- - Thursday, September 7, 2017

ANALYSIS/OPINION:

Last of three parts.

Understanding our vulnerability to acute and chronic pain has been the topic for the past several weeks. Everyone at some point in life experiences the misery of pain. And facts are that when acute pain goes away, a person can generally go on with life as usual. In contrast, chronic pain is ongoing and too many times outlasts the normal time of healing, with no recognizable end-point.

The overarching goal of managing chronic pain is to draw upon the resilience and courage from within to take healthy steps forward, with viable options. And an important part of this process is developing a good support system, including physicians, clinicians, family and friends. While it may not be possible to completely eliminate pain from diseases such as osteoarthritis, there are steps we can take in order to help gain control. This can minimize suffering while improving the level of function and quality of life.

Last week, the focus was on some conservative treatment options that a chronic sufferer can discuss with their physician. This week we continue with more options (medication, surgery and minimally invasive techniques) as well as some key understandings. The therapy of chronic pain should rely on a good support team with a depth of understanding of multidisciplinary approaches which involve more than one therapeutic option.

This is the last of a three-part series.

Dr. Nina’s What You Need to Know: Additional Options for Chronic Pain

Understanding and Coping: Understanding the available therapy options as well as coping strategies are very important – especially in light of our nation’s clinician history of relieving pain through narcotics that aim to “numb” it rather than encouraging patients to cope more effectively. Through understanding adaptive pain management, within boundaries, chronic pain patients can draw on their own strengths instead of seeing themselves as invalids.
Be Aware - About Pain and Opioids: The opioid epidemic throughout our nation is in part due to a campaign describing pain as the fifth vital sign (the original four vital signs were pulse rate, blood pressure, respiration rate and body temperature). When viewed as such, it was something that had to be treated—it is vital—just like low blood pressure or a low heart rate.
Today we are facing a national emergency from circumstances that have contributed to both the inadequate treatment of pain as well as inappropriate prescribing of opioids by far too many physicians—some doctors write opioid prescriptions more often, for longer, and more than others. Research shows that the likelihood of chronic opioid use increases with each additional day of medication supplied! Taking opioids for just five days — days, mind you, not weeks or months — can lead to long-term use. So, when a doctor writes an initial prescription for 10 days instead of three, that doctor is increasing the patient’s risk of opioid addiction.
As well, patients share with physicians a responsibility for appropriate use of opioid analgesics. This responsibility encompasses providing the physician with complete and accurate information and adhering to the treatment plan. While many patients take their medication safely as prescribed and do not use opioids problematically, some patients—intentionally or unintentionally—are less than forthcoming or have unrealistic expectations regarding the need for opioid therapy or the amount of medication required. It is paramount to:
    •    Use medications as prescribed
    •    Ensure there is understanding with the physician’s instructions
    •    Never share medications with others
The goal is to empower chronic sufferers, physicians and medical providers with healthy, viable pain therapy options.  
Medications: Prescription painkillers for chronic pain sufferers may be appropriate in certain situations when taken as directed and monitored by your physician—they are a legitimate option. But easy availability and a lack of appreciation for the true risk of addiction have contributed to the opioid epidemic. And, the recent declaration for a state of emergency on opioids by President Trump, will result in a very new landscape on if, when, and how narcotics are written for chronic pain. It should also be understood that pain relief is not limited to narcotics. There are a number of other medications that have been shown to perform well to ease pain, including seizure and anti-depression medications. When appropriate, your doctor may custom tailor a combination of medications to achieve the best results.
Surgery: In some situations, going under the knife can, literally, help with chronic pain. In fact, knee replacement surgery is one of the most common bone surgeries performed in the United States and can ease the pain caused by arthritis. And oftentimes, hip replacement surgery is performed to remove a painful, arthritic hip joint and replace it with an artificial joint that is made from metal or plastic. It is usually done after other treatment options have failed to provide adequate pain relief.
Back surgery may be appropriate for certain pain conditions such as a pinched nerve that causes leg pain. Research shows that decompression of bone to relieve the pressure on the nerve has a high success rate of approximately 90 percent.  
Non-surgical pain procedures Epidural steroid injections involve insertion of steroids into the epidural space (around the spinal cord and nerves) to decrease inflammation that can cause pressure on the nerve roots leading out of the spine. It may be indicated for conditions such as spinal stenosis or spinal disc herniation. And, although relief is often temporary—lasting for a few days to up to one year—it can be remarkably helpful during an acutely excruciating pain episode. Or, it can provide enough relief to allow a patient to participate in physical therapy or other rehabilitative programs, and even to confirm the source of pain and if a more permanent treatment option—surgery or a radiofrequency ablation will be beneficial. Radiofrequency ablation utilizes radiofrequency waves to produce high heat directly to the nerve and destroy its ability to transmit pain signals.  
Additionally, there are a number of other techniques such as nerve blocks for the neck, back, feet, and head where local anesthetic and steroids can be injected near the nerve group associated with the pain foci. An example of this is an occipital nerve block which may be used to treat headaches over the back of the head, certain tension headaches, and migraines.   
Trigger points are focal areas of muscle spasm and trigger point injections involve inserting a needle into the muscle group and injecting either a local anesthetic and possibly a steroid to relax the muscle. It may be utilized to treat conditions such as fibromyalgia, tension headaches or myofascial pain (tenderness and spasm) in the arms, legs, lower back, and neck.
Devices such as spinal cord stimulators can be implanted that generate electrical pulses to the nerves to alleviate pain or intrathecal pumps can deliver pain medications directly into the spinal fluid. And, too, botulinum toxin (brand name Botox) has been approved by the Food and Drug Administration for the treatment of chronic migraines.

Every day, an estimated 100-million plus Americans live with acute or chronic pain. September is Pain Awareness Month and the goal is to provide insights for people with pain, so that living a full and active life becomes a possibility. Doing so can reduce the sense of suffering. The key, like many other challenges in life, is to take courage, remain resilient – do the homework to become informed on options, support and direction to help manage pain.

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