign for milk. Milk products are difficult for many people to digest. They add calories and fat to your diet. We know humans don’t actually need dairy products to get enough calcium. We were around for a long time before animals were tamed in order to get at their milk. You probably aren’t making soup and chewing on the bones of the animals you eat. This is what our ancestors did to get calcium. Today, eating lots of dark leafy greens (like broccoli, which is very high in calcium) and taking a supplement is your best bet for having all the calcium you need.

Adult men and women, 50 years of age and younger, should take in about 1,000 mg – 1,200 mg/day of calcium. Older men and postmenopausal women should get 1,200 mg – 1,500 mg/day of calcium. Taking a supplement containing at least 10 mcg (400) IU/day of vitamin D will help to make sure your calcium is absorbed in your gut.

5-Hydroxytryptophan (5-H PT)

This amino acid is a safe and effective support for increasing serotonin. Serotonin is a key brain chemical that helps you feel calm and satisfied. It can help you lose fat by reducing carbohydrate cravings. It helps stop eating binges and therefore reduces calorie intake. It can trigger a feeling of fullness so you have a greater sense of satisfaction from your meals. This product will not help you lose weight if you don’t choose the proper amount of healthy foods and if you don’t exercise regularly. The recommended dose is 100 mg three times daily. Take it 20 minutes before meals for at least four weeks.

A condition known as Serotonin Syndrome can result if your body produces excessively high levels of serotonin. This syndrome can also occur if your body can’t break down serotonin fast enough. Symptoms include confusion, fever, shivering, sweating, diarrhea, and muscle spasms. This syndrome does not occur when 5-HPT is taken alone. There have been some reports of this syndrome when a related amino acid called L-tryptophan was used with prescription drugs that inhibit serotonin activity. These drugs are called monoamine oxidase (MAOs). MAOs break down molecules of serotonin.

You should stop taking an MAO-inhibitor for at least four weeks before beginning therapy with 5-HTP or any other serotonin-active substance. Also, you should not take 5-HTP at the same time as any prescription anti-depressant. For example, don’t take 5-HTP if you are taking Prozac, Zoloft, or Paxil unless supervised by a physician. Do not stop or adjust the doses of any prescription medication without first talking with your physician.

Possible side effects include a mild nausea that doesn’t last. This is more likely to occur at higher doses, in the range of 200 mg to 300 mg. Treatment of depression and insomnia require smaller doses, so this isn’t usually a problem. Even if nausea develops, it disappears for most people in two to 14 days. Consider using ginger tea or capsules to decrease the nausea.

L-Theanine

Theanine, an amino acid found in green tea, helps you relax. When you are more relaxed, you are more in charge of your behaviors. You have better control if you have the food cravings that lead to increased weight. It is safe and fast acting. The adult dose is between 50 to 200 mg of L-theanine. In about 30 to 40 minutes you will notice feeling more alert. You will be in a calm, relaxed state. These feeling usually last from eight to 12 hours.

There are no known safety problems with L-theanine taken in doses up to 600 mg every 6 hours. In Asian countries women have been drinking the teas that theanine is extracted from for hundreds of years with no problems. However, there is no research on L-theanine in capsule form. So we can’t state it is safe for use by pregnant women and nursing mothers.

Green Tea Extract

Green tea has at least two different chemicals that work together to increase the amount of calories you burn in a day. One study showed that people taking green tea extract containing at least 90 mg epigallocatechin-3gallate (EGCG) burned 266 more calories per day than those who didn’t take the green tea extract. The supplement was taken three times daily. Other chemicals in green tea have also been shown to reduce how much fat is digested from a person’s meals.

Green tea is generally thought to be a safe, non-toxic drink. There are no bad side effects. There is caffeine in it. Drinking too much can cause irritability, insomnia, nervousness, and fast heart rate. Green tea extracts in capsules may be caffeine free. Many health care providers advise pregnant women and nursing mothers to avoid caffeine. Some studies suggest large amounts may harm a developing fetus. Some infants may become over stimulated by caffeine in their breast milk.

Summary

Nutrition is another key factor in managing chronic pain. Talk with your healthcare provider about help with a healthy diet. There are many reliable resources available to help you achieve a healthy diet.

Naturopathic doctors (NDs) are available to help patients develop healthier nutritional habits for the spine. Naturopathic physicians practice the art and science of natural health care.

Registered dietitians are another source of nutritional counseling. The ongoing support of a progressive nutritionist can help you start new, healthy habits that will become a permanent part of your daily life.

A Patient’s Guide to Pain Management: Complex Regional Pain Syndrome

Introduction

Complex Regional Pain Syndrome (CRPS) is divided into two categories, CRPS I and CRPS II. CRPS I (caused by an injury to tissues) was previously called Reflex Sympathetic Dystrophy (RSD), Sudeck’s atrophy, and shoulder-hand syndrome. CRPS II (caused by damage to a nerve) was previously called causalgia. The symptoms and treatments of the two types are almost identical. For the purpose of this document we will refer to them jointly as CRPS.

Early recognition of the signs and symptoms of CRPS as well as early treatment are usually effective in preventing it from becoming a chronic condition. When the condition becomes chronic, significant irreversible disability can occur.

This guide will help you understand

• what parts of the body are involved
• what causes this condition
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the body are involved?

The sympathetic nervous system consists of ganglia, nerves and plexuses (a braid of nerves) that supply the involuntary muscles. Most of the nerves are motor, but some are sensory.

Sympathetic nerves are responsible for conducting sensation signals to the spinal cord from the body. They also regulate blood vessels and sweat glands. Sympathetic ganglia are collections of these nerves near the spinal cord. They contain approximately 20,000-30,000 nerve cell bodies.

CRPS is felt to occur as the result of stimulation of sensory nerve fibers. Those regions of the body rich in nerve endings such as the fingers, hands, wrist, and ankles are most commonly affected. When a nerve is excited, its endings release chemicals. These chemicals cause vasodilation (opening of the blood vessels). This allows fluid to leak from the blood vessel into the surrounding tissue. The result is inflammation or swelling leading to more stimulation of the sensory nerve fibers. This lowers the pain threshold. This entire process is called neurogenic inflammation. This explains the swelling, redness, and warmth of the skin in the involved area initially. It also explains the increased sensitivity to pain.

As the symptoms go untreated, the affected area can become cool, have hair loss, and have brittle or cracked nails. Muscle atrophy or shrinkage, loss of bone density (calcium), contracture, swelling, and limited range of motion in joints can also occur in the affected limb. These are in part caused by decreased blood supply to the affected tissues as the condition progresses.

Causes

What causes this condition?

CRPS commonly occurs after an injury as minor as having blood drawn, or a sprained ankle. Other times, it may be the result of a more significant injury such as surgery, a fracture, immobilization with casting or splinting, or the result of a stroke.

Risk factors for developing CRPS include immobilization of the affected limb with a cast, splint or sling; smoking; genetics; and psychological factors.

Symptoms

What does the condition feel like?

Complex regional pain syndrome more commonly affects the hand or foot, but may spread further up the affected limb and even into the opposite limb. The common symptoms of CRPS are unrelenting burning or aching pain, skin sensitivity, swelling, discoloration, sweating, and temperature changes. If the condition becomes chronic, dystrophy or deterioration of the bones and muscles in the affected body part may occur.

The course of CRPS is commonly divided into 3 stages.

In the acute or first stage the affected region is painful, tender, swollen, and warm. Also, sweating, discoloration (usually red), and an increase in hair and nail growth is evident.

The second stage is characterized by burning pain, allodynia, hyperalgesia, coolness of the skin, hair loss, changes in skin such as paleness, and brittle or cracked nails. Allodynia is when pain is felt from stimulation which is not usually painful, such as light touch or a breeze. Experiencing pain from the sheet over an affected foot or leg is an example. Hyperalgesia is an increased, prolonged pain response. This is from something that would typically result in only mild discomfort.

The third stage is permanent and is characterized by dystrophy or defective growth of bones or tissue. It consists of muscle atrophy or shrinkage, bone density (calcium) loss, contracture, edema, and limited range of motion of the affected joints. Pain is worsened by any kind of touch and movement of the affected limb.

Sometimes only two stages are used to describe this condition. Temperature of the skin is either warm (stage 1), or cold (stage 2).

Diagnosis

How do doctors diagnose the problem?

The diagnosis of CRPS begins with a thorough history and physical examination. Conditions that may mimic CRPS should be ruled out and the proper treatment provided.

Your doctor will ask questions about possible trauma or a period of immobilization that may have caused your symptoms.

Your physical examination may include a skin examination to evaluate for swelling or a change in skin blood flow. Assessing temperature, color, sweating, hair and nail growth, range of motion, reflexes, and sensation testing may be included.

There is no specific test to make the diagnosis of CRPS. The following symptoms or factors are usually considered when making the diagnosis of CRPS

• triggering injury or cause for immobilization
• continuing pain, allodynia, or hyperalgesia that is out of proportion to what would be expected by the injury or immobilization
• evidence at some time of edema or change in skin blood flow

Other associated symptoms may include

• atrophy of the hair, nails, skin, and muscles
• alteration in hair growth
• loss of joint mobility
• impairment of motor function, including weakness, tremor

Your doctor may also ask for one or more of the following tests.

Diagnostic Sympathetic Nerve Block

A local anesthetic is injected into the stellate ganglia in the neck when treating the upper extremity. The stellate ganglia are a group of interconnected nerve cell bodies. Injecting anesthetic into the low back is used to treat the lower extremity. The injected anesthetic should numb the affected limb. Pain relief and improved temperature of the extremity is a positive diagnostic test.

Measurement of Blood Flow

Thermal imaging may be used which gives an infrared mapping of the skin temperature. A device called a laser doppler flow meter can also be used to measure skin blood flow.

X-rays

X-rays show problems with bone demineralization or loss of calcium from the bone. These changes can develop as the condition progresses.

Bone Scan

A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special X-rays of the affected limb. In the CRPS affected limb, the uptake will be greater around the joints. Early on in the condition, the bone scan may be normal.

MRI

Your doctor may request that you have a magnetic resonance imaging (MRI) of your spine or other part of your body. This test can show nerve compression either at the spine or of one of the larger nerves in your body that could be causing the pain. If nerve compression is found, then it is treated.

Laboratory Tests

Your doctor may request that you have blood drawn. Doctors use blood tests to identify other conditions such as arthritis or infection.

Electromyogram

Your doctor may request that you undergo an electromyogram (EMG) to help determine the source of your pain. If compression of nerves is found, then referral to a surgeon to release the pressure may be necessary.

An EMG is a special test using needles and electricity that is used to determine if there are problems with any of the nerves going to the limb. It may also be used to assess atrophy of the muscles of the affected limb when CRPS is present.

Treatment

What treatment options are available?

Early intervention is important for long-term positive outcomes. Most of the time CRPS will go away if the condition is recognized and treated early.

Nonsurgical

Treatment may involve a multidisciplinary approach. Nerve blocks, drug therapy, physical therapy, behavioral therapy, and psychologic support may be included.

Anesthetic Interventions

Sympathetic ganglion blocks used to diagnose the condition are also used to help treat CRPS. This treatment option is usually considered in the early stages. It can be performed several times. The stellate ganglia, located near the base of the neck, are injected with numbing medication in order to make the diagnosis of CRPS and to help treat the condition. This is where nerve blocks are done when CRPS involves the arm or hand.

The lumbar ganglia are injected to diagnose and treat symptoms of CRPS in the leg or foot. You may see a physical therapist during this period of time when the pain is decreased. Exercises and activities will focus on restoring motion, strength, and function.

A regional sympathetic block involving the entire limb may be considered. An IV is used to administer a local anesthetic in the affected limb. A tourniquet is used to keep the medication from spreading to the body.

Medication Therapy

Medications used for CRPS include anti-inflammatories. Sometimes steroids, very potent anti-inflammatories are used. Antidepressants can be beneficial as they help block the nerve pain whether you are depressed or not. Medications that prevent or stop seizures are often used. Other medications that dilate (open) blood vessels may be helpful. Topical creams can be used that contain an anesthetic such as lidocaine or other medications. Additionally, medications to prevent or halt the loss of calcium from the bones in the affected area may be considered. For the best results, two or more medications may be needed.

Behavioral Therapy

Psychological support may be useful. Decreased self-esteem from decreased activity tolerance can occur. Anxiety and depression as a result of pain is also common. Relaxation and biofeedback are commonly used.

Surgery

In cases of chronic CRPS that has failed all other therapies, spinal cord stimulation is used with some success. It involves the implanting of wires placed near the spinal cord that are attached to an electrical device. This helps to ‘short-circuit’ the pain pathway to the brain.

If sympathetic blocks were temporarily beneficial but painful symptoms have become chronic and can’t be changed or reduced, then a more permanent solution may be needed. Sympathetic ganglia can be permanently treated. Destruction of the sympathetic ganglion either surgically (radiofrequency ablation), or chemically may be considered.

In the extreme and rare case, amputation of the affected limb may be a surgical option.

Related Document: A Patient’s Guide to Spinal Cord Stimulators

Related Document: A Patient’s Guide to Radiofrequency Ablation

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Physical therapy should be started as early as possible. Since pain from CRPS is made worse with movement, there is a tendency to protect the limb by holding it stiff. This lack of motion can lead to muscle atrophy (shrinkage) and stiff or frozen joints. Early movement of the joints involved is important. Physical therapy may also include alternating hot and cold soaks and massage to the affected region to help control inflammation. Weight bearing activities to prevent bone density (calcium) loss are also important. The therapist may start you on a desensitization program. You will begin by applying various textures and touch to the painful area. For example, you may start by rubbing the affected area with a soft hairbrush or washcloth. This can help desensitize the area and decrease pain. More stimulation is gradually added by rubbing or tapping with various textures and pressures.

Although it may be quite painful, physical therapy is very important. The goal is to prevent the condition from progressing into chronic pain, disability, and deformity.

Immobilization of the limb is discouraged unless necessary in the case of fracture. You may be asked to wear a compression stocking or glove to assist with management of swelling.

After Surgery

You will likely be asked to resume or continue physical therapy following surgical interventions. Limited activity is allowed the first few days following placement of a spinal cord stimulator or destruction of the sympathetic ganglion. Maintaining range of motion and weight bearing activities is encouraged. These exercises are crucial to preventing permanent disability due to joint deformity, contracture, and bone density loss.

A Patient’s Guide to: Medication Approach to Chronic Pain

Introduction

Pain is the most common reason for visiting a doctor. Treatment for pain consists of non-drug therapy and drug therapy. Examples of the non-drug therapies are physical therapy, relaxation exercises, injections, and massage. Most patients with chronic pain will need to use both non-drug and drug therapies to get the best pain relief possible.

This guide will help you understand

• how healthcare providers choose medications
• how pain affects the decision
• what is polypharmacy
• what are the possible medication side effects

Analgesic Ladder

The World Health Organization (WHO) developed the analgesic ladder. It is designed to help healthcare providers manage cancer pain with medications in a systematic way.

Step 1 of the Analgesic Ladder

The WHO recommends a non-opioid (non-narcotic) medication as the first step. This can be given with an adjuvant medication. Adjuvants are medications that can give additive pain control when used with the primary pain medication. Common adjuvants include certain antidepressants, antiepileptics, and topical medications.

Non-opioid pain medications include acetaminophen (Tylenol®) and the non-steroidal antiinflammatory drugs (NSAIDs). NSAIDs include drugs such as aspirin, ibuprofen (Advil®, Motrin®) naproxen (Aleve®), Naprosyn®), piroxicam (Feldene®), meloxicam (Mobic®), celecoxib (Celebrex®), and many others.

Step 2 of the Analgesic Ladder

If pain is not controlled with a Step 1 medication, then one should proceed to Step 2. This would be adding or changing the medication to include a weak opioid. Weak opioids include the drugs such as hydrocodone or oxycodone with acetaminophen, ibuprofen, or aspirin. Common brand names are Lortab®, Vicodin®, Vicoprofen®, Bancap HC, Percocet®, and Percodan®.

Step 3 of the Analgesic Ladder

If the weak opioid is not enough, then a strong opioid should be tried. Examples of strong opioids are morphine (Kadian®, MS Contin®, Avinza®), oxycodone (OxyContin®), fentanyl (Duragesic® patches), oxymorphone (Opana®), and methadone (Dolophine®.)

Problems with the WHO Analgesic Ladder

The WHO analgesic ladder has been a helpful guide to slowly step patients up as they need stronger medications. There has been some debate over where some medications fit on the ladder.

Tramadol (Ultram®)

Tramadol is a synthetic analogue of the opioid codeine. The Drug Enforcement Agency (DEA) did not classify it as a controlled substance. This means that some see it as a Step 1 non-opioid drug. Others view it as a Step 2 opioid drug. It can be helpful for mild or moderate pain. It is one of the few medications that show benefit in patients with fibromyalgia.

The term weak opioid is a confusing term. Combining a low dose of an opioid with acetaminophen, ibuprofen, or aspirin, improves efficacy (gives the desired effect). Adding hydrocodone and oxycodone to other substances make them weak opioids. This is because there are dose limits to these products. The dose of the combined product is not limited by the opioid. It is limited by the non-opioid component. Exceeding the daily-recommended dose greatly increases the risk of dangerous side effects from the non-opioid component. Hydrocodone and oxycodone are low dose strong opioids without the added acetaminophen, ibuprofen, or aspirin.

At first propoxyphene (Darvon®, Darvocet®, Balacet®) was called a Step 2 weak opioid on the analgesic ladder. However, it is no longer recommended for use in chronic pain. The potential side effects of this drug outweigh the benefits. It gives little pain relief and can cause serious heart and lung problems when taken for long periods of time.

Just because medications are listed as Step 1 or Step 2 does not mean that they are safer medications than Step 3 medications. All medications have risks. The risks, or side effects, need to be balanced with their possible benefit. In chronic pain, the benefit you hope to get is pain control.

Side Effects of Non-opioid (Step 1) Medications

Acetaminophen

Excessive doses of acetaminophen can cause liver failure. Accidental overdose is the most common reason for liver transplants. In healthy individuals the daily dose limit is 4,000 mg per day (8 extra-strength 500 mg tablets or 12 regular strength 325 mg tablets.) The dose limit for patients with a history of liver problems or a history of alcoholism (or heavy drinking) is 2,000 mg per day. This includes acetaminophen from all sources. You must read the labels very carefully. Acetaminophen is often included in other medications such as cold, flu, and sinus preparations.

Ibuprofen and Aspirin (NSAIDs)

Ibuprofen and aspirin belong to the NSAID (non-steroidal antiinflammatory) group. The recommended dose limit for ibuprofen is 3,200 mg daily in healthy adults. This is about 16 of the over-the-counter 200 mg tablets per day. For aspirin, the daily recommend dose is 4,000 mg per day. The problem with all NSAIDs, not just ibuprofen and aspirin, is that major side effects can occur at doses lower than the recommended daily limit. The most concerning side effects are stomach ulcers, kidney failure, and making congestive heart failure worse. The side effects are related not only to the dose but also to the length of time you take the medication. Long-term use of any NSAID can increase the risk of heart attacks and strokes.

Side Effects with Opioids (Step 2 & 3) Medications

Although opioids do not cause liver or kidney damage, they have their own unique set of possible problems.

Common Side Effects

The most common side effects of all opioids are constipation, nausea, vomiting, and drowsiness. Rash, itch and mood changes can also occur. None of these side effects are allergies. Except for constipation, all of these side effects are expected to go away over five to seven days. This works best if the opioid is started at a low dose and your body is allowed to adjust to it. Most patients need to take a daily laxative to prevent constipation. You must do so for as long as you are on an opiate.

Sleep Disorders

Inadequate sleep increases the intensity of pain and decreases your ability to cope with pain. Pain can cause sleep disorders. Anxiety, depression, and fibromyalgia are also linked with sleep disorders. And opioid pain medications can cause sleep disorders. The most common disorders associated with opioids are sleep apnea and altered sleep patterns.

Sleep apnea is a condition in which you stop breathing during the night. The symptoms are loud snoring, gasping, and snorting while sleeping. Daytime drowsiness, fatigue, and/or falling asleep easily such as when driving a car or reading can occur. Opioids can make sleep apnea worse even to the point of causing death. If you think you may have sleep apnea, be sure to discuss it with your healthcare provider. If you have sleep apnea, you will need to treat it before starting an opioid medication.

Opioids can change sleep patterns. Even though you could be getting the same amount of sleep, it may not be restful sleep. While tiredness the first few days on an opioid is common, it should go away quickly. If you find that you are still tired, it is likely that the medication is altering your normal sleep pattern. Changing the medication should improve sleep. It can also improve pain management and your ability to cope with the pain.

Mood Changes

Opioids can cause mood changes. Some patients feel dysphoric (unhappy or sad) or in a worse mood. The biggest problem with opioids is that they can cause euphoria (intense happiness) or improve mood. Some patients describe this as getting energy from the medication. This would be great if this energy high didn’t go away after one to three weeks. Many patients think that euphoria is the same thing as pain relief. Once the euphoria wears off, it’s easy to think the opioid isn’t working any more. This is what causes people to start increasing doses. It takes more drugs over time to get the same change in mood.

Addiction

Addiction is defined by craving, uncontrolled, or compulsive use of a drug. and using it even though it causes harm. Addiction is a complex chronic disease. Simply taking an opioid does not cause addiction. If you have no risk factors, it is rare to develop the disease of addiction. However, if you have the right (or wrong) genetics and psychological and social stressors, addiction can occur.

There is no test for addiction. Addiction reveals itself by aberrant (abnormal) behaviors over time. Your healthcare provider looks for any of the following as a sign of a developing problem

• reporting that prescriptions have been lost or stolen
• asking for early refills
• not following medication directions
• taking extra medication without being told to
• increasing the dose without approval
• obtaining medications from multiple healthcare providers
• wanting to continue a medication despite major side effects
• wanting to continue a medication despite worse function
• using a drug for a reason other than it was prescribed (such as using a pain medication to calm down after a heated argument)

Physical Dependence

Physical dependence occurs when your body becomes used to a medication. Stopping the medication suddenly causes withdrawal symptoms. Withdrawal can occur with many medications including antidepressants and blood pressure medications. Physical dependence is not addiction. Physical dependence can occur in anyone on a regular dose of an opioid for more than one or two weeks. Withdrawal from an opioid can be mild or severe. Symptoms can range from mild irritability to sweating, diarrhea, vomiting and muscle cramps. You may feel like you have a severe case of the flu. Withdrawal may be miserable but it is not life threatening. It can always be avoided. Slowly decrease the medication over several days to several weeks. Let your body readjust to the lower dose.

Pseudo-addiction

Pseudo-addiction is the term used to describe what looks like dangerous or aberrant behavior but occurs when pain is not adequately treated. For example: you are prescribed a pain medication and told that you can only take two tablets per day. You have constant pain all day and night. The pain medication that you are prescribed works and allows you to be active but it only relieves pain for four hours. You are only allowed two tablets per day. How would you respond? Some people take more medication than is prescribed. They run out early. Others complain bitterly at every appointment. They demand more medication, and appear to be drug seeking. Some may go to more than one physician to get what they think they need to relieve the pain. Under-treatment of pain can cause this type of behavior. An increase in the dose stops the behavior.

Therapeutic Trial

It would be wonderful if your healthcare provider could pick the right drug at the right dose at your first appointment. This doesn’t happen very often. Everyone responds differently to different drugs. Pain will respond to some drugs in some people and not in other people. In some people, the pain responds, but they get side effects. Others don’t have any side effects. It really becomes a process of trial and error. It can take several visits and perhaps several trials of different drugs for you to get enough pain relief with side effects you can handle. It is not uncommon to feel like a guinea pig. Don’t give up. Keep telling your healthcare provider how the medication is working for you.

Polypharmacy

It would also be wonderful if one drug worked well. However, most patients with chronic pain will not get enough pain relief from a single medication. Using two or more medications that complement each other is called polypharmacy. The drugs have different mechanisms of action and can give better pain relief. As the WHO Analgesic Ladder suggests, pain specialists often combine opioid medications with other adjuvant medications. The goal is order to treat chronic pain adequately. The most common adjuvants are the following

• Antidepressants: The two groups that are used in pain management are the serotonin norepinephrine reuptake inhibitors (SNRIs) and the tricyclic antidepressants (TCAs). The SNRIs are duloxetine (Cymbalta®) and venlafaxine (Effexor®). The commonly used TCAs include amitriptyline (Elavil®), nortriptyline (Pamelor®), and desipramine (Norpramin®).
• Antiepileptics (anticonvulsants): These drugs are used to treat epilepsy and stabilize mood. They also work well treating nerve pain. Some of the antiepileptics commonly used in pain management are gabapentin (Neurontin®), pregabalin (Lyrica®), carbamazepine (Tegretol®), topiramate (Topamax®), levetiracetam (Keppra®), and lamotrigine (Lamictal®).
• Topicals: Capsaicin ointment and lidocaine patches are some of the medications that can be effective when applied to the skin.

Choosing the Right Medication

How do doctors choose the right medication?

There are many things to consider when choosing the right drug(s) for patients. Patient safety and ability to tolerate the drug come first. Efficacy (how well the medication works for the condition being treated) is also important. Affordability and ease of use (such as how many pills need to be taken daily) are important factors, too.

It may not be possible to use only one medication. But it is still best to treat with the fewest medications possible. Most chronic pain patients also suffer from depression, anxiety, and sleep disorders. It may be possible to pick a medication that not only helps with pain but could also help with the other problems.

Classifications of Pain

Pain can be defined by the underlying mechanism. It can be classified as either nociceptive pain or neuropathic pain. Nociceptive means unpleasant pain. It occurs when the nervous system is working as it should. Pain is a signal that something is wrong. Pain is caused by a stimulus such as injury, infection, or inflammation. The pain signal is sent to your spinal cord and then to your brain. Your brain then interprets the pain and acts on it. Your brain can release substances such as your own natural opioid-like endorphins to calm the initial pain signal down and help you deal with it. The pain intensity is usually related to the degree of injury and amount of actual tissue damage. Nociceptive pain generally responds to opioid medications, NSAIDs, and acetaminophen.

Neuropathic pain is caused by a nervous system that isn’t working right. Think of it as irritable nerve cells that react for no reason. The pain can arise from the central nervous system (spinal cord or brain) or from the peripheral nervous system such as in the legs, arms, skin, and so on. Insults such as trauma, inflammation, or diseases such as shingles, diabetes, and HIV can cause it. Neuropathic pain can be constant or episodic(comes and goes). It is often described as burning, streaking, lightening, tingling, or pins and needles.

Neuropathic pain serves no known purpose. It is not related to the degree of injury or disease. Neuropathic pain is meaningless outside the amount of suffering it causes. It is usually more difficult to treat than nociceptive pain. Most often more than one drug is needed to control neuropathic pain. Opioids aren’t as effective for this type of pain as they are for nociceptive pain. The drugs that are considered first-line choices are the antiepileptics and the antidepressants listed in the previous section.

Controversies About Opiate Treatment of Nonmalignant Chronic Pain

Acute pain lasts a short time. This is the kind of pain you may have after breaking a leg or after surgery. Acute pain goes away as the injury heals. Chronic pain is pain that lasts longer than expected after an injury. Cancer pain can be both acute and chronic. With both acute and chronic cancer pain, there is an expectation that the pain will go away sooner or later. As the injury heals or the cancer is cured (or the patient dies) there is an expectation of an end to the pain. Chronic nonmalignant (or non-cancer) pain is different. The pain can result from an acute injury that lasts beyond the healing or simply appears without a known reason. A few examples are diabetic neuropathy, post-herpetic neuralgia (shingles), low back pain, and fibromyalgia. Patients can have these painful syndromes for decades.

It is acceptable to treat severe acute and cancer pain with opioid medications. However there is debate about treating chronic nonmalignant pain (CNP) with opioids. All medications carry risks. The hoped for benefit of a medication must outweigh the possible risk. Opioids have great risk for abuse and addiction, especially when used for long periods of time. Because of these risks, opioids are only used in CNP after other appropriate medications and non-medication therapies have failed. Most experts consider opioids as the treatment of last resort for CNP.

Risk-Benefit Analysis of Opiates and Sedatives

The biggest risks of taking opiates and sedatives are addiction and death. The overall risk of substance abuse in the general population is around 10%. Your specific risk depends on your own risk factors. If you have no history of addiction and no significant history of mental health problems, then you have a low risk of addiction. If you have a history of addiction or substance abuse, then you are at greater risk for addiction. But if you are in remission and have good support systems, you may still do well on opioids. You are at high risk for abusing an opioid or sedative medication if you are actively abusing alcohol and other substances. Untreated mental health issues and poor support systems add to your risk.

There are ways to decrease the risk of addiction or substance abuse. Diagnosing and successfully treating any mood disorder reduces the risk. The most common mood disorders include depression and anxiety. Avoiding short acting opioids reduces the risk of addiction or abuse. Long acting opioids are safer as they are less likely to feed into the changes in mood that fuel substance abuse. The long acting opioid, methadone is considered the safest of the opioids. It causes little to no mood alteration. Long-acting morphine is usually the second choice.

Opioids cause death by stopping the body’s drive to breathe. This can happen as an intentional overdose such as in suicide. It can also be the result of an accidental overdose when an addict tries to get high. Combining an opioid with another substance such as alcohol also decreases the desire to breathe, or makes sleep apnea worse. Death can be avoided. Don’t take extra medication without approval from your healthcare provider. Let your healthcare provider know about all other medications and drugs you take including alcohol. Finding out if you have sleep apnea and treating it is also important in preventing death.

The benefit of these medications is better function and improved quality of life. If, after weighing your specific risks, you and your healthcare provider decide that the possible benefit is greater than the potential risk, then a medication trial is indicated.

Careful monitoring of your response to a medication trial is essential. Risky behavior or serious side effects can be caught early. Preventing and solving problems before there is a bad outcome is important.

Hyperalgesia

Hyperalgesia is described as an extreme sensitivity to what is normally not painful such as a simple touch. This comes from nerves sending pain messages of increasing frequency and intensity to your brain. It can be from the same area that was previously hurt. Or it can expand beyond the initial painful area. Opioids can cause hyperalgesia. If you feel more pain after starting or increasing an opioid, you may be experiencing hyperalgesia. If hyperalgesia develops, stopping the opioid will improve pain control. Other treatment options can then be explored.

Detoxification

Detoxification (detox) is letting your body get back to its natural state without any pain medications in it. There are several reasons you might want to detox. One reason is hyperalgesia. Another reason is if you are on several medications and you aren’t sure if they are helping or not. Or you might be having a side effect and you aren’t sure which drug is causing it. By slowly going off one drug at a time, you can find out if the medication was helping or not. Likewise, you’ll see if it was causing any side effects. If the pain is worse when you’re off the drug, it can be restarted. It is surprising how many patients feel better after stopping many of their drugs.

Some experts believe that your body stops making its own natural painkillers (endorphins) when it is given artificial ones. Stopping the medications for one or two months lets your body rest and reset its own natural response.

Opiate rotation

Opiate rotation is changing from one opioid to another. Opiate rotation is used when tolerance to the pain relief develops after several dose increases. If this happens to you, be sure to explore all the possible reasons for the medications no longer working as well. One reason for medications not working as well is if the there is a new injury or the underlying disease is getting worse. An example is a new compression fracture in someone with low back pain and osteoporosis. Once that is ruled out, keep in mind anything that makes you feel worse such as worsening depression, increasing anxiety, or stresses at home will make pain feel more intense. The best treatment is to treat the underlying problem.

Once those issues are sorted out, it may be a good idea to switch from one opiate to another. Changing to a different pain medication can result in better pain control at a lower comparative dose and help keep opioid creep (when the dose of the opioid keeps slowly but relentlessly increasing over time) under control.

Opiate Holiday

Similar to detoxification, giving you a holiday from opiates for four to eight weeks can be a good idea. It helps reset your body’s natural ability to cope with pain. And it can help you decide if you even still need the medication. A drug holiday can also reduce tolerance and allow you to restart the medication at a lower dose.

Some surgeons are reluctant to operate on patients taking high doses of opiates. Patients on high doses cope less well with surgical pain and recover more slowly after surgery. Tapering off the medications three weeks before surgery can be a good idea for two reasons. First, you may respond better to lower doses of the pain medication. And second, the surgery may give you significant relief so that you no longer need such a high dose anymore.

Summary

Chronic pain management is a complex process. Most chronic pain patients have both neuropathic and nociceptive pain, along with depression, anxiety, and sleep disorders. Chronic pain can also cause social stresses such as the loss of a job or contribute to the failure of a marriage. When constant pain is combined with these types of stresses, the overall suffering becomes much larger than just the physical pain. It can be a vicious circle as these stresses make the physical pain seem stronger.

The risks associated with the medications used to treat pain also increase the complexity of the problem. However, with careful drug selection and close monitoring, it is possible to decrease pain, increase function, improve quality of life, and decrease the suffering associated with chronic pain.

A Patient’s Guide to Pain Management: Radiofrequency Ablation

Introduction

Radiofrequency ablation is a treatment where radio waves are used to create heat and destroy a part of a nerve. This technique is most commonly used to treat pain that is originating in the facet joints of the spine. The procedure is used to destroy the end of the small nerves that provide sensation to the facet joints. Once the nerve is destroyed, you should no longer feel the pain from the worn out, painful facet joints. This procedure is also sometimes called a RFA, rhizotomy, or a neurotomy.

This guide will help you understand

• What parts of the spine are involved
• What is the surgeon is trying to achieve
• What happens during the procedure
• What are the possible complications

Anatomy

What parts make up the spine?

The spine is made up of 24 bones called vertebrae that stack on top of one another. Each vertebrae has a ring of bone that encases and protects the spinal cord. When the vertebra are stacked one on top of the other, these rings of bone create a hollow tube called the spinal canal. The spinal cord runs through the spinal canal from the brain to the lower spine. Between the vertebrae are intervertebral discs. The intervertebral discs cushion the spine and make it flexible. There are also two facet joints between each vertebrae of the spine. The facet joints are located on the back of the spinal column in the lumbar and thoracic spine. In the neck, or cervical spine, they are located on the each side of the vertebra.

A facet joint is a small, bony knob that extends out from the vertebral body. Where these knobs meet, they form a joint that connects the two vertebrae. The surface of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the surface of all synovial joints. It allows the bone ends to move against each other smoothly without friction. Each joint is surrounded by a joint capsule. The joint capsule is made up of the ligaments and connective tissues that help hold the joint together. The joint capsule forms a water tight sac that contains the joint fluid. The facet joints allow freedom of movement as you bend forward and back.

Like all joints, the facet joints can wear out – or degenerate. This condition is sometimes called degenerative arthritis or osteoarthritis. When this occurs in the facet joints it can cause neck and back pain. When the facet joints of the cervical spine are affected the pain can radiate into the upper back and shoulder area. When the facet joints of the lumbar spine are affected, the pain may radiate into the buttock and back of the thigh.

Small nerves called the medial branch nerves provide sensation to each facet joint. These nerves carry the pain signals from the facet joint to the spinal cord. The signals eventually reach the brain where you feel the sensation of pain.

Rationale

What do surgeons hope to achieve with this procedure?

There are several structures in the spine that can be a source of pain. One of the most common sources is the facet joint. As these joints degenerate and develop osteoarthritis they become painful. The pain from facet joint arthritis may come and go depending on activity.

The goal of radiofrequency ablation is to destroy the small nerves that carry the pain signal from the joint to the spinal cord. The goal is to reduce your pain, allow you to do more activity, and enable you to reduce your pain medications.

Radiofrequency ablation is usually done only after you have had a successful facet joint injection. Your doctor will perform a facet joint injection to try and determine if the facet joints are the cause of your back pain. The injection may only reduce your pain temporarily, maybe only for a few hours. Once your doctor is sure that it is the facet joint causing your pain, radiofrequency ablation is done to reduce your pain for a longer period of time. Radiofrequency ablation is not a permanent fix, but it lasts much longer than a facet joint block.

Preparation

How should I prepare for the surgery?

To prepare for the procedure your doctor may tell you to remain “NPO” for a certain amount of time before the procedure. This means that you should not eat or drink anything for the specified amount of time before your procedure. This means no water, no coffee, no tea – not anything. You may receive special instructions to take your usual medications with a small amount of water. Check with your doctor if you are unsure what to do.

You may be instructed to discontinue certain medications that affect the clotting of your blood several days before the injection. This reduces the risk of excessive bleeding during and after the injection. These medications may include the common Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin, ibuprofen, naproxen, and many other medications that are commonly used to treat arthritis. If you are taking any type of blood thinning medication you should let your doctor know. You will most likely need to have this medication regulated or temporarily discontinued prior to the procedure. Your doctor will need to determine if it is safe to discontinue these medications in order to have the procedure.

You may need to arrange to have transportation both to and from the location where you will undergo the procedure. Wear loose fitting clothing that is easy to take off and put on. You may wish to take a shower the morning of the procedure, using a bactericidal soap to reduce chances of infection. Do not wear jewelry or any type of scented oils or lotions.

Procedure

What happens during the procedure?

When you are ready to have the procedure, you will be taken into the procedure area and an IV will be started. The IV allows the nurse or doctor to give you any medications that may be needed during the procedure. The IV is for your safety because it allows very rapid response if you have a problem during the procedure, such as an allergic reaction to any of the medications injected. If you are in pain or anxious, you may also be given medications through the IV for sedation during the procedure.

You will be awake for the procedure to help the doctor with correct placement of the electrode used for radiofrequency ablation. You will not be given a general anesthetic. The area to be treated will be cleaned and then numbed with a local anesthetic.

Radiofrequency ablation is done with the help of fluoroscopic guidance. The fluoroscope is an x-ray machine that allows the doctor to actually see an x-ray image while doing the procedure. This allows the doctor to watch where the needle electrode goes as it is inserted. This makes placing the electrode much safer and much more accurate. In performing radiofrequency ablation, your doctor inserts a needle electrode near the facet joint so that the tip of the needle is very near the medial branch nerve that travels to the facet joint. Once your doctor is sure that the tip of the needle is in the right place, the tip of the needle is heated to cauterize and destroy the nerve. Once the nerves carrying the sensation from the painful joints are destroyed, your pain should be reduced.

After the procedure, you will be taken to a recovery area. The nurses will monitor you to be sure you do not have an allergic reaction. You will be allowed to leave once you are stable.

Complications

What might go wrong?

There are several complications that may occur during or after the facet joint injection. Injection procedures are safe and unlikely to result in a complication, but no procedure is 100% foolproof. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Complications are uncommon, but you should know what to watch for if they occur.

Allergic Reaction

Like most procedures where medications are injected, there is always a risk of allergic reaction. The medications that are commonly injected include lidocaine, bupivicaine, radiographic dye, and cortisone. Allergic reactions can be as simple as developing hives or a rash. They can also be life threatening and restrict breathing. Most allergic reactions will happen immediately while you are in the procedure room so that help is available immediately. Most reactions are treated and cause no permanent harm. You should alert your doctor if you have known allergies to any of these medications.

Infection

Several types of infections are possible complications of radiofrequency ablation. Any time a needle is inserted through the skin, there is a possibility of infection. Before any invasive procedure is done, the skin is cleansed with a disinfectant and the health care provider doing the procedure uses what is called sterile technique. This means that the instruments and the area where the skin is punctured remains untouched by anything that is not sterile. The doctor will also use sterile gloves.

Infections can occur just underneath the skin, in a muscle, or in the facet joint. You should watch for signs of increasing redness, swelling, pain, and fever. Almost all infections will need to be treated with antibiotics. If an abscess forms, then a surgical procedure may be necessary to drain the pus in the abscess. Antibiotics will also be necessary to treat the infection.

Nerve Damage

Many pain procedures are done close to nerves. Radiofrequency ablation is one of the safest spinal procedures because the needle electrode is usually not near the spinal nerves, but the needle electrode used to do the injection may accidentally hit a nerve while being positioned. This can cause damage to the nerve and result in increased pain. Numbness and weakness may also result. Nerves that have been punctured with a needle will usually recover and do not require any additional surgical procedures.

Neuritis

Neuritis is an inflammation of the nerve that causes pain and tenderness in the back. It may last from three to six weeks. This can occur in 10 to 15 percent of patients. Neuritis usually goes away by itself. If it does not, your doctor may suggest injecting a local anesthetic along with a steroid medication around the nerve. This may reduce the inflammation and ease your pain.

Increased Pain

Not all radiofrequency ablation procedures work as expected. Even though a test block was beneficial, some patients have no pain relief from the procedure. Even though a test block was beneficial, some patients have no pain relief from the procedure. Sometimes, the procedure can actually cause more pain. Increased pain that begins several days after the injection may be a sign of infection. You should alert your doctor if this occurs.

After Care

What should I expect after the procedure?

You will be able to go home soon after the procedure, probably within one hour. If all went as planned, you probably won’t have any restrictions on activity or diet. Immediately following the procedure, you may have some relief of pain from the numbing medication used during the procedure. You may not be able to drive or do any physical activity for 24 hours.

You may experience an increase in pain for the first several days following the procedure. Additional pain medications may be necessary to make you comfortable. If these include narcotics, you will need to watch for constipation. Drink lots of fluids and eat foods with plenty of fiber. If constipation should occur you will need to use a laxative, available over-the-counter.

You may also note some swelling and bruising where the needle was inserted. Using a cold pack may ease the discomfort.

The degree of pain relief varies from person to person. You may continue to see a decrease in your pain for up to three weeks. You may see a 50 percent or greater pain relief. Pain relief can last from 6 to 12 months, sometimes even longer. The nerves will grow back eventually and your pain will probably return. When this occurs, the procedure may be repeated.

Most doctors will arrange a followup appointment, or phone consult, within one or two weeks after the procedure to see how you are doing and what effect the procedure had on your symptoms.

And remember, radiofrequency ablation is not a cure for your pain; it is only a part of your overall pain management plan. You will still need to continue working with the other recommendations from your pain management team.

A Patient’s Guide to Pain Management: Spinal Cord Stimulators

Introduction

A spinal cord stimulator, also called a dorsal column stimulator, is an implanted electronic device used to help treat chronic pain. These devices have been in use for the treatment of pain for over 30 years and they continue to improve. The area of medical science responsible for developing these devices is called neuromodulation.

The spinal cord stimulator will not cure your pain. But, you should see a reduction in your pain of 50 percent or more if the stimulator procedure is successful. The goal of the spinal cord stimulator is to allow you to be more active and take less pain medication with less pain.

This guide will help you understand:

• what parts of the spine are involved
• what is the surgeon trying to achieve
• what the spinal cord stimulator looks like
• what happens during surgery
• what could go wrong

Anatomy

What parts of the spine are involved?

The spine is made up of 24 bones called vertebrae that stack on top of one another. Each vertebrae has a ring of bone that encases and protects the spinal cord. When the vertebra are stacked one on top of the other, these rings of bone create a hollow tube called the spinal canal. The spinal cord is a tube of nerve cells that create the motor and sensory pathways that link the brain to the body. The spinal cord runs through the spinal canal from the brain to the lower spine. Inside the spinal canal, the spinal cord is covered by a watertight sac called the dura. Inside the dura, the spinal cord is bathed by cerebral spinal fluid that cushions and protects the fragile nerve tissue.

In between the vertebrae are intervertebral discs. The intervertebral discs cushion the spine and make it flexible. The nerve roots exit the spinal canal between the vertebrae. The openings in the spinal canal where the nerve roots exit are called neuroforamen. If there is not enough room for the nerve roots to easily travel through these neuroforamen, this can lead to irritation and pressure on the nerves. This may cause symptoms of nerve dysfunction such as burning, pins and needles, and hypersensitivity. Pain from an irritated or pinched nerve root follows a pattern that matches where the nerve travels through the body. In the case of the lower or lumbar spine, these nerves travel into the lower extremities.

Damage to nerves can lead to a specific type of pain called neuropathic pain. Neuropathic pain can have many sources, for example: amputation leading to phantom limb pain, diabetes causing peripheral neuropathy, shingles leading to post herpetic neuropathy and injuries leading chronic regional pain syndrome (CRPS). When the spinal nerve roots have been damaged due to constant pressure or irritation, this is also considered neuropathic pain. Neuropathic pain is difficult to treat. Medications have not been very effective in relieving this type of pain. Spinal cord stimulation is one technique that pain physicians find helps to reduce the symptoms of neuropathic pain.

Rationale

What does my surgeon hope to achieve?

Spinal cord stimulation can be thought of as blocking the pain signal as it travels up the spinal cord to the brain. The small stimulator device is similar to a pacemaker and is implanted underneath the skin, usually in the lower abdomen or upper buttock. The device is connected to special electrodes that are positioned over the back of your spinal cord by wires placed inside the spinal canal. The stimulator device delivers an electrical current to the electrodes that interrupts the conduction of the pain signal, replacing the pain with a tingling, or buzzing sensation. The electrical stimulation serves as a distraction and allows your brain to focus on the tingling, often soothing sensation it makes.

Spinal cord stimulation is usually considered when the pain is chronic and severe – and surgery, injections, physical therapy, medications, and other treatments have failed to give enough relief of pain. The spinal cord stimulator will not cure your pain. But you should expect a 50 percent or greater decrease in your pain following successful spinal cord stimulation. This should allow you to be more active, have less pain and need less pain medications.

Spinal cord stimulation has been approved by the Food and Drug Administration (the FDA) for the treatment of chronic intractable pain in the trunk and limbs. It seems to work best for neuropathic pain, the type of pain caused by injury or disease to nerves. It has also been used when there is continued pain into the legs following back surgery. This condition is sometimes called Failed Back Surgery Syndrome. Spinal cord stimulation seems to be less helpful for back pain without pain into the legs. Spinal cord stimulation has also been used successfully for reducing pain from chronic regional pain syndrome (sometimes called CRPS), diabetic neuropathy, and vascular insufficiency.

Preparation

How should I prepare for surgery?

Before having the device implanted, you will be need to undergo both a physical examination and a psychological evaluation.

There are several conditions that would prevent you from being considered a candidate for a spinal cord stimulation.

If you have a pacemaker or cardioverter defibrillator already implanted, the spinal cord stimulator could interfere with this device and cause life threatening problems.

If you have a disease that requires that you take blood thinners you may be at too great a risk for bleeding into the spinal canal from the stimulator electrodes.

If you have any type if active infection, this will increase the risk of infection around the spinal stimulator. If the infection is cured, this contraindication may be removed.

Finally, if you have an untreated substance addiction or significant psychological problems, you may not be considered an appropriate candidate for the spinal cord stimulator until these problems are under optimal control.

To prepare for the procedure your doctor may tell you to remain “NPO” for a certain amount of time before the procedure. This means that you should not eat or drink anything for the specified amount of time before your procedure. This means no water, no coffee, no tea – not anything. You may receive special instructions to take your usual medications with a small amount of water. Check with your doctor if you are unsure what to do.

You may be instructed to discontinue certain medications that affect the clotting of your blood several days before the injection. This reduces the risk of excessive bleeding during and after the injection. These medications may include the common Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin, ibuprofen, naproxen and many other medications that are commonly used to treat arthritis. If you are taking any type of blood thinning medication you should let your doctor know. Medications used to prevent strokes, such as Plavix, can also affect blood clotting. These medications usually need to be stopped seven days prior to the procedure.

Wear loose fitting clothing that is easy to take off and put on. You may wish to take a shower the morning of the procedure, using a bactericidal soap to reduce chances of infection. Do not wear jewelry or any type of scented oils or lotions.

Surgical Procedure

What happens during the surgery?

A surgeon, anesthesiologist, or other doctor who specializes in the treatment of pain does the implanting of the spinal cord stimulator.

The complete spinal cord stimulation procedure is actually done in two stages. In the first stage, called the trial, the electrodes and wires are placed into position in the spinal canal and left protruding through the skin. Think of this as similar to having an IV in your arm. The stimulator device can be connected to these wires and used to control the amount of spinal stimulation. The trial can last up to seven days while you test the amount of pain relief you get from using the device. If you and your doctor are pleased with the result and both of you consider the trial a success, you will be scheduled to have a second procedure where the device is implanted permanently under the skin. If you and your doctor are not pleased with the result and consider the trail a failure, the wires are removed and nothing remains inside your body. Being able to undergo a trial is one of the great benefits of spinal cord stimulation – you get to give the procedure a test drive before you commit to having the device permanently implanted.

Both the trial implantation and the permanent implantation procedures usually take place in an operating room, either in a hospital or in a same day surgery facility. An operating room is a sterile environment that decreases the risk of infection. Each procedure may last up to three hours. You should be able to go home the same day.

To perform the procedure, you will be given an intravenous sedative to help you relax and a local anesthetic will be used to deaden the area where the wires are inserted. A general anesthetic is not normally used, especially during the procedure for the trial implantation. You will need to be awake so that you can help guide your doctor when adjusting the device in order to provide the best pain relief.

If the trial is successful, you will undergo a second procedure that involves placement of the electrode wires near the spinal cord. If your pain is in the arm(s), the wires are placed in the upper back. If your pain is in your leg(s), the wires are placed in the low back.

Usually this is done through the skin with a needle just like the trial. Sometimes a small piece of bone on the vertebrae must be removed. The wires are then run under the skin and attached to the implanted spinal cord stimulator device.

Placement of temporary wires for the trial is a minimally invasive procedure. An epidural needle is placed through the skin and into the spinal canal near the spinal cord. This is done with the help of a special X-ray called fluoroscopy. The electrode wires are then inserted through the needle and pushed through the spinal canal until they are in the right position. The wires are then attached to the external stimulator device. Your surgeon will adjust the wires and tune the stimulator. When satisfied with the placement of the wires, a stitch to your skin is used to keep the electrode wires in place for the trial period. You are able to adjust the strength of the electrical stimulation and turn it off and on using the external device. When the stimulator is on, you should feel a tingling sensation that covers the area of your pain.

The procedure for permanent placement of the spinal stimulator is very similar to the trial. The new electrodes can be placed in the same way using the needle technique, or if more precise placement is needed a small incision may be necessary over the spine. The wires are then tunneled under the skin to the area where a small incision is made to place the stimulator device under the skin. If your pain is in your legs, an incision is made on your lower abdomen or upper buttock. For pain involving the arms, an incision is made on the side of the chest.

The stimulator device is controlled by a wireless controller that you should keep with you at all times. The controller allows the stimulator to be programmed to adjust the type and strength of the electric stimulation. The spinal cord stimulator is not necessarily permanent. It may be removed if necessary. The battery may last two to five years. The device must be removed surgically and the battery or the device replaced.

Complications

What might go wrong?

Spinal cord stimulation is considered minimally invasive and safe. However there are several complications that may occur during or after this procedure. No invasive procedure is 100 percent foolproof. Complications are uncommon, but you should know what to watch for it they occur.

Infection can occur at the incision site, around the wires, or around the device itself. You should watch for signs of increasing redness, swelling, pain and fever. Almost all infections will need to be treated with antibiotics. When the infection involves the spinal canal, it may be more serious. A condition called an epidural abscess may form inside the spinal canal. This infection can cause a large pocket of pus to form around the nerves putting too much pressure on the nerves. If this complication occurs, you will probably need a surgical procedure to drain the infection and remove the pressure from the nerves. The device, the electrodes and the wires will need to be removed. Antibiotics will also be necessary to treat the infection.

An epidural hematoma occurs due to excessive bleeding into the spinal canal. The bleeding can cause pressure on the spinal cord. This, in turn, can cause paralysis or loss of movement of the limbs. Loss of bowel and bladder function can also occur. This complication requires emergency surgery to drain the hematoma and relieve the pressure. The spinal cord damage can be permanent.

A pneumothorax is the collapse of a lung. A lung can be punctured when needles are inserted in the area of the chest or upper back. If the pneumothorax is small, then it may only require watching for several days until it resolves. If it is severe and interferes with your breathing, a chest tube may need to be inserted to re-inflate the lung.

Damage to the spinal sac during the insertion of the electrodes may cause a persistent spinal fluid leak. The symptom that you will experience if this occurs is a very bad headache. The headache is worse when you are sitting or standing upright. It may cause nausea and vomiting. It will go away if you lie flat or with your head a bit lower that your feet.

The headache occurs because the spinal fluid pressure in the skull decreases. That is why the headache goes away when you lie down – the spinal fluid pressure goes back to normal in your skull. Most spinal headaches go away in a few days when the hole in the spinal sac heals and closes. You may be instructed to stay flat for a couple of days until this occurs. If your headache lasts longer than 48 hours, call your surgeon. A spinal fluid leak may require surgery to correct.

Nerve damage caused by needles and electrodes placed in the area of the spinal cord may occur. Even paralysis that could be permanent could occur.

Allergic reactions can occur, usually to medications or dye used during the surgery. A severe allergic reaction called anaphylaxic shock can be deadly.

A seroma is the collection of fluid that develops in the pocket around the implanted device. It can last several weeks or months. It can be drained by your surgeon. If the fluid in the seroma becomes infected, the device must be removed and the infected fluid drained.

Finally, technical problems or failure of the device can occur. The electrodes may slip out of position. This may change the area of stimulation and could reduce or eliminate the effectiveness of the pain relief. The wires or the electrodes can break leading to failure of the device.

After Care

What happens after the procedure

You will need to lie down as much as possible for 12 hours following your surgery. Your surgeon will allow pain medication for the first few days following surgery. Narcotic pain medications can cause constipation and laxatives may be necessary to have regular bowel movements. You may be asked to avoid the use of an anti-inflammatory such as aspirin, ibuprofen, (Motrin), naproxen (Aleve) as they can cause bleeding.

You will be asked to avoid bending, twisting, stretching, reaching overhead, or lifting objects over five pounds for the first six to eight weeks. This is to avoid movement of the wires that connect the device to the electrodes. You will probably not be allowed to drive for two to four weeks after the procedure. Sexual activity may also be restricted initially.

You should expect some mild swelling and bruising at the incision site. Ice packs may help with pain and swelling. There will be sutures or staples and a dressing covering the incision. Call your doctor immediately if you run a temperature, or notice redness, swelling, separation, or drainage from the incision.

You will be allowed to shower but you should not bathe or submerge your incisions for four weeks. Watch for visible swelling or leaking of fluid from the incisions. You should wear loose clothing over the incision sites. If you should have sudden weakness of your legs, loss of bowel or bladder function, or sudden severe back pain, you should call your surgeon and go to the emergency department. It may indicate pressure on the spinal cord, a complication that could require emergency surgery.

You will be given instructions on how to operate your spinal cord stimulator. Usually one or two hours of stimulation, three to four times a day is enough to relieve pain for the rest of the day. You should expect 50 to 70 percent improvement in your pain. The device should be turned off when driving and operating machinery or power tools.

You will have a follow up appointment with your doctor seven to 10 days after surgery to remove sutures or staples. Your surgeon may make adjustments to the device at this and other follow-up appointments.

After six to eight weeks, you should be able to resume and eventually increase your activity level. As you learn to live with your new device there are a few things you should know. Electronic systems that contain magnets will need to be avoided. They can interfere with the electrical current from your device. These include security systems found in libraries and airports. Strong X-rays, ultrasound, and magnetic resonance imaging (MRI) should also be avoided. Microwaves, cell phones, pagers, and anti-theft sensors will not affect your stimulator. You will be given an identification card that can be shown to airport and other security officials when necessary. The ID card can also be used in the event of a medical emergency. It is important for medical providers to know about the implanted device.

And remember, the spinal cord stimulator is not a cure for your pain; it is only a part of your overall pain management plan. You will still need to continue working with the other recommendations from your pain management team.

A Patient’s Guide to Pain Management: Pain Pumps

Introduction

Pain pump delivery of narcotic drugs is a rather new option available to persons with cancer and non-cancer pain. It is also called intraspinal (within the spine) or intrathecal (within the spinal canal) delivery. It was first used in 1979 after the discovery of narcotic receptors in the spinal cord. The use of an implant device to deliver medications directly in the area of the spinal cord was first used in 1981 for cancer pain. Since then, the pain pump has been used for chronic non-cancer pain such as failed low back surgery syndrome and spasticity from neurological conditions like multiple sclerosis, spinal cord injury, and cerebral palsy.

This guide will help you understand:

• what parts of the spine are involved
• what is the surgeon trying to achieve
• what the pain pump looks like
• what happens during surgery
• what are possible complications

Anatomy

What parts of the spine are involved?

The spinal cord is a nerve tube that is housed within the bony spine. A thin, delicate membrane called the pia mater covers it. The second membrane layer surrounding the spinal cord is called the arachnoid mater. The outermost covering of the spinal cord is called the dura mater and is somewhat tough.

The fluid filled space between your spinal cord and the arachnoid mater is called the subarachnoid or intrathecal space. This is where the pain pump delivers medication. It is then mixed with the cerebral spinal fluid.

Cerebral spinal fluid is a clear liquid that bathes and cushions the spinal cord and brain. If the cerebral spinal fluid leaks out of this space, it can cause a headache of variable severity.

Rationale

What does my surgeon hope to achieve?

The pain pump was first used in 1979 after the discovery of opiate receptors in the spinal cord. Opiate receptors are the connections on the nerve cells where medications such as morphine actually connect to the cell. These receptors are necessary for the medication to create the signals to the cell to reduce pain. Prior to 1979, no one believed that pain medications worked on the nerves of the spinal cord. We now know that much of the pain control achieved by medications such as morphine occurs in the spinal cord nerves. It makes sense that we should try to deliver the medications directly to the receptors so the medication(s) has the greatest effect.

The other great benefit of the pain pump is that less medication is required to get the same effect. When you take pain pills, the medication must travel through your bloodstream in the same concentration throughout your body. This causes side effects when the medication affects different organs systems, such as the bowels, kidneys, and liver. By placing the medication directly into the spinal canal, there is less medication in the bloodstream. Less medication in the bloodsteam means fewer unwanted side effects.

Preparation

How should I prepare for surgery?

Talk to your surgeon about all medications you are taking before the procedure is scheduled.

Follow your surgeon’s pre-op instructions, they may include the following

• Do not eat or drink for at least six hours before the procedure. You will be able to take your usual medication with a small amount of water. If you have diabetes, do not take your insulin or diabetic pills until after the procedure.
• You will need a driver to return home.
• Do not take any aspirin or aspirin-containing medication at least eleven days before the procedure. They may prolong bleeding.
• Wear loose fitting clothing that is easy to take off and put on.
• Take a shower the morning of the procedure, using a bactericidal soap to reduce chances of infection.
• Do not wear jewelry.

Surgical Procedure

What happens during the operation?

Before we discuss the surgery, lets look at the pain pump itself.

Pain Pump

The pain pump is a round metal device that your surgeon places just under the skin of your abdomen. It is about the size of a hockey puck. Inside the device there is a space called a reservoir. This holds the medication(s). Attached to the pump is a catheter or small plastic tube. The catheter is surgically placed near the spinal cord in the intrathecal space. The tubing is then tunneled under the skin and connected to the pump. The tubing is what delivers the medication stored in the pump to the spine.

The pump is programmed to dispense the medication at a certain rate throughout the day. The pump stores the information. It can be adjusted when needed. The medication lasts one to three months depending upon the amount infused. When the pump needs to be refilled with medication, a doctor or nurse inserts a needle into the top of the pump through your skin. The medication is then refilled through the needle.

Chronic non-cancer pain can be complicated by physical, psychological, and behavioral factors. Candidates for pain pump undergo evaluation for untreated addiction, psychological problems, and evaluation for medical contraindications such as risk for infection.

Criteria used to determine whether or not you are a good candidate for placement of a pain pump include but are not limited to the following

• You have tried multiple conservative therapies such as physical therapy, chiropractic, massage, relaxation, acupuncture and spinal injections and they have failed to provide significant benefit
• You are not a candidate for surgery
• You do not have psychological or addiction problems
• You have no medical conditions that would be considered a complication
• You are presently taking oral pain medication and are having significant side effects
• You benefited from a trial of epidural anesthesia

Once it is decided that you are a candidate for an intrathecal pump, you will have a trial period with medication delivery to the intrathecal space. Usually this involves placing a catheter (small plastic tubing) into the intrathecal space. It is then connected to an external pump. The trial period lasts for two to three days. Sometimes a trial period will consist of just a single or multiple injection of medication placed in the intrathecal space by a lumbar puncture.

A 50 percent or greater improvement in pain (or spasticity) and function would suggest that the implanted device is reasonable to consider. The doctor then knows best where to place the tip of the catheter and what medication(s) is effective.

If during this trial period the medication is not tolerated or does not provide relief, the implantable device is not considered. The implanted pump is not necessarily permanent as it can be removed at any time.

The Procedure

What happens during the procedure?

Anesthesiologists, neurosurgeons, and other doctors who specialize in spine disorders implant the pump. Surgery is performed as an outpatient. It is a two-part process and usually takes three to four hours. You will have anesthesia during the procedure. Most patients are discharged to home the same day as the procedure.

The catheter or small plastic tubing is inserted into the intrathecal space through a small incision near the spine and secured there. Careful placement of the catheter is important as the medication is only beneficial if placed in the area surrounding the spinal cord, the intrathecal space. Once the catheter is in place, an extension catheter is threaded under the skin around to your abdomen where the pump will be implanted.

Next your surgeon makes a four to six inch incision in the side of your abdomen, below the waistline. The pump is then inserted between the skin and muscle layers. The catheter is then attached to the pump. Medication is then allowed to flow from the device through the tubing.

Positioning of the catheter is checked with a fluoroscopy. Fluoroscopy is an imaging technique using a continuous X-ray beam that is passed through the body part being examined. You are placed between the X-ray beam and a fluorescent screen. The image is transmitted to a TV-like monitor so that live video images can be played. This allows the physician to watch the procedure he/she is performing to ensure proper placement of the catheter. It also allows them to check and make sure the medication from the pump is delivered correctly.

Medications

When opiates for pain relief are determined to be necessary, the most commonly used opiate in the pain pump is morphine. Another commonly used opiate is hydromorphone. There is significant amount of research and clinical experience using these medications.

Other medications that can be administered by the pain pump include bupivacaine and clonidine. Sometimes one of these medications is used in combination with a narcotic.

Baclofen is another medication this is safe to use in the intrathecal space and is helpful for the management of spasticity. Spasticity is the abnormal contraction of a muscle making it somewhat rigid. This causes the muscle to have difficulty relaxing. This also interferes with normal movement. As a result, spasticity can be painful.

Other medications that have been studied for use in a pain pump include fentanyl, methadone, and ziconotide.

Oral medications are more likely to cause side effects than intrathecal medications. Usually the amount of medication required is significantly less when delivered directly to the spinal cord. A reduction in side effects such as sedation, nausea, and constipation should be expected. However, limb numbness, swelling of the lower legs, orthostatic hypotension (sudden drop in blood pressure), and difficulty starting urine flow (urinary retention) are the most common side effects of intrathecal medications.

Most patients have a significant decrease in pain and improvement in functional abilities. You should be able decrease or discontinue oral medications altogether. If the pump is implanted because of spasticity, a reduction in spasticity should be noticeable.

Possible Complications

What might go wrong?

Implanting the intrathecal pump can have complications, the most common ones are infection, bleeding, neurological injury, and cerebral spinal fluid leaks.

The use of anticoagulants such as coumadin (Warfarin), aspirin, most of the antiinflammatories, and some herbal supplements can interfere with the ability of your blood to clot. This can increase the risk of bleeding. Your surgeon will ask you to discontinue these medications several days before the procedure. Bleeding that occurs around the spinal cord is a problem as it may cause spinal cord compression and neurological damage. Emergency surgery to remove the blood may be necessary to avoid neurological damage. If not recognized or treated early, weakness of the muscles or paralysis, change in sensation, and loss of control of bowel and bladder can be permanent.

Because the tubing of the pump is placed in the space around the spinal cord, an infection or bleeding could be dangerous and even life threatening. It can cause permanent nerve damage and even paralysis. Use of a pain pump is usually considered only when other therapies have failed and surgery is not an option. Infection of the surgical site needs to be identified early and treated aggressively to prevent serious complications. Most surgeons take several precautions to decrease the risk for an infection. Antibiotics are given intravenously during the surgery. Your surgeon may want to do a nasal swab to determine if you have a resistant bacterium that can be carried on your skin.

Neurological injury can also be caused by catheter placement. It can be the result of inflammation that can occur at the tip of the catheter. It can cause a mass or granuloma at the tip of the catheter.

Cerebral spinal leaks may cause you to have a headache and if the leaking continues, it can cause stiffness of the neck (nuchal rigidity) and even neurological damage.

Although less likely, there is the risk of pump failure. If a opiate is being delivered by the pain pump, withdrawal symptoms will likely occur. Withdrawal can be caused when medication runs out, the pump malfunctions, or the tubing breaks. Withdrawal symptoms can make you feel like you have the flu. Body aches, nausea, stomach cramping, nervousness, and chills are some of the symptoms reported. There is always a risk of overdose and even death.

One other potential inconvenience is that there are few professionals available to refill and adjust the pump in some areas. This may complicate your care and necessitate travel to a center that can provide this service.

After Care

What happens after surgery?

You will have a follow up appointment with your doctor seven to 10 days after surgery to remove sutures or staples. Adjustment in medications can be made also.

You will be allowed to shower but not bathe or submerge your incisions for four weeks. Watch for visible swelling or leaking of fluid from the incisions. You should wear loose clothing over the incision sites.

Rehabilitation

What should I expect during my rehabilitation?

You will be asked to avoid bending, twisting, stretching, reaching overhead, or lifting objects over five pounds for the first six to eight weeks. This is to avoid movement of the catheter near the spinal cord. You may not be allowed to drive for two to four weeks after the procedure. Sexual activity may also be limited at first.

Usually walking is advised following the procedure. Gradually you will be allowed to return to daily activities. You may be asked to see a physical therapist for formal education and exercise instruction.

A Patient’s Guide to Pain Management: Relaxation Training

Introduction

Learning to relax can help you manage your pain.

Most chronic back pain sufferers are very familiar with the fact that stress and tension tend to make pain worse. Increased stress and worse pain tend to go hand in hand. This is true whether we have endured a traumatic life event or crisis, or are simply living with ongoing, everyday stresses and strains that cause us to feel tense, tight, and unhappy.

This guide will help you understand

• what is known about the relationship between anxiety, stress, and pain
• how learning to relax can be a powerful tool for effective pain
  management
• practical ways you can relax and quiet your body when in pain

The Nature of Tension and Relaxation

Our physiology and emotions work together to produce the many personal experiences we have every day. These include thoughts, feelings and memories, and obvious behaviors. Our mental and physical processes are so closely linked, there’s probably no way to really separate them. This is also true for the experience of tension, and for the comfortable resolution of tension, relaxation.

For our purposes, we will define stress as the set of physical and emotional changes that occur when we feel threatened. The intensity of the perceived stress can range from mild to severe. Stressors can be acute (short-lived) or chronic and long lasting. They can be huge and very obvious, or they may be quite subtle (not very noticeable).

Physiological Aspects

Let’s first look at the physiological changes that take place in our bodies when we experiences stress. The human nervous system is very complicated. Billions of individual nerve cells communicate in complex signaling patterns. The results are intricate thoughts and behaviors that we take for granted each day.

For example, we may not even notice how smooth our movements are because of how well balance and coordination work together. We may not consciously recognize when we are having lofty ideas and subtle feelings or experiencing boredom, creativity, pleasure, or pain.

In an effort to try to simplify the nervous system so that we can study it, scientists have divided it up into several parts or systems. The central nervous system (CNS) is made up of two main parts: the brain and spinal cord. The CNS is the master control system of the body. It has the job of moving the body and overseeing all of its functions. It also manages all of the communication between the body and the brain.

The rest of the nervous system, the nerves that run from the brain and spinal cord into the rest of the body, is called the peripheral nervous system (PNS). These are the nerves that provide information to our brains about what’s happening in our muscles, joints, skin, and internal organs.

The PNS carries sensory information from the body to the brain. This includes information about touch, hot and cold, pain, pressure, and so forth. The peripheral nerves also send signals from the brain to our muscles and internal organs. These messages tell the body when it’s time to move or make other changes that will keep us safe, comfortable, and healthy.

Normal day-to-day living relies on the ability of the CNS and PNS to work closely together. Together, they accomplish a wide variety of integrated tasks. They perform a very specific and critical set of functions. Most of these processes involve maintaining the body’s internal balance. For example, there are automatic daily functions of the body, such as temperature regulation and using and storing energy and nutrients that must be regulated. These systems also alert us to dangers or discomforts so we can respond in ways that keep us safe.

The nerves that make up this arousal and alert system are called the autonomic nervous system (ANS). The ANS is so named because this system looks after itself. It is not under conscious control. Our heartbeat, breathing, blood pressure, temperature maintenance, and body alert systems are part of the ANS. These functions do not require conscious thought or attention. If they did we probably wouldn’t have time to do anything else, since we would be spending all of our time remembering to breathe and move our blood around.

It is the ANS that controls the physiological components of tension, stress, and relaxation. Remember that the primary function of this system is to alert us to any possible threats and to prepare us for action. When the alarm sounds, heart rate, respirations, and blood pressure all increase. Muscle fibers contract as the body prepares for either defense or escape. This is the fight-flight-or freeze response that most of us are familiar with.

Emotional Aspects

The emotional aspects of stress and tension refer to changes in our feelings that take place when we perceive a threat. These are feelings that we describe using words like worry, fear, distress, unease, and anxious.

Most of us don’t think much about how our emotions are under physiological control too. In the CNS, a large part of the brain has developed as the emotional center. This is called the limbic system. Its job is to create the emotional reactions we have to life events. Then it sends information about our feelings to other brain centers.

In our bodies, and especially in our internal organs, numerous physiological changes take place in response to signals from the limbic system. All of these interactions help us interpret our emotions accurately. For stress and tension, these changes can occur in the body. For example, there may be an increase in heart rate and blood pressure. You may feel tightness in the chest along with faster and shallower breathing. You may experience a queasy or uncomfortable sensation in your gut or stomach. Muscles tighten up throughout the body.

When these changes occur in response to an event that we find threatening, we label our feelings as stress, tension, or worry. We find ourselves strongly motivated to change the situation in some way so that those feelings and tense body state will go away.

Why do we become tense?

It’s clear that our brain has developed a very sophisticated and effective warning system. We know if our well-being is challenged or threatened in any way. Physical discomfort and arousal motivate us to either neutralize the threat or get out of the unpleasant situation. Our stress response is a warning system that allows us to care for ourselves.

Sometimes the system malfunctions or works too well. The result can be long-term bad effects on our health and quality of life. Remember that stress is the result of perceived threat. In some cases, the danger we sense may not be real. For example, worry is often described as the fear of what might happen:

• “Oh, I hope his surgery went OK. Why hasn’t someone called?”
• “If this keeps up, I’m going to end up in a wheelchair.”

We also have the ability to exaggerate perceived threats. In this case, we turn a situation that is uncomfortable or unpleasant into something much worse than it is.

We also have the ability to override or ignore the stress warning system. If we do this, our health and well-being may suffer. This probably happens to most of us. Most of the time, stress is very subtle. Humans can adapt to a tremendous amount of distress. We may do this to the point that we aren’t even aware of it. We learn to ignore signals from our brain and body that tell us we need to make some changes in our lives. Eventually something in the system begins to break down or give way. This is how we end up with ulcers and high blood pressure or chronic tension headaches.

The Relationship Between Tension and Chronic Pain

It would be helpful if everyone learned how to manage stress to safeguard our physical and emotional health. But patients with chronic back pain have a special set of concerns to contend with. Remember that most of the time pain also serves as a warning signal. It alerts us to the fact that we have damaged or are about to damage a part of ourselves. In this function, pain is another kind of warning system. It can be a literal lifesaver.

Nerves that signal pain are linked to the ANS described above. Like the stress warning system, the pain system is designed to rouse us and put us on alert. It tells us we need to do something to get away from a potentially damaging situation. It informs us that damage is occurring and we need to stop it.

Or we become aware that damage has occurred. Now we need to rest the injured body part so it can heal. In this way, the pain system and the stress system work hand in hand. These two systems feed into each other in a way that makes the warning signals louder and more unpleasant. In other words, pain can be viewed as its own very potent source of stress. The more I hurt, the more tense I feel, and the worse my overall quality of life becomes. Likewise, as my stress level increases, there is a good chance that I’m going to hurt more.

A big reason for this has to do with the way muscles tense up in response to a threat, including pain itself. Even when our activity level drops because it hurts to move, we still have an automatic tendency to tighten our muscles. We brace ourselves in rigid postures or positions. The goal is to decrease the risk of making the pain worse. Along with these changes, breathing gets shallow and rapid, blood pressure goes up, and we feel tense and uncomfortable.

These reflexes are designed to serve a protective function. But they actually tend to make our pain worse. Tight muscles can cause inflammation in the body and contribute to the formation of trigger points. These are the sore, hard knots of muscle that sometimes develop at or near the site of an injury. Painful, tight muscles become weak and atrophied. This leads to tight connective tissue that is prone to further inflammation.

There is also a kind of negative feedback loop involving stress, pain, and emotion. The more tense and aroused we are in response to a stressor, the more uncomfortable we are emotionally, and the more we hurt. The more uncomfortable and sore we are, the more tense we become, and so on.

There is a solution to these problems. We can learn how to manage stress so that it does not make an existing pain problem worse. Whenever possible, we need to solve the problems that are threatening to us so that they are no longer a source of tension. If solving the problem is not possible (and all too often it’s not), then we need to find a way to cope with the problem that minimizes our physical and emotional stress response.

This is where quieting techniques come into the picture. We need to learn active relaxation as a pain management skill. We can do this through practice. Be aware that this is much more than just slowing down, relaxing for a few minutes, watching TV or reading, or taking a nap. It is a skill that changes the reflexive protective patterns in the body. The result is that we become more calm and comfortable and hurt less.

Specific Skills For Physical and Emotional Quieting

Below are five specific skills or practices for quieting the body’s physical and emotional reactions to stress. Although they are not hard to learn, they require regular short periods of practice to be effective.

Deep breathing: This is perhaps the simplest and most underused quieting activity on the list. Our nervous system is wired in such a way that there is a complicated set of reflexes that connect breathing to other autonomic activities such as heart rate and muscle tension. Breathing is unique because it can come under conscious control. We can use our breathing to trigger the ANS to slow things down and ease off on the stress response. We can do this by developing a habit of slowing down our breathing and breathing deeply into the abdomen. In many other cultures around the world, breathing exercises have been practiced to improve health for hundreds of years. In the West, we are just now beginning to understand how vital and effective this practice can be for improving health and overall quality of life.

Deep muscle relaxation: Some kinds of muscle tension are also under conscious control. With practice, we can teach ourselves to loosen up and relax contracted muscles and muscle fibers. The easiest way to acquire this skill is by using audiotape instructions, perhaps with feedback from a therapist or coach. Some approaches to deep muscle relaxation involve first tensing tight muscles or muscle groups, and then letting go of the tension. In this way the brain begins to identify what tight muscles feels like. This in turn makes it easier to let go of tightness when you feel it. Another approach is to simply sit or lie quietly, pay attention to particular muscles or muscle groups, and then give yourself verbal instructions to “just relax and let go.” Deep muscle training is always focused on releasing muscle tension. It is almost always practiced along with deep breathing.

Quieting imagery: Quieting imagery involves learning to tell yourself a story or developing a mental picture that you associate with being deeply relaxed. Typical quieting scenes may involve lying on the beach on a warm day or sitting in a sunny meadow in beautiful mountains. First you must find a scene that you find relaxing. Then you begin to practice by placing yourself in that scene. Using a combination of imagination and deep breathing is very helpful. Again, the key to success is a few minutes of regular practice, ideally on a daily basis.

Hypnosis: This is very similar to the use of quieting imagery. However the instructions are to focus on deeper concentration rather than a relaxing image. Often instructions are used for developing control of a mental or physical process reducing pain in a part of the body. And, like the techniques already mentioned, hypnosis needs to be practiced regularly. Instructions to breathe deeply are a key part of this exercise. It’s probably best to practice hypnosis with a coach or instructor, especially at the beginning.

Gentle stretch and exercise: Finally, we should note that all efforts at learning stress reduction are enhanced by regular exercise and daily stretching. Muscles that are toned and loose respond better to our efforts to relax them further. We also know that autonomic arousal tends to quiet down in response to gentle physical activity. Warm, loose muscles simply don’t hurt as much.

Getting the Help You Need

Information and instructions that will help you learn to relax and quiet your body are available from a variety of sources. A good starting place is the Internet. Keep in mind that the quality of material available in cyberspace is quite variable. Look for information that is accurate, useful, and safe to follow.

All things being equal, finding a local coach, instructor, or therapist to work with face-to-face is probably a much better option. This is especially true when you are just getting started and need initial feedback about the new skills you are trying to develop.