A Review of Management of Chronic Pain

Chronic pain is constant pain that lasts long after the expected time frame of healing. For instance, if you roll your ankle you would expect that ankle to be painful for the length of time that it takes for the ligaments and tendons to heal—say a week or so depending on the extent of the sprain. If there was an underlying chronic, or persistent pain, component then your ankle might still hurt six months after the injury, long after the actual tissue damage has corrected itself.

To understand why the pain that people feel is very real we need to look at how we actually feel pain. For 400 years the medical model for understanding pain was simple: when you step in a flame the sensors in your feet feel the pain and a pain signal is sent via nerves to your brain which shouts Tissue is being damaged! Move your foot! Then in the 1960s this model was proven to be much more complicated. Instead of one continuous pathway (foot to brain), there is a pathway going up with three junctions (at your limb, at your spine, and in your brain) and a pathway going down with the same junctions. Each of these junctions interprets pain and can do so in multiple ways via pain sensors.

At the level of your limbs there are two types of pain sensors, which are then further divided into sub categories. Each of these categories is responsible for a different type of pain detection such as hot or sharp. They also each transmit signals to the spine at varying speeds. This explains why when you accidentally touch something hot you quickly pull back your hand but when your leg falls asleep from sitting you do not notice for a while. To make things more complicated, one category of these pain sensors (known as C fibers) sends signals very slowly with generalized information in regards to pain location and are extra sensitive to inflammatory chemicals that your body creates to help to heal itself. As an example, C fibers are responsible for that achy pain you might have after rolling your ankle; the pain is in your foot and a little up your calf even though the tissue damage might only be at the outside of your ankle. Luckily, C-fibers respond well to NSAIDs like ibuprofen so you take a few of these and the pain signals being sent from your ankle to your brain are quieted as the inflammation decreases.

Pain sensors at the next level, your spine, are more complicated. The sensors here are the go-between from your limbs to your central nervous system (think brain and spinal cord). The caveat is these pain sensors can be ignored by your brain. For instance, if you are in a house fire you grab your baby and run out of the house before you realize that your arm is burned. Your arm is obviously hurt, but you didn’t feel it at the time because of your brain sending a message down to your spine pain receptors saying, Override, there are more important matters at hand!

The highest levels of pain sensors are in your brain in multiple locations. At each of these locations pain is controlled by complex relationships between emotions, brain chemicals, and the nerve matrix itself. Your brain determines what pain you acknowledge and what pain you ignore.

Remember that there are three levels of pain sensors going in both directions? If our brains responded to all of the pain sensors signals at all three levels imagine how much information that would be. A key piece to a healthy pain response is for our brain to recognize which signals are important to acknowledge and which ones we should ignore. Or, which signals are telling us that there is actual tissue damage occurring, and which ones are simply saying, this surface is lukewarm.

In people with persistent or chronic pain, their pain response system at one of those three levels has lost the ability to send accurate signals or ignore signals all together. In other words, the communication lines are crossed and even though there is no tissue damage occurring that person is feeling very real pain. Psychotherapy, relaxation techniques, and rehabilitation (physical therapy or occupational therapy) to down-train the hypersensitivity of the pain sensors are all ways the muddled pain system can be addressed without drugs at the brain level and are often rather effective since the brain is the control center of the pain itself.

Drug management of chronic pain is complicated and controversial. NSAIDs (i.e. ibuprofen), aspirin and acetaminophen (i.e. Tylenol) have mixed effects for treating chronic pain depending on pain location. Long-term use of NSAIDs can cause issues in your stomach and intestines. Opiates and opioids (most commonly morphine) has been the standard drug prescribed. This drug class acts at all three levels of pain sensors. The catch is three fold: you develop a dependency, require higher and higher doses, and suffer side effects as a result. Long-term use studies (>6 months) show that opiates lose their effectiveness over time so it is not recommended to take them long term.

More promising are drugs that address the pain at the control center itself: your brain. These drugs include:
1. Anticonvulsants (i.e. gabapentin and carbamazepine)
2. Antidepressants (which low doses address both depression as well as diminish the pain signals being sent)
3. Tramadol (acts similarly to anticonvulsants and antidepressants but can cause many of the same side effects as opiates).
4. Muscle relaxants (i.e. cyclobenzaprine, tizanidine, both which do not have evidence to support the effectiveness of long term use)
More location specific treatments include creams or patches placed on your skin at the pain location such as lidocaine or NSAID patches.

Moderate evidence exists for non-invasive treatment strategies, which include transcutaneous electrical nerve stimulation (TENS) (this confuses your pain sensors and decreases pain by wearing sticky pads with mild current flowing to your skin), hot or cold packs, and acupuncture. Spinal injections or nerve blocks are yet another way to help to manage pain but have mixed results as well.

However, no matter what drug options are used, it should be noted that the most effective way to treat persistent pain is in utilizing multiple approaches and calling on a team of health care providers to help to restore a person’s overall function.

A Closer Look at Worker Compensation Patients with Failed Back Surgery Syndrome

In this article, Richard Deyo, MD presents us with new information about worker compensation patients who have chronic back and/or leg pain following spinal surgery. This condition is often called failed back surgery syndrome (FBSS). Most people return to normal function and work quickly after back surgery. But in the case of FBSS, pain continues even with conservative care (pain relieving medications, physical therapy).

Failed back surgery syndrome (FBSS), is also known as post-laminectomy syndrome but the condition can occur after any back surgery, not just removal of the lamina (pillar of bone that is removed to take pressure off a protruding disc).

The pain is often described as dull, aching, and diffuse. Diffuse pain means the patient cannot point to one spot where the pain is located. Instead, the pain is present over a general area. There may be some abnormal sensations with sharp, pricking, and/or stabbing pain.

Dr. Deyo is a well-known and often quoted researcher on the subject of back pain. The topic this time is the cost-effectiveness of spinal cord stimulation for failed back surgery syndrome (FBSS) as compared to two other treatment methods. The group included 158 worker compensation patients diagnosed with FBSS. Many other studies of worker compensation patients have consistently shown that this group has worse outcomes than other non-worker compensation patients with the same diagnosis and same (or similar) treatment.

This report is actually the second published paper based on data gathered and reported on earlier.The focus on worker compensation patients makes it a unique study. The first study reported on the results of three separate treatment approaches. The three treatment groups included: 1) spinal cord stimulation, 2) pain clinic, and 3) usual care. This second look compares the costs associated with each treatment method. The most cost-effective treatment is discussed.

In the first study, the authors measured outcomes over a two-year period of time based on pain, disability, and use of opioid (narcotic) medications. They found that five per cent of the spinal cord group reached the treatment goals in these three areas. Only three per cent of the patients treated at the pain clinic met the outlined treatment goals. And 10 per cent of the group receiving usual care had a successful final outcome. Success was defined as at least a 50 per cent improvement in pain, less than daily use of opioids, and a two-point improvement on the disability score using the Roland Disability Questionnaire.

Now taking a look at the costs of each approach, it turns out that the spinal cord stimulation was the most expensive. And the added costs were not offset by better results or fewer visits to the doctor than the usual care approach.

The differences in results could not be attributed by differences among the patients because they were evenly matched by age, sex (male versus female), and other personal characteristics. It was observed that the spinal cord stimulation group had more intense leg pain that had been present longer than in the other two groups.The worker compensation group was also more likely to have a lawyer representing their case.

To give you some idea of the costs involved in treating this patient population, the combined costs of total productivity loss and medical costs for each group was as follows:

  • $98,637 per patient for the spinal cord stimulation group
  • $84,340 per patient for the pain clinic patients
  • $67,292 per patient in the usual care group

    The conclusion of this study is that usual care for failed back surgery syndrome is the most successful and least expensive course of treatment. Spinal cord stimulation is not a cost-effective approach to this problem. This information will be of interest to state worker compensation programs when deciding what services to cover for injured workers. This particular study was done in Washington state where the use of spinal cord stimulation for this patient population group was approved by the Department of Labor and Industries back in 2004.

  • When Opioid Pain Relievers Stop Working

    What do 100 million Americans have in common? Pain. Chronic pain. Pain so persistent and so severe that it interferes with daily function. If you aren’t one of those people, it’s likely you know someone or maybe even several people who fall into that category.

    Many people experiencing chronic pain are taking narcotic medications in a class called opioids. The most common use of opioids for chronic pain involves taking one drug that is long-acting with a sustained-release over time. The goal is to control baseline pain.

    A short-acting opioid can be prescribed for those days and times when there is breakthrough pain (pain that can be felt or perceived even with opioids). When the combination of the long- and short-acting opioids don’t work anymore, then it may be time to try a different medication within the opioid family of drugs.

    Switching opioids sounds easy enough. After all, the person is already taking opioids for pain control. What’s so difficult about taking a different one? The biggest concern is for drug-drug interactions. Safety is a key issue.

    Physicians want their patients to experience good pain control with the fewest side effects possible. We may all be the same species (i.e., humans), but every person is slightly different in how the body reacts to medications. We can’t predict how they will respond to individual drugs, drug combinations, and/or opioid switching.

    Sometimes the underlying disease or condition that is causing the pain affects medications at a biochemical level. Those reactions aren’t always predictable either. To take it even a little further, consider this: drugs are metabolized (broken down) by the liver and then sent through the blood stream throughout the body.

    The drug doesn’t just affect one system. It impacts all the systems. Then the kidneys have to filter out all the chemicals and get rid of any by-products that aren’t used. Many patients who are taking opioids are also taking other medications and supplements (vitamins, calcium, antioxidants, etc).

    Studies show that the average person taking opioids also swallows 10 or more other pills each day. All of these substances have to be broken down and processed within the body. The potential for adverse effects increases with each medication or supplement taken.

    Where are we going with this line of thinking? Experts suggest that physicians pay attention to the ways in which opioids are metabolized and work. If it becomes necessary to switch opioids, then try and find an opioid that works in a slightly different way.

    For example, if one medication is broken down by the cytochrome P450 (CYP) system of the liver, then prescribe an opioid that does not require involvement of that system. This approach could potentially lower the number of drug-drug interactions (DDI) that occur with opioid combinations, especially when there are other medications being taken as well.

    One alternate opioid now available on the market is called EXALGO. EXALGO is a form of hydromorphone (other examples of hydromorphone include Palladone and Dilaudid). This type of extended-release opioid is not broken down by CYP enzymes. It can be considered when baseline pain is not being managed well with other opioids that are dependent on breakdown by cytochrome enzymes.

    As with any new medication, there are precautions (warnings about what to watch out for) and contraindications (reasons not to take them). The EXALGO drug cannot be prescribed for patients who have any gastrointestinal or respiratory problems. It is intended for use with patients who have significant, chronic pain (not mild cases).

    One final note about opioids. It is possible to develop a condition called opioid toxicity. Breathing becomes impaired. Blood pressure drops and the patient becomes very lethargic.

    Reporting any new symptoms when taking these medications can help prevent this problem from developing. Even minor problems such as upset stomach, nausea, headaches, constipation, vomiting, and dizziness should be reported immediately to the prescribing physician or dentist.

    What To Do About chronic Pain

    When you don’t know how to fix something, it’s tempting to set it aside and just forget about it. But when that “something” is pain — well, there are 116 million adults in the United States alone looking for some help. And telling them “it’s all in your head” or “there’s nothing that can be done” just isn’t acceptable.

    That’s the stance of the Institute of Medicine (IOM) and they are throwing their weight behind it. The IOM is calling for a greater dedication to pain research and more money to fund it. There is a need to support researchers as they help find better ways to treat chronic pain,

    Experts in pain management want to see new pain medications and therapies for the patients suffering this disease. They are advocating for training and education for physicians. And leaders of the Institute of Medicine (IOM) are asking for better reimbursement for health care professionals who spend the time to really understand and care for these patients.

    Where do we begin? Those in charge of this project at the Institute (IOM) say it’s a three-prong problem. First, we need a change in our attitudes about chronic pain and the people who suffer from it. There is enough scientific evidence now to channel our thinking toward the idea that chronic pain is a disease — a long-term, persistent, and disabling disease. It requires every bit of time and resource management as any other chronic long-term health care problem.

    Second, pain management needs a face lift. For too long, physicians have been afraid to use narcotic (opioid) pain medications for fear their patients will become addicts. There are plenty of studies to show that opioids are safe and effective. Yes, they require appropriate monitoring but they shouldn’t be withheld out of fear and ignorance.

    Third, we need a partnership in health care as it relates to pain management. With proper training and education, the primary care physician can effectively care for many chronic pain patients. Not everyone needs a full-blown, multidisciplinary team approach. But when patients don’t get the help they need and especially in very complex, complicated cases, then referral can be made to a pain specialist or team of professionals at a pain clinic.

    The Institute of Medicine (IOM) made several other recommendations of interest:

  • Add required courses to all medical school curriculums on pain and pain management.
  • Licensing and certification exams for physicians should include pain-related assessments
  • Expansion of pain-centered care under Medicare, Medicaid, Workers’ Compensation, and private insurance plans.
  • Remove barriers from physicians (and other health care professionals) billing and receiving reimbursement for the time it actually takes to find a workable solution for these patients.
  • Broaden the research scope to include genetic, psychologic, environment, social, and cultural aspects of chronic pain.

    In summary, the IOM hopes that with more funding, researchers can develop better drugs and better management techniques for chronic pain patients. Finding factors that would predict who will respond to what medications and approaches is another area for scientific study. It’s time to lay down the gauntlet on chronic pain and find workable solutions through the maze of complexities these patients often present. Such an approach will require the coordinated efforts of private, public, and governmental agencies.

  • The Effects of Pain, Anxiety, and Depression on Function After Severe Injury

    Three-hundred and twenty seven (327) adults with a severe leg injury were studied to see the effects of pain, anxiety, and depression on physical function at home, at work, and at play. Measures for each effect were taken at regular intervals up to two years after the injury.

    Most of the patients were men between the ages of 26 and 45 who had either broken a leg and/or damaged the soft tissues in a motor vehicle accident. The goal of the study was to gain a better understanding of the psychological factors affecting function in complex injuries.

    This topic is important because when physical activities are restricted by injury, chronic disability can develop. Such conditions can have both personal as well as social implications. For example, only one out of every two patients goes back to work after severe leg injuries. Function limited by pain and psychologic distress are considered the main problem.

    This study takes a closer look at the psychologic distress after injury and its effects. Most other studies examine the complex interactions among pain, psychologic distress, and physical function. This one tries to tease out how much of the disabling effects are from the psychologic aspects of severe injury.

    First, they gathered data on patient characteristics (age, sex, education, marital status, economic status, race/ethnicity, and health insurance. Then they looked at the type and extent of injuries. Factors that might affect recovery were also reviewed. These included such things as level of preinjury health and exercise, smoking and drinking habits, and legal involvement or compensation for the injury.

    Outcomes and psychologic distress were also measured using self-report questionnaires and surveys such as the Sickness Impact Profile (SIP), Brief Symptom Inventory (BSI), and Visual Analog Scale (VAS).

    And here’s what they found. Pain and psychologic/emotional distress both decrease patients’ function. The effects are most noticeable during that first year after the injury.

    Once the physical body has recovered as much as it can, then the effects of psychologic and emotional distress take on a more significant (and obvious) role in long-term recovery. As might be expected, the higher the psychologic distress, the lower the physical function. It appears that pain and negative mood affect level of function rather than the other way around (low function results in increased pain and negative mood).

    What does all this mean for the patient? A comprehensive program to address all postinjury needs is required. Physical and emotional pain must both be treated in order to maximize function. Loss of control leads to anxiety and anxiety is linked with fear of pain. The end result is a self-imposed limitation on any movements or activities that might produce pain. This, in turn, reduces physical function and contributes to long-term chronic impairments or disability.

    Paying attention to the psychologic needs of patients with complex/severe injuries is just as important as treating the physical wound, fracture, or other injury. This is true even when anxiety, depression, or other negative emotions are mild or moderate.

    The focus on the emotional and psychologic aspects of recovery must begin early on for the best results. Health care professionals should also keep in mind that despite this approach, there will always be some patients who will have to learn how to live with disability that doesn’t go away.

    One Treatment Model for All Chronic Pain Patients

    If you suffer from chronic pain or if you provide help to those who do, the information in this article will be of interest to you. It comes from the Department of Rehabilitation Medicine at the University of Washington School of Medicine in Seattle.

    The basic idea is that chronic pain is managed in many different ways by different health care professionals. Psychosocial treatment recognizes there are psychological, emotional, spiritual, and social factors that affect pain perception. Techniques such as hypnosis, relaxation, meditation, and behavioral therapy are just a few examples of psychosocial interventions for chronic pain.

    Each one of these approaches has its own background and theory and addresses some aspect of the psychosocial factors that affect patients in pain. Most are designed to help people learn to accept their pain and live with it in a way that increases their function (even if it doesn’t reduce their pain level or intensity).

    The one drawback to so many different ways to approach chronic pain is that not all psychosocial factors will be addressed in treatment. And that means probably some patients aren’t going to be helped if the approach selected doesn’t meet their specific psychosocial needs. How do we get around this?

    Well, that’s where this new proposed model comes in. It is a single, overarching plan designed to recognize, explain, and eventually measure the effects of all interventions. Such a model or organizational framework would also make it easier to study and compare different treatment effects on pain. And hopefully, it would make room for techniques that may be developed in the future.

    The author reviews details of eight psychosocial treatments to pain management and then describes the proposed organizing framework to encompass them all. For example, cognitive therapy teaches people to be aware of their inner thoughts and replace the negative ones with more positive, helpful thinking. The concept is that “thoughts are not necessarily the truth, they are just thoughts” that can be changed to affect how we live and function.

    Coping skills along with time and activity management (including scheduling pleasant activities) is another type of cognitive therapy. Accepting pain in a way that allows patients to live based on goals and values rather than on feelings, thoughts, and pain falls under the category of acceptance-based cognitive-behavior therapy.

    A slightly different approach using hypnosis involves suggestions for ways to think about and experience pain. Many people who try hypnosis report decreased pain intensity. Studies show that combining hypnosis with cognitive therapy yields even better results. Not too different from hypnosis are the self-relaxation procedures used by some patients.

    Relaxation techniques usually involve contracting and relaxing muscles, biofeedback, or listening to instructions (suggestions) to train the body to relax. Research has shown that this approach works by changing patients’ beliefs about what they can do for themselves. Reducing the stress response and experience of pain results in less perception of pain.

    The proposed model recognizes five main parts of each approach including environmental factors, brain state, cognitive content, cognitive coping, and behavior. These terms may not have as much meaning to the lay reader (e.g., patient, family or support member) but they are common terms used by health care professionals helping people cope with pain.

    In fact, health care providers are included (along with family and friends) under environmental factors since these folks can all have an effect on how patients think and act. Brain states refers to the relaxed, calm that results from hypnosis, meditation, and relaxation techniques and leads to better coping and tolerance for pain and suffering.

    Cognitive content addresses what patients believe about their pain (especially how pain can lead to disability). How often patients think about their pain and let it control their lives falls under the cognitive content area. Cognitive coping is a way to manage mood by focusing on pleasant memories and ignoring pain. Patients are taught to set goals that lead to acceptance of pain and living life at its fullest despite pain.

    And finally, behavior describes patient actions and function. The goal is participation in social activities, hobbies, work, and so on despite chronic pain. Any and all of these five factors can affect psychosocial pain treatments. Having a model that recognizes, addresses, tests and measures them may help us understand how to treat the problem of chronic pain more effectively.

    The author concludes that having a broader, more encompassing psychosocial model of treatment for chronic pain will give health care providers a better overall understanding of each patient. No one will fall through the cracks because only one aspect of recovery was addressed. This proposed model with its overarching framework for organizing pain treatments takes us out of the more restrictive single-approach management of chronic pain.

    How and Why Pain Starts, Stays, and Spreads

    What do these conditions have in common: rheumatoid arthritis, osteoarthritis, temporomandibular disorders (TMD), fibromyalgia, headache, complex regional pain syndrome (CRPS), and post-surgical pain? If you guessed “pain,” you were right. And not just pain but chronic (long-lasting) pain.

    For the last 25 years, the National Institutes of Health (NIH) have contributed a great deal of money to research on the topic of pain. Trying to find out why pain starts, why it spreads, and why it doesn’t stop in some people has been a challenge. The most likely reason is something called central sensitization.

    As much as 100 years ago, physicians realized that something gets turned on in the central nervous system that contributes to the start and spread of pain that doesn’t get turned off. The injury or local trauma has long since healed but the patient continues to experience daily, ongoing, and often very disabling pain.

    That is the crux of central sensitization. Nerve cells called neurons in the spinal cord transmitting pain information from body part to brain don’t just pass the information along — they remain excited about the information. It’s too much (intensity) for too long (duration).

    At the same time, the person’s threshold (level at which a response occurs) lowers so there’s a faster response to less input. Not only that but other nearby tissues get in on the act. They aren’t injured or damaged but they set up the same pain-inducing racket in the nervous system. That phenomenon is called field-expansion.

    Other questions revolve around risk factors or predictive factors. In other words, why do some people become so sensitive and others do not? Are there environmental, social, genetic, and/or psychologic triggers? What is happening at the cellular and molecular levels? Are there separate mechanisms for what turns the pain on and what keeps it going or sustains it?

    Scientists have been able to find out that it’s not just a matter of some pain switch getting turned on in the hand or foot (or other body part) that’s injured. There’s much more to it than that. It appears that in some people, the central nervous system is overly sensitive. Words like hypersensitive, exaggerated, or ramped up are used to describe it.

    The question becomes, what can be done about it? If we can understand the mechanism, it may be possible to turn it off — or better yet, keep it from getting turned on in the first place. We know now that various parts of the nervous system from the individual cells to the message pathways (like a relay system) and brain are adaptable and changeable. That’s referred to as neural plasticity.

    Now we come back to our original question: how is it that so many different physical problems like arthritis, fibromyalgia, migraines (or other headaches), and jaw pain (temporomandibular disorders) can create such similar pain patterns?

    The answer is likely central sensitization. And if that theory is correct, then it means that scientists may be able to find a solution that could possibly work for all chronic pain problems.

    Scientists may be able develop ways to work with neural plasticity. Right now, they are looking for ways to turn down the excitability of neurons in the central nervous system or even turn them off. If they are successful, it could give patients who have suffered chronic pain a new lease on life and keep others from suffering the same fate in the first place.

    First Step in Screening for Nerve Pain

    Nerve pain (also known as neuropathic pain) is difficult to diagnose and measure. Patients often describe the pain as “burning” or like “electric shocks.” Others may report itching, numbness, or a pins and needles sensation.

    The source of neuropathic pain is not always easy to locate. It could be coming from muscles, joints, spinal cord injury, or a neurologic disease such as multiple sclerosis, Parkinson disease, or Lou Gehrig disease. Loss of blood supply to the nerves from diabetes or as a side effect of chemotherapy for cancer can also cause neuropathic pain.

    For some time now, neuroscientists have been working on finding easy and simple ways to identify and quantify neuropathic pain. So far, they have come up with several screening tools in the form of questionnaires.

    These include the Leeds Assessment of Neuropathic Symptoms (LANSS), the Neuropathic Pain Questionnaire (NPQ), the Neuropathic Pain Scale (NPS), the Douleur Neuropathique en 4 Questions, DN4, ID-Pain, and painDETECT.

    Each one measures type of sensations experienced by patients. Most are self-administered (the patient fills out the form). A few are clinician-administered (the examiner asks the questions and completes the form).

    The questionnaires are not designed to measure frequency, intensity, or duration of the symptoms. Only the Neuropathic Pain Scale (NPS) attempts to measure quality of pain. The rest are just screening tools but represent a step in the right direction for at least recognizing what’s going on in the patient’s body. They provide a piece of the diagnostic puzzle but the information gained must be used in context of the whole patient.

    As useful as these screening tools are in clinical practice, there are some drawbacks. For one thing, they were designed to assess just one area of pain. Many patients come to the physician or pain clinic because of pain in several areas of the body. There are often cases of widespread pain (throughout the head, neck, body, and limbs).

    Sometimes the questionnaires fail to identify someone who (when tested by the physician) is found to have a true neuropathic problem. Neuropathic pain questionnaires don’t cover all possible pain types — just the most commonly reported descriptors. So some people will fall through the cracks if the survey doesn’t include questions about the specific type of pain experienced by that person.

    The questionnaires do not help point to the underlying cause or true etiology of the problem. That requires additional testing, lab work, and X-rays or other imaging studies. Electrophysiologic tests such as EMGs (electromyograpies of the muscles) or nerve conduction tests may also be needed.

    But from the studies done so far, the screening questionnaires are simple and easy to use and do help identify neuropathic pain. That is an important first step because it can be very difficult to sort out pain types and pain patterns without a starting point like this.

    In summary, having a tool that can screen specifically for neuropathic pain is a break through in pain diagnosis. The information gathered from studies using these tools has shown that neuropathic pain is linked to specific pathophysiologic mechanisms.

    That means it may someday be possible to develop “designer drugs” to help with pain management. Such drug treatment targets the exact cell receptor or nerve fibers that can turn off (or prevent) the pain or blocks the nerve pathways causing the pain. Now that we have valid and reliable screening tools for neuropathic pain, future studies to develop assessment tools to measure treatment effects are also needed.

    Pain Management With Acupuncture

    Acupuncture as a healing tool has been around for many, many years. In fact, it is one of the oldest medical arts. The use of modern acupuncture is increasing in popularity for pain and other health conditions. In this report, Dr. Ji-Sheng Han from the Neuroscience Research Institute and Department of Neurobiology in Beijing, China brings us up-to-date on acupuncture for pain relief.

    Since 1991, there have been almost 4,000 research articles published on the topic of acupuncture. Almost half of those (41 per cent) were just on the use of acupuncture for pain control. With advances in technology, more and more evidence is mounting to show the benefit of acupuncture.

    The basic idea behind acupuncture is that by placing a needle through the skin, blocked channels of energy called meridians can be reopened. The result is a balancing of the body’s energy flow (called Qi, pronounced “chee”). Meridians flow through every part of the body from head-to-toe.

    Now that there’s no doubt acupuncture is a valuable treatment tool, many more studies are underway. Scientists are looking for the best location for needle placement to get the most optimal results.

    At the same time, methods of application (e.g., depth of needle placement, needle placement inside versus outside meridian pathways, length of time in place) are being studied. It’s likely that each medical condition treated will have specific points that are most effective.

    And it’s possible that individual variability exists. In other words, each patient when matched by age, gender, body type, and condition or problem will respond slightly differently when the same acupuncture technique is applied.

    What we know so far is that when used before and after surgery, acupuncture helps reduce pain, nausea, and vomiting. Chronic pain seems to respond after several treatments (usually one to two sessions each week for three weeks). Some people are more sensitive to this modality. They seem to respond better to weaker needle stimulation spaced out over a longer period of time.

    For those who think a positive response is just a placebo effect (the person expects to get better and does), there is a grain of truth to that. But studies have also shown that the psychologic response is separate from an equally powerful physiologic response. And interestingly enough, the pathways in the nervous system and brain that light up on functional MRIs (fMRI) are different when studying sham versus real acupuncture.

    Where does this leave the science of acupuncture study? There are still some areas where further study is needed. For example, are the meridians (channels or pathways of energy flow) separate from the nervous system?

    Are the acupoints specific for diseases? What prescription (if any can be determined for each condition) is advised? Can needles be placed anywhere in the body and still get the same response?

    Today’s acupuncture treatments can be stimulated manually (after the practitioner places the needles, he or she turns and twists them). Or they can be stimulated electronically, a technique called enhanced acupuncture (EA). Needles can be replaced with skin electrodes, a process called transcutaneous electrical acupoint stimulation (TEAS). The different electrical applications and frequencies of the electric pulses will require additional study and comparison.

    Other questions that have been raised for future study include: should everyone who is having surgery also have before and after acupuncture treatment? Will that add to the cost of health care or save money in the long-run? And, of course, what every scientist wants to know: how does acupuncture really work?

    These and many, many other questions will need to be studied before acupuncture will replace more traditional approaches in western medicine. But from the evidence gathered so far, acupuncture as a safe and effective treatment tool for pain as well as other problems looks very promising.

    What To Do About Chronic Sacroiliac Joint Pain

    How can patients with pain in the low back pain, leg, sacrum, pelvis, or buttocks coming from the sacroiliac joint (SIJ) get relief? For the last 10 years, radiofrequency denervation (using radio waves to destroy nerve tissue) has been used as an alternative treatment. It’s time to evaluate the results and see if this new approach is working and who might benefit from it the most.

    The sacroiliac joint (SIJ) is a complex joint with ligaments to support and stabilize it (hold it in its proper place) and muscles to move the pelvis. It is formed by the two iliac (pelvic) bones on either side of the triangular-shaped sacrum.

    The sacrum is located at the lower end of the spine, just below the lumbar spine. It is actually formed by the fusion of several vertebrae during development. The sacroiliac (SI) joint is formed where the sacrum and the iliac bones meet (thus the name “sacroiliac” joint). You can see these joints from the outside as two small dimples on each side of the lower back at the belt line.

    The SI joint is one of the larger joints in the body. The surface of the joint is wavy and doesn’t always line up exactly. There is some (but not much) motion in the SI joint. The motion that does occur is a combination of sliding, tilting and rotation. Even a small change in alignment can cause shearing forces and considerable pain.

    When nothing short of surgery helps relieve the pain, then radiofrequency ablation is considered. The surgeon inserts a long, thin probe into the area under the guidance of a type of real-time X-rays called fluoroscopy. The offending nerve(s) are hit with high voltage radio waves that heat up the tissue and destroy the sensory nerve (the one that sends pain messages).

    Radiofrequency can be delivered in several different forms (e.g., conventional, pulsed, cooled-probe, bipolar). The pulsed form doesn’t cause a rise in tissue temperature. Instead, it sets up an electromagnetic field around the nerve. The result is pain relief that may last six months or more. But because the nerve remains intact, the painful symptoms can come back.

    The cooled-probe technique allows the target tissue to be heated up while keeping the surrounding tissue cool. This method makes it possible to heat up a slightly larger area than the conventional probe but without damaging other nerves in the area. There is also less tissue trauma with the cooled-probe because of the way the needle enters the tissue (perpendicular rather than parallel).

    The results of using bipolar radiofrequency for chronic SI joint pain was only reported in one study. This technique is done by passing radiofrequency power between two points on either side of the nerve tissue. There are some concerns using this technique because the tissue’s ability to transmit or impede (keep out) the radio waves varies so much. More studies are needed before this form will be used routinely.

    Whenever a new form of treatment arrives on the scene, physicians want to know: 1) How well does it work? and 2) Who would benefit most from this treatment? Let’s start with the answer to the second question. Patient selection is always a key factor in the success of any treatment like this.

    What we know so far is that people with sacroiliac joint pain who get some relief from a steroid injection into the joint seem to respond best to radiofrequency ablation. Younger patients have the best results.

    How well does it work? That’s harder to say for a number of reasons. First, the SI joint can vary considerably from patient to patient. Likewise, the number, size, shape, and location of the nerves are equally variable.

    Finding the most affected nerve can be a challenge. Then getting to the involved nerve is the next dilemma. Some of the nerves are right on the bone, while others are embedded in the soft tissues around the joint. Often more than one nerve is involved requiring more than one procedure.

    And evaluating the results of studies already published isn’t as clear and easy as physicians would like. For example, different surgeons use different techniques, select their patients using different criteria, and have different standards by which to judge “success” or “failure”. Those kinds of differences make it difficult to compare one study to another and/or report overall trends for this treatment technique.

    After reviewing the studies that have been published, the authors made the following observations. Radiofrequency does have some potential in the successful treatment of chronic sacroiliac joint pain. The most effective nerves to target for most patients are between the L5 and S3 levels. Cooled-probe radiofrequency seems to have the best outcomes but more studies are needed to compare the different techniques.

    Predicting Chronic Pain After Peripheral Nerve Injuries

    Pain is a funny thing. Two people can have the same injury and still experience pain completely differently. After some nerve injuries, there are individuals who just never fully recover. They have pain (referred to as chronic pain) the rest of their lives. Why is that? Why do some people recover just fine while others don’t?

    These are questions researchers at the University of Toronto tried to answer in this study. They compared three groups of people: two groups had nerve injuries. One group was the normal, healthy control group for comparison.

    Of the two groups with nerve injuries, the same nerves (median and/or ulnar nerves of the forearm and hand) were transected (cut across completely). After surgery to repair the damaged nerve, one of those groups recovered while the other group went on to develop chronic neuropathic (nerve-related) pain.

    There are some theories about why some people have a poor recovery after nerve injury. Experts suspect personality, psychologic factors, and belief systems as the main reasons for impaired nerve regeneration. They name three specific individual factors addressed in this study: neuroticism, extraversion, and pain catastrophizing.

    Let’s define each one. Neuroticism describes the way a person views his or her world. They experience most of life in a negative emotional state. They see even the ordinary day-to-day events as threatening. When it comes to pain, they focus on the sensation and see it as very disturbing until everything is blown way out of proportion.

    Extraversion refers to a person who is outgoing, positive, active, and busy socially. An extravert is less likely to develop chronic pain than someone who is described as an introvert (shy, less outgoing, and more sensitive to things that might cause pain).

    Pain catastrophizing means the person focuses more and more on the experience from a negative point-of-view. The person begins to fear moving as it might lead to pain or reinjury. The result can be disuse of the affected body part, disability, depression, and chronic pain.

    How can these individual factors be identified in people? There’s a battery of physical and psychologic tests that can be given. Everyone in this study filled out numerous questionnaires about pain, activity, and hand function. They took a specific test called the Pain Catastrophizing Scale (PCS) designed to measure pain catastrophizing.

    Physical tests of sensation (two-point discrimination, cold, vibration, texture) and nerve conduction were performed on each person. The researchers only included patients who had the nerve injury and surgery at least one-year ago. That gives the nerve time to recover and regenerate before testing its function. All test procedures used in this study were named, described, and discussed in detail.

    What did they find? Is it really possible that personality and psychologic differences can account for why one person with a nerve injury heals and another one doesn’t? Actually yes — they did find that chronic pain following repair of peripheral nerves was linked with individual factors.

    The patients with chronic pain were more likely to perceive stimuli (e.g., application of cold) as more unpleasant and more intense than the people in the group who had the same nerve injury and surgical repair but recovered.

    The chronic pain group had more severe loss of nerve conduction (signals traveling along the nerve to the spinal cord and up to the brain). The results of the nerve conduction tests showed incomplete or inadequate recovery of nerves in the chronic pain group. They were less able to manipulate small objects with their fingers and more overall difficulty with movement (motor control).

    How do these results relate to personality and pain catastrophizing? It seems the patients who had the worst results were more likely to focus on every aspect of their pain day and night. This behavior is referred to as pain vigilance. With pain vigilance comes the pain-related fear of movement already described.

    People with neurotic tendencies scan their bodies over and over looking for signs of pain or disability. They focus on those symptoms and see them as threatening. Anxiety becomes a key feature in this cycle of vigilance-fear-avoidance-disability. Pain catastrophizing and neuroticism set the two pain groups apart.

    The authors report that these findings are consistent with what other studies have shown. For example, previous studies looking at catastrophizing before surgery found that patients with a high degree of catastrophizing are less likely to recover fully after surgery. The catastrophizers are more likely to develop chronic pain.

    This study adds to the knowledge we have about personality and beliefs as factors in health, healing, and recovery after peripheral nerve injury. Instead of thinking that incomplete nerve regeneration is the reason patients don’t recovery sensory-motor function, it is suspected that personality traits, pain beliefs, and coping strategies affect the healing process.

    In summary, personality and psychologic testing may be able to predict who will recover after a peripheral nerve injury. On the flip side, these same tests may be able to point to patients who will have a poor recovery with chronic pain, loss of function, and long-term disability.

    Changing Views about Complex Regional Pain Syndrome

    Scientists in The Netherlands have added a new piece to the mystery of treating complex regional pain syndrome (CRPS). CRPS is a very painful disorder that affects people after a seemingly minor injury sometimes. The problem is not understood very well. Doctors don’t know what causes it or why it happens. That makes CRPS a difficult condition to treat effectively.

    In recent years, anti-inflammatory medications have been used with mixed results. But the fact that this approach works for some patients makes it worth investigating further. If CRPS is an exaggerated response of the immune system to tissue injury, then inflammatory messengers and inflammatory cells must be part of the signaling system that bring on the painful symptoms.

    People with complex regional pain syndrome (CRPS) often experience intense pain, swelling and skin changes (color, texture, hair growth, temperature). The net result is a loss of motion and function along with reduced quality of life.

    Scientists hope that by cutting off immune cells like cytokines, chemokines, and mast cells, it might be possible to stop (or even prevent) these disabling symptoms. How successful have anti-inflammatories been so far? That’s the topic of this review article.

    The authors searched all publication databases looking for any information on results of treatment for complex regional pain syndrome (CRPS) using medications. They were specifically interested in outcomes with the use of anti-inflammatory drugs.

    A total of 24 articles were found that were of good enough study quality to be included. The two types of medications used in these studies were corticosteroids and free radical scavengers. Corticosteroids included oral prednisolone and piroxicam (CNT). Free radical scavengers included DMSO, vitamin C, and Mannitol.

    Free radicals are unstable oxygen atoms that form when they lose an electron. Electrons like to be in pairs. The loss of one electron literally puts the atom into orbit. It becomes a scavenger looking for another oxygen atom so that it can rob or steal the necessary electron.

    The result is a cascade of damage to the cells as new radicals are formed in order to salvage the damaged oxygen atoms. Compounds like DMSO, vitamin C, and Mannitol work by getting rid of free radicals. Inflammatory reactions are reduced by eliminating free radicals. The end-result is to limit the amount of tissue damage that occurs from inflammation. In some studies, corticosteroids and free radical scavengers were used together.

    For anyone who wants to take a closer look, the authors created a table with study characteristics for all 24 studies. Items of interest for comparison included references cited, diagnostic term used for patients, study design, intervention (drug treatment used), outcome measures, and results. Some of the ways results were measured included joint range of motion, pain, change in sensory symptoms, and improvements in daily activity level.

    Here’s a quick summary of what they found. Both classes of drugs (corticosteroids and free radical scavengers) worked. Patients receiving either medication showed significant improvements. This tells us that it is possible to stop the inflammatory process in different ways (turning off inflammatory cells, getting rid of damaging free radicals).

    But there’s a big “But” in their findings. There were just as many patients who didn’t get better as those who did improve. Naturally, the scientists wondered “Why”? (Or more appropriately, “Why not”?) There are several possibilities.

    First, let’s go back to the symptoms. Not all patients with complex regional pain syndrome (CRPS) have the exact same symptoms. There is some belief that perhaps the differences have to do with different pathologic and physiologic mechanisms for the CRPS from one patient to another.

    Second, the medications were not all in the same formulation. Some were topical (applied to the skin) while others were oral (taken by mouth). Some studies used intravenous (IV) directly into the blood stream, which is a faster method of drug delivery when compared with topical or oral dosing.

    If nothing else, the results of this review study confirmed there is a role for anti-inflammatories in the treatment of complex regional pain syndrome (CRPS). But much more study is needed to figure out what works best (single drugs or combinations), in what form (topical, oral, intravenous), at what dosage, and for which patients.

    Ideally, finding a way to prevent this painful condition would be the best goal. Some researchers will continue to study treatment comparisons. Others will continue to look for the key to unlock the mysteries behind the mechanisms of complex regional pain syndrome (CRPS). One way or the other, the goal is to find a better way to manage this chronic pain problem.

    Summary of Studies on Long-Term Opioid Use

    People who have severe, chronic pain may be given the option of taking opioid medications (narcotics) to help manage their pain and live some semblance of a normal life. For those who are not facing end-of-life issues with cancer, this can become a life-long management tool. Whenever opioids are discussed, there is always a concern raised about physical dependency and addiction.

    But as the authors of this study point out, addiction isn’t the only downside of opioids. Difficulty concentrating, memory loss, slower physical reaction time, and slower processing of information are additional potential side effects of these powerful pain relievers. What’s the current evidence that such effects on cognitive function are really a problem?

    To find out, pain experts from Denmark, Sweden, and Brazil teamed up to review data published in medical and psychologic journals around the world. They summarized the results in a table that included type of study (design), sample size (number of patients), type and dose of opioid, and outcomes.

    A total of 13 studies met the inclusion criteria and were analyzed and included in the table. All studies were examining non-cancer patient groups who had chronic pain. When it comes to the design of each study, the most common types of study were randomized controlled trials (RCTs), comparative studies, and observational studies.

    As the names suggest, a randomized controlled trial means patients were placed randomly in one of several groups being tested and studied. Random selection can be done by a computer or the patients can be assigned to the next available group as they enter the study. Comparative studies look at the results of a group of normal, healthy adults contrasted with those individuals receiving opioids. Observational studies just watch what happens and record the results for a specific type of treatment.

    After reviewing and summarizing all 13 studies, the final conclusion was that information about the effect of long-term use of opioids on cognitive function in noncancer patients is still very limited. Whether they do harm, benefit, or don’t affect cognitive function at all remains unclear.

    In cases where there was improvement in mental processing there were some things about the studies that didn’t measure up so the results weren’t as strong as would be hoped for. And some of the comparative studies were good but each study compared patients on long-term opioids to different groups.

    For example, one study looked at healthy people as the comparative group while another study studied chronic pain patients who did not take opioids. Sometimes the comparative group had similar neurologic problems as the main study group, while others did not select patients with neurologic deficits for the comparative group. Without a consistent comparative group, it becomes difficult if not impossible to get meaningful information. It’s too much like comparing apples to oranges.

    One other problem observed in the studies that were available was the fact that many patients taking long-term opioids for non-cancer problems are also taking other medications. Some of those drugs have the ability to alter cognitive function. So then it becomes a problem identifying how much and what kind of effects occur with the opioid prescription.

    And as is often the case, people who suffer from chronic pain become depressed. Altered mood or depression is also linked with changes in cognitive function (especially speed of mental or motor processing). Sorting out which factor has the most power over mental abilities can be difficult.

    Some recommendations can still be made on the basis of these findings. But the strength of the advice is weaker than if there were coming from multiple high-quality studies with strong evidence. First, keep in mind the goals of pain control: to reduce the intensity of pain so the person can function better (mentally and physically). Better function can mean improved quality of life.

    Second, keep in mind that long-term use of opioids can be harmless and even beneficial but use does come with some risks. Those risks have been mentioned including tolerance, addiction, and altered mental and/or motor function. Patients and their families should be fully informed about the benefits and risks of long-term opioid use.

    Third, prescribing physicians must monitor their patients for signs of cognitive impairment. This is especially important for patients who are working, driving, or operating equipment. Periodic tests of cognitive function should be given to assess changes in mental processing. There are many different test measures available that show even slight changes or shifts in physical or mental function.

    And finally, the results of this review of evidence about the long-term effects of opioid-use by non-cancer, chronic pain patients point out the need for future (improved) studies in this area. High-quality studies with matching designs are needed to really assess the potential harm, benefit, or no-effect of long-term (even lifelong) use of these powerful drugs.

    The authors suggest that anyone who is given a prescription for opioids should be given a simple baseline test to assess cognitive function. Then if it turns out the prescription becomes a long-term event, retesting can be done. Any observed change(s) in cognitive function signal the need to review the medication and possibly change the drug or drug dosage.

    At the same time, the more patients who are formally tested for cognitive effects, the more likely equal comparisons can be made between groups. Future review studies like this one would have more data to go on and a better chance of making helpful recommendations.

    Something New About Complex Regional Pain Syndrome

    Patients with complex regional pain syndrome (CRPS) are faced with some very unpleasant symptoms. The first is unrelenting burning or aching pain followed by skin sensitivity, swelling, discoloration, sweating, and temperature changes.

    The most commonly affected area of the body is the hand or foot, but the symptoms can spread further up the affected limb and even into the opposite limb. If the condition becomes chronic, dystrophy or deterioration of the bones and muscles in the affected body part may occur.

    CRPS doesn’t just come on without a reason. Usually there’s been 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.

    Many patients have such a distorted sense of where the affected arm is that they wish the arm could be cut off and be done with it. Imagine not knowing where your arm is even when you are touching something with that hand. Now imagine trying to use your keys to open a door, using your fingers to pick up a pen, or even using your hand to wipe yourself after going to the bathroom but you don’t know where that arm is.

    That’s the sensation many people with complex regional pain syndrome (CRPS) experience everyday. Therapists working with these patients refer to this phenomenon as a distortion of body image or distortion of body schema. The failure to recognize limb position is a problem with position accuracy.

    In this study, efforts are made to measure upper limb (arm) position accuracy in patients with CRPS of one arm. Movements of the arm were videotaped and compared against movement in the healthy arm and arm movement in volunteers who did not have CRPS. Patients were matched by age and sex (males and females) with the normal, healthy volunteers (control group).

    Everyone moved the arm through a set pattern of motions based on the position of numbers on a horizontal clock. Twelve o’clock was straight out in front of the person seated in a quiet room. Three o’clock was out to the right side. Nine o’clock was out to the left side and so on.

    The individuals moved the arm (or attempted to move the arm) to various times randomly selected by a computer. Each person completed six sets of arm positions based on clock hour positions. Half the trials were done using vision, while the other half was done wearing glasses that prevented the person from seeing the arm. The idea was to measure how much vision affects movement in patients with complex regional pain syndrome (CRPS).

    The movements were captured on film by a camera stationed above the person being tested. Video analysis software was used to make judgments about the arm movements and provide data on how far off each actual arm movement was from the intended target.

    In other words, if the patient/subject was supposed to point to three o’clock, how far away from that point did the arm go? The difference in degrees between the correct arm position and the actual arm position was the main measure of arm position accuracy. Arm pain and perceived level of difficulty in awareness were also measured using rating scales. There were several important findings from this study:

  • Limb position accuracy was distorted in both arms (affected and unaffected) of the patients
    with complex regional pain syndrome (CRPS). This suggests a problem with general awareness of limb position.

  • All but one patient in the CRPS group had a mental picture of the affected arm that
    included some distortion. For example, part of the arm was missing altogether or a finger was oddly shaped. Some patients described the arm as much larger than it actually was.

  • Having pain anywhere in the affected arm did not help them find the arm. Being able to see
    the arm did help.

    The authors suggested that since limb position awareness was challenged in both arms when only one arm had CRPS points to the possibility of what is called central processing errors. Central processing refers to the natural function of the nervous system (nerves, spinal cord, brain).

    In the case of CRPS, errors occur in the nervous system’s ability to keep track of all body parts at any given time. Vision helps keep the nervous system up-to-date on just where that arm really is at any point in time. Factors other than vision may come into play but for the moment, this is only a theory. What those other factors may be remains unknown at this time.

    How does this new information help in the treatment of patients with complex regional pain syndrome (CRPS)? First, knowing that vision is an important feedback mechanism may help therapists use visual input and visual cues when working on limb position accuracy. Visual feedback may also help improve the brain’s mental representation of the arm. Improving the accuracy of reaching and grasping function can go a long way in avoiding accidents and injuries.

    Second, experts working in the area of motor control and motor dysfunction may be able to find ways to improve function. Discoveries made with other problems that involve distortion of central processing of sensory and motor input may work with complex regional pain syndrome.

    And third, this first insight into impaired limb position accuracy in patients with complex regional pain syndrome has opened the door to further study of the problem. Scientists can begin to look for the exact neural processing pathways that are affected by CRPS and perhaps find ways to restore normal sensorimotor function.

  • What to Do About Chronic Pain in Older Adults

    When you’re younger, it may be easier to shrug off pain or work through it. The old expression, No pain, no gain is the mantra of many athletes. But as we get older, pain has a way of getting us down faster and keeping us there longer. We don’t bounce back like we used to. This is especially true when pain is present.

    Older adults often find that managing the chores and activities of daily life are a challenge enough without pain being added to the mix. Suddenly, making a cup of tea can become impossible — much less preparing a nutritious meal. Sleep is disrupted, thinking becomes cloudy, and the affected adult is no longer getting out with other people. Persistent pain in this age group can create a steady decline in physical and cognitive function.

    What can be done about it? Medications are one possibility but knowing what to take and when to take it can be another difficult hurdle to jump. In this special edition, the American Geriatrics Society’s Guidelines for Pharmacologic Therapy are reviewed. The specific focus is on medications for chronic pain in older adults. Chronic (or persistent) pain is defined as pain that lasts more than three months. Older adult refers to men and women 65 years old and older.

    The next logical question is, What medications are available and who should take them? Pain medications including acetaminophen (Tylenol), nonsteroidal antiinflammatories (NSAIDs), opioids (narcotics), adjuvant (additional other) analgesics, topical analgesics (rub on creams and gels), and other drugs are discussed. Here’s a brief summary of each class of drugs.

  • Acetaminophen (Tylenol): Safe and effective, the first choice of drug for pain relief. Patients should not take more than a total of 4 grams each day. Anyone with liver disease or who abuses alcohol cannot take this drug.
  • Nonsteroidal antiinflammatories (NSAIDs): More effective than acetaminophen for chronic inflammatory pain but with possible gastrointestinal problems. Should not be used by anyone with an active stomach ulcer, kidney disease, or heart failure. Patients on NSAIDs must be monitored carefully for any signs of adverse effects.
  • Opioids (narcotics such as Lortab, OxyContin, Percocet or Percodan, Morphine): Anyone who has not responded to acetaminophen or NSAIDs and who has moderate to severe pain that affects daily function should be considered for opioid pain relievers. Newer and better drugs of this type are available that are safe and effective. Opioids should only be prescribed and monitored by knowledgeable physicians with experience using these drugs.
  • Adjuvant analgesics: refers to drugs developed for some other purpose than pain relief but useful for persistent pain. Includes some anticonvulsants, antiarrhythmics, and antidepressants. Used most often for people with fibromyalgia, nerve pain, chronic and severe back or bone pain, and headaches. Often prescribed along with other pain relievers.
  • Topical analgesics including lidocaine, NSAIDs, and capsaicin: Available as a patch or topical gel, these medications are useful in controlling nerve pain. Patients with diabetic neuropathies or chronic musculoskeletal problems seem to benefit the most. Patients must avoid use around open wounds or mucous membranes and stop use if a skin rash develops.

    Patients should be warned to expect a burning sensation when using capsaicin. Unlike lidocaine, which is a numbing agent, capsaicin produces a counter irritant. The mild burning sensation draws blood to the area and improves circulation needed for local healing.

  • Other drugs: Efforts are ongoing to find other drugs that might be useful in controlling or managing various types of chronic pain. For example, muscle relaxants, oral (systemic) corticosteroids, calcitonin, and bisphosphonates have been used as a second-line treatment approach after some of these other, less risky medications. When it comes to pain control, much more research is needed to understand what works and why.

    One of the problems in prescribing pain medications for older adults is their unwillingness to take them. Often, they suffer in silence and refuse to see a doctor or mention their pain. They may believe that their symptoms are just part of aging. Unidentified or undertreated pain can spiral into a worse problem with additional complications if and when it is not addressed early on.

    Physicians are faced with the challenge of finding the right medication in the best possible dosage for a wide range of different problems. There can be joint pain from arthritis, muscle cramping associated with restless legs syndrome, or nerve pain from shingles. They must watch out for the adverse effects that can occur when patients are already taking multiple different medications for other problems like high blood pressure or diabetes.

    There’s also the problem of how older adults metabolize drugs. They don’t always break drugs down the same way or at the same speed as younger folks. The result can be overdosing or underdosing. Either way, there is less than optimal results. And finally, not all older adults are able to report pain verbally. Strokes, dementia, Alzheimer’s, and other conditions can leave patients without the ability to speak or communicate their problems and/or needs.

    The authors of this special edition hope that reviewing updated guidelines established by the American Geriatrics Society (AGS) will benefit professionals who are working with older adults. Recommended starting doses are provided for each drug. Whenever possible, other nondrug methods of pain management should be encouraged. This may include physical therapy, cognitive behavioral therapy, and complementary and alternative medicine (e.g., acupuncture, chiropractic, massage, Reiki, therapeutic touch, BodyTalk).

    Special instructions are offered when necessary such as how to monitor patients and what types of adverse effects to watch out for. With so many elderly people in the American population and a high incidence of pain among this group, this updated set of guidelines is a valuable tool for pharmacists, primary care physicians, and geriatricians (physicians who specialize in working with older adults).

  • Why Opioid Pain Relievers Don’t Always Work

    Most everyone knows narcotic pain killers like morphine, Percocet, and Vicodin are powerful. Doctors prescribe them with caution because although they relieve pain, they also have some nasty side effects. Addiction being one of those effects. But sometimes physicians are too cautious not realizing that some people require 10 to 40 times the standard dose to get the same effect.

    Animal studies have confirmed what doctors see in the clinic — there are some unique differences in patient responsiveness. Scientists have found that the wide variability in how people respond to these drugs might be genetic. And once they discovered this factor, they found more than one genetic trait that is involved.

    For example, some folks don’t have the CYP2D6 enzyme needed to activate the drug. Without this enzyme, the drug isn’t metabolized (broken down) and the patient gets no (or very minimal) pain relief. Another problem occurs when P-glycoprotein doesn’t function properly. This is the protein that transports the opioid across cell membranes. Without normal P-glycoprotein, there can be too little or too much opioid in the cells.

    Here’s one more example of genetic mutations that affect how opioids work in the human body. When the COMT gene is mutated, it no longer makes the enzymes that break down neurotransmitters that carry chemicals around the body. Without proper COMT, the cell receptor sites for opioid are also affected.

    These examples are really only the tip of the iceberg. The more scientists explore this direction of research, the more differences in genetic makeup are discovered. The cell receptor sites just mentioned? It turns out there are probably many different types of pain receptor sites — a change in any of these can affect how well opioids attach to the cell, transfer across the cell membrane, and have the intended effect to reduce pain messages.

    Genetics isn’t the only factor in how people respond to opioids. There is still a significant effect of personality and psychology — some people tend to lean toward suffering rather than overcoming. And the source of the pain can also contribute to how well opioids work.

    But for all we’ve learned about individual factors (including genetic variability), we are no closer to finding a successful treatment for pain. Scientists will continue to pursue genetic-guided pain therapy. It’s likely that there are multiple genes involved and additional factors yet to be discovered. Finding the combination for each patient that prevents successful opioid use or in the opposite vein — finding the combination of genetic (and other) factors that can lead to pain relief may become the next step in scientific discovery.

    The vision experts in pain management suggest the future looks like this. Treatment will be personalized for each patient based on his or her individual genetic code. Their DNA will be examined with the information used to find the exact right drug that will be an effective pain reliever using the lowest dose possible. Even better yet, doctors will be able to take a blood sample and identify who is at risk for developing an addiction to specific opioids.

    For now, it’s helpful for health care providers to recognize and acknowledge that there are individual differences in how opioids work for different patients based on genetic variability. Just because someone doesn’t get pain relief with the standard dose prescribed, doesn’t mean they are addicted or becoming addicted. It could simply be an indication that they fall into that group of patients who need more (sometimes much more) of the same drug to get the same pain relief as someone who responds to the lowest dose possible.

    Understand Myths in the History of Complex Regional Pain Syndrome

    Complex regional pain syndrome, called CRPS, is a little understood but often very disabling condition that can occur after a seemingly small injury or trauma. The pain from the injury is out of proportion of the actual injury and can get worse, rather than better. It usually affects one limb or hand or foot, but can spread to the entire limb with time. Since doctors and researchers don’t know what causes CRPS, there are many theories, some of which include psychiatric or psychological factors. Precisely because the causes aren’t known, perhaps too much emphasis is placed on the alleged mental side of the condition, resulting in myths that continue to be present. The authors of this article wanted to find these myths and understand the evidence of what brought people to believe them.

    Complex regional pain syndrome has been around for a very long time – it was first noticed in the sixteenth century and was documented during the Civil War in the United States. It was originally named causalgia (from the Greek word kausis, which mean fire) because of the intense burning pain caused by CRPS. The condition was officially named reflex sympathetic dystrophy in 1939, but was changed to CRPS when it was decided that this was a more fitting description. It may be no surprise that if a condition is difficult to name, it may be difficult to understand.

    How CRPS comes on differs from person to person – it can come on very quickly and suddenly or it can develop slowly. It can be caused by a fracture, a nerve injury, after surgery, or just about any other way you can injure yourself – even after an injection. The symptoms can include increase in pain (hyperalgesia), pain from something that isn’t normally painful (allodynia), swelling (edema), changes in skin color, muscle wasting (atrophy), excessive sweating in that one particular area (hyperhidrosis, and/or decrease in bone mineral density (osteopenia).

    If the presentation (how it comes on and the symptoms) isn’t confusing enough, the parts of the body that are affected can vary tremendously as well. In some patients, the pain starts and stays in the area of the initial injury, but for others, it could be the mirror image – the opposite limb – that has the pain. It may start as soon as the injury occurs or triggered by delayed (or no) treatment.

    It’s not a common disorder, but it’s not rare. CRPS happens after about one to two percent of fractures, after two to four percent of peripheral (surface) nerve injuries, and after up to 35 percent of Colles fractures, a specific type of broken wrist. More women have it than men (60 to 80 percent) and it happens more often after arm or hand injuries than leg or foot injuries.

    The myths associated with CRPS are numerous but we don’t have to look far in history to see physical illnesses that are blamed on psychological problems. Most recently, fibromyalgia has been in that group as well. It seems that if there is unexplained pain, theorists will find a way to blame it on a mental problem. For example, some theorists said that patients with CRPS had psychologic disturbances and maladaptive personalities. When the inkblot tests were at their height of popularity (the Rorschack Inkblot Test), they were used on patients with CRPS to see if a psychological issue could be identified. And, because CRPS occurred more often in women, the term hysteria was also applied to patients with CRPS. Then, in the early twentieth century, doctors and researchers were learning more about psychosomatic disorders, physical complaints caused by mental issues, so this exploration was perfect for unknown illnesses, such as CRPS.

    What the researchers involved in this study found was that the causes of CRPS were often attributed to the Zeitgeist of the time, the general rule of thought. As certain theories became popular, they were applied to CRPS, in an effort to explain it. However, through looking through the literature, the researchers could not find any evidence to support a relationship between the disorder and a psychological disorder, debunking much of what had been said about such a connection. However, the authors do not say that there is no psychological connection. Managing chronic pain does usually include an approach from a psychological angle as part of a multi-disciplinary approach. The trick is to keep in mind that they go together and that one doesn’t supersede the other.

    A Powerful Tool for Pain Control: Neurostimulation

    Think about your 10 closest friends and/or relatives. Is any one of them in pain today? One out of every 10 Americans suffers from chronic (long-lasting) pain of some type. Have you ever wondered why that person doesn’t just get over it? Scientists, researchers, and pain experts are actively seeking to find out how to break the pain cycle — or even prevent it from starting in the first place.

    This article looks at one way to stop chronic pain: neurostimulation. Neurostimulation involves the application of electric current near or along the nerve pathways causing the pain. The idea may seem barbaric at first. In fact, according to stone carvings, it was probably used thousands of years ago. Fish that emit electric currents were applied to people to treat headaches and arthritis pain.

    Today, the electrical stimulation is applied in a more technological fashion — but it still amounts to sending an electric impulse either to or through the spinal nerves, spinal cord, or brain. The idea is to override the pain messages that seem to have gotten stuck in the on setting. The idea of neurostimulation is currently in use for conditions like migraine headaches, back pain, post-operative pain, phantom limb pain after limb amputation, and even angina that won’t go away.

    How is it applied? There are several different by which electrical stimulation can be delivered. The first and easiest method is called peripheral nerve stimulation (PNS). Flat, surface electrodes (square, round, or rectangular shaped) are placed over the skin over the area of pain or near the affected nerve. A small handheld device is connected to the electrodes that can be set to deliver low-level electrical impulses through the electrodes. The little box can be attached to a belt for ease of use.

    A second method is called percutaneous implantation. The peripheral nerve stimulator is actually placed under the skin. This works best for patients with low back, head, neck, and/or facial pain because the implant can get close to the spinal nerve roots causing the problem.

    When peripheral nerve stimulation doesn’t work, then spinal cord stimulation is considered. Spinal cord stimulation is used most often for severe, constant back or limb pain that isn’t relieved by any other means (e.g., medications, peripheral nerve stimulation, physical therapy, nerve blocks). The unit is implanted into the spinal canal where it can relay electrical impulses to the brain through the spinal cord.

    A third method directly to the brain is called motor cortex stimulation or deep brain stimulation depending on where the implant is located. These implantable devices generate a low-voltage electrical pulse that blocks the brain’s ability to perceive and register pain. These units are battery powered and have multiple settings that allow the patient to choose different intensities, patterns, and duration of stimulation. They can even be turned off and back on to vary the input and try to override or fool the brain.

    There are some cases where neurostimulation of this kind cannot be used. That includes anyone with a pacemaker or defibrillator for the heart, a systemic infection, and/or pregnant women or nursing mothers. Sometimes exceptions can be made for the patients with a pacemaker, defibrillator, during pregnancy or while nursing. But the systemic infection is always considered an absolute contraindication (no-no) for neurostim.

    For those who might benefit from neurostimulation to treat chronic pain, it’s a trial and error sort of process to find the best choice for each patient. Two people with the exact problem may not respond the same to equal treatment. It can be a very frustrating experience for the affected individual. But with a little patience and some time, it is often possible to achieve a successful outcome.

    Of course, chronic pain has other affects mentally and emotionally that may require some attention, too. Neurostimulation is just one of many tools used in a comprehensive pain management plan. It has the advantages of being reversible, safe, and cost-effective. Best of all, the use of medications are not required and patients taking pain relievers are often able to reduce the dosage and number of pills required. Sometimes, it’s even possible to get off all medications with the use of neurostimulation. Many patients find that a great boon to this form of treatment.

    Last Resort for Pain Control: Intrathecal Drug Delivery

    Patients with severe, constant pain that has not responded to any other treatment may be candidates for something called intrathecal (IT) drug delivery. Intrathecal means within the spinal canal. The spinal canal is the opening for the spinal cord to travel from the brain down to the bottom of the spine. Delivering pain medication through the spinal canal directly into the spinal fluid is a fast and effective way to override pain messages to the brain.

    This type of pain control is done with a pump that can be implanted (placed) inside the body. The pump is usually placed in the abdomen with a catheter (tube) up into the spinal canal. When placed internally, the intrathecal pump provides a constant stream of pain relieving medications into the spinal fluid. Various medications can be used. They all have advantages and disadvantages. Opioids (narcotics) are commonly tried first.

    It’s really a last resort effort to gain control of pain when everything else has been tried and failed. And even these implantable pumps aren’t used without a trial first. Electrodes are placed on the outside of the spine first to see if the patient can get good pain relief this way. The external (outside) unit is left on for one to two weeks before considering implantation.

    Some pumps seem to work better than others for individual patients. There can be a trial and error period when different drugs (or combination of drugs) are used to get the desired results (pain relief) with the fewest side effects. Common side effects with any of the opioid medications include nausea, dizziness, confusion, difficulty walking, and problems with memory.

    The intrathecal (IT) drug delivery system has been in use for 30 years now, so there have been some studies to help guide doctors when prescribing the system and choosing the specific drugs. There are two groups of chronic pain patients who can benefit from this treatment approach: those with cancer pain and those with noncancer pain.

    Pain Medicine News has published updates on the use of IT drug therapy for both groups. In this issue, Dr. Richard L. Rauck, Director of Clinical Research on Pain at Wake Forest University School of Medicine (North Carolina) presents an update on the use of IT for noncancer pain.

    Patients considering IT therapy should be told that complete pain relief is rare. They can expect some improvement (up to 50 per cent reduction in pain) — enough that they can function better. They may be able to tolerate their pain enough to complete daily activities and participate in life more comfortably. Dr. Rauck provides physicians prescribing the medications used in IT therapy with details about each drug.

    Physicians who specialize in pain management will benefit from the discussion about specific drugs, types of drug trials to use, determining dosages, and calculating ratios when combining drugs. Drugs may be given in steady streams of smaller dosages or with a single larger dosage called a bolus. The prescribing doctor makes the determination based on patient problem, drug (or drugs) used, and type of system used.

    Companies making the implantable units are continuing to improve these delivery systems. The systems now come with options to choose from and can be programmed to provide medications on a schedule or at the patient’s request (self-administered). The devices are more durable than when they first came out. And the batteries last longer. Manufacturers of a new programmable IT drug pump called Prometra hope to have it on the market in the New Year (2010).

    Patients must be educated about this method of pain control. Besides the side effects mentioned, there can be problems with low blood pressure that can suddenly switch to dangerous high blood pressure. It’s possible to develop a tolerance to the drug. This means the patient no longer gets the same pain relief with the standard prescribed dosage and must start taking more of the medication — and that can lead to even more problems.

    Too strong of a reaction to a medication may require a switch to another drug. Even the process of withdrawing from one drug to try another can cause problems. Then the catheter used to deliver the drug can get blocked or kinked. And patients run out of their drugs. That’s just the short list of things that can go wrong with IT drug therapy.

    Sometimes the body forms fibrous tissue around the device that can be a problem. This is an immune inflammatory reaction. The immune cells that travel to the area attempt to wall off the device forming a ball of cells called a granuloma. Development of a granuloma requires immediate attention to avoid serious neurologic problems. The drug must be stopped. A series of MRIs will then be done over time to make sure the granuloma is going away.

    Patients must let their doctor know any time the pain increases and they lose the pain relief initially offered by IT drug therapy. This may be a sign of a granuloma forming or an indication that a change in drug selection is required.

    IT therapy isn’t for everyone. Like many other modalities used to manage pain, it is a tool that works well for some, but not all, patients. With continued improvements in the technology available for the implantable pumps, more patients might benefit from this treatment approach in the years ahead. Keeping abreast of the new developments will remain an important part of the pain specialist’s job. Updates like this one from Dr. Rauck are very helpful.

    Siblings’ Risk of Complex Regional Pain Syndrome

    A group of Dutch scientists have been studying a condition called complex regional pain syndrome (CRPS). They are pulling together data to help us understand this painful problem. Their studies are carried out and reported through a group called TREND (Trauma RElated Neuronal Dysfunction). This study looks at the likelihood that a sibling(brother or sister) might develop the same condition.

    Complex regional pain syndrome (CRPS) is a common problem after trauma to an arm or leg. The injury could be as a result of surgery or bone fracture. Distal radial (wrist) fractures are the most common injury leading to CRPS, but no one knows why this particular fracture leads to CRPS. CRPS can occur without any known trauma or injury. Non-traumatic cases of CRPS make up about 10 per cent of all affected patients.

    No matter what the cause, the patient develops wrist and hand pain, swelling, and skin color changes. The pain and swelling are accompanied by a loss of motion and function. There can even be changes in skin temperature (warm or cold) and increased hair growth on the arm compared to the other (healthy) side. In one-third of all cases documented by TREND, more than one extremity (arm or leg) is affected. CRPS occurs in women much more often than men (75 to 85 per cent of all cases).

    The question of whether there is a genetic link with CRPS has been raised by other studies. If that’s the case, then siblings might be at risk for CRPS if a brother or especially a sister develops CRPS. To find out, these Dutch scientists interviewed 405 patients already diagnosed with CRPS. They asked the patients how many siblings were in the family, if any of them had ever been diagnosed with CRPS, or if any of the brothers or sisters had ever had symptoms of CRPS.

    Contact was made with 24 individuals out of the total 1,242 siblings who might be affected with CRPS. The physicians of these siblings were also asked to verify history, clinical presentation (signs and symptoms), and confirm a diagnosis of CRPS. Fractures and surgeries were the most common causes mentioned in the patients’ histories.

    In order to tell if there is a link between family members with CRPS, a special mathematical formula was used to calculate the sibling recurrence risk ratio. They further assessed risk of siblings by the patient’s age (under 50 years old and 50 or older). Then they calculated the risk of developing CRPS for the general population and compared the results.

    They found that the overall risk in the CRPS sibling group was the same as in the general population. In other words, the overall risk of developing CRPS if you have a brother or sister with this condition is no greater than your risk of developing CRPS when none of your siblings are affected. They did find that the patient’s age at the time of diagnosis may be a factor. Siblings of younger patients (less than 50 years old) with CRPS had a greater risk of developing CRPS. This finding in the subgroup by age may point to a genetic factor but further studies are needed to take a closer look at this link.

    The authors concluded that this is the first study to look at the sibling recurrence risk ratio for patients with complex regional pain syndrome and their siblings. The CRPS problem is a complicated one that probably involves many factors, not just a genetic one. If there is a genetic link, it appears that it is more obvious in younger patients with CRPS.

    There is always the question of whether the reason for CRPS in a sibling is environmental (the patient and sibling grew up together in the same home and were exposed to the same things). That is another area for future study. The authors suggest another study to confirm the findings in this sibling study first before expanding to investigate potential environmental factors.