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A Bit of Vacation…

July 7th, 2014 · No Comments

I’ll be on vacation for July.  I hope you can join me in relaxing for the month!

If you’d like some good books to read while relaxing, here are some recommendations:

Or, if you’d like to brush up on some skills that help with pain, here are some suggestions:

Happy Summer!!!

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Medications for Pain Series: Research Advances

June 30th, 2014 · No Comments

This article is one in a series on Medications for Pain… What are your choices? How do various medications work? What are the pros and cons? How about side effects?

Today is the last article in this series, and we’ll look at 2 promising advances in research for pain.

1. The first advance is studying multiple medications together.  As you might know all too well, it’s usually not a single medication alone which helps in chronic pain.  Patients often use 2, 3, or even more medications together.  However, most research looks at only 1 medication at a time.  While this practice is simpler, it doesn’t help us know how to best combine medications for pain management.

Studies looking at more than 1 medication at a time are beginning to be published. Yeah!! Here’s an example:

Lamotrigine in Combination with Other Medications for Neuropathic Pain. This study looked at adding lamotrigine (an anti-seizure medication) to either neurontin, a tricycle antidepressant, or another non-narcotic medication, in patients whose pain wasn’t well controlled with only 1 medication.  The results showed that the addition of Lamotrigine didn’t help with pain.

As more studies are done, we’ll know better:

  • what drugs to use together
  • in what order to prescribe them
  • what dosages to use together

(Study is: Silver M, Blum D, Grainger J, Hammer A, Quessy S, “Double-blind, placebo-controlled trial of lamotrigine in combination with other medications for neuropathic pain.” Journal of Pain and Symptom Management, Vol 34, 2007, 446-454.)

2. The second advance is studying medications for pain specifically and for particular pain disorders.  National research organizations (eg NIH) as well as pharmaceutical companies are directing more dollars towards the study of pain.  This will create advances in pain medicine – more options and quicker development of medication options.  As well, specific pain disorders are being researched.  For example, fibromyalgia has gone from being a questionable diagnosis to having multiple medications being approved to treat it.

This is the end of our series on Medications for Pain.  I hope you’ve enjoyed this series and that the information has been helpful to you.

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Medications for Pain Series: Medication Advances

June 23rd, 2014 · No Comments

This article is one in a series on Medications for Pain… What are your choices? How do various medications work? What are the pros and cons? How about side effects?

Today we’ll look at what medication advances are coming soon. How exciting!!

1. Improvements to opiates (narcotics)
While opiates or narcotics are sometimes helpful, they have more than their share of negatives.  Selective narcotics, which give pain control but have fewer side effects, are being developed.  Instead of working everywhere in the body, they’re being designed to work at pain sites, but not at so many other sites (for example, in your digestive tract) where they cause the problematic side effects.

Another improvement is medication that will decrease side effects, such as this medication for the side effect of constipation from opioids.

2. Different delivery systems for narcotics
Narcotics are being developed to be given either by inhalation (in inhalers, like asthma medication) or through the skin inside your mouth or nose (by rubbing a little gel there).  Why?  Medications used in these ways work faster and can last for a shorter time.  These delivery systems may be very helpful for people who have “break-through pain,” which are short-duration spikes of pain.  These short flares of pain can be hard to treat because medication didn’t work fast enough, or lasted too long.  And, because of other advantages of getting medication into your body in these ways, lower overall dosages can be used, which also mean fewer side effects.

3. Using medications more safely
Research is being done to see how to use the medications we have now more safely.  For narcotics, how do we avoid tolerance (tolerance = your body “gets used to” a dosage, so to get the same benefit, the dosage must increase).  We’re finding that another pain medication, Ketamine, may be helpful to prevent tolerance.

4. Using genetics to predict which medication is right for you
Depression research in studying how genetics can predict which antidepressant is right for you.  No guessing, no waiting… just a simple blood test which can be used to say, “This one should work the best.”  We’re not at this stage yet with pain medication, but my hope is that such tests will be available soon.  We could tell, Lyrica versus Neurontin? Cymbalta or Effexor?  This would save a lot of time – not using medications which won’t work – and prevent a lot of side effects.

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The Pain Management Network Website

June 18th, 2014 · 3 Comments

There’s a new, cutting edge website on chronic pain, The Pain Management Network, which is hosted in Australia.  There’s something helpful and interesting for everyone!  Here’s a sampling:

The New Basics of Pain

Pain and Physical Activity

Pain and Sleep

For Youth:  Pain and School

For Healthcare  Providers:  Chronic Pain Management

Please share what you think, in the comments, if you look over the site!  Thanks.

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Medication for Pain Series: Antipsychotics

June 16th, 2014 · No Comments

This article is one in a series on Medications for Pain…  What are your choices?  How do various medications work?  What are the pros and cons?  How about side effects?

Today we’ll look at the medication category of Antipsychotics.  The original use of antipsychotics is for psychiatric disorders like Schizophrenia or Bipolar Disorder, where a person’s thinking becomes disorganized or delusional.

Like many medication classes, antipsychotics aren’t FDA-approved for any pain disorders.  There are only a few “case reports” of a single patient’s experience.  So antipsychotics are not primary medications for pain.

Effect of Antipsychotics:
The only antipsychotic for which I could find any report of its use in pain is Zyprexa.  Antipsychotics such as Zyprexa effect many neurotransmitter systems, including dopamine and serotonin, so it’s not clear where its pain-relieving effect comes from.  As well, antipsychotics typically cause sedation, so some wonder if they help mainly through improving a patient’s sleep.

Side Effects:

  • sedation (which can be helpful at night)
  • dry mouth
  • dizziness
  • weight gain
  • “metabolic syndrome” in some patients, which includes weight gain, increased blood pressure, and elevated cholesterol and triglycerides

Specific Pain Disorders
In these case studies, Zyprexa had a positive effect when used for both neuropathic pain disorders and Rheumatoid Arthritis (RA), an inflammatory pain disorder.  This is quite interesting, as these are 2 different types of pain disorders.  A medication more commonly works in 1 type of pain only.  For example, anti-inflammatory medication works in RA, but not neuropathic pain disorders, such as diabetic pain.

While these medications may be worthwhile to study for their effect on pain, currently they should only be used when other more traditional medication has not worked.

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Pain Pathways Magazine, Summer 2014

June 11th, 2014 · No Comments

Here’s the Pain Pathways magazine Summer 2014 issue.

Current Issue

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Medications for Pain: Opiates

June 9th, 2014 · 1 Comment

This article is in our series on Medications for Pain…  What are your choices?  How do various medications work?  What are the pros and cons?  How about side effects?

Today we’ll look at the medication category of Opiate Medication, sometimes called “narcotics”.  These are medications designed to treat both acute and chronic pain.

Of all medications for pain, narcotics probably get the most press and cause the most controversy.  If you judged how important or effective narcotics were based on how much is written about them, you’d assume they were the primary treatment for pain:

Blue = Narcotics,  Red = Everything else

Instead, you’re probably better off if your medication regimen for chronic pain looks like this:

If used for chronic pain, narcotics should be 1 medication in an array of helpful treatments.

Narcotics:
Narcotics include opium derivatives (Morphine and Codeine) and synthetic opiates (Methadone, Demerol, Oxycodone).

Effect of Narcotics:
Narcotics work at opioid receptors, where they interfere and stop the transmission of pain messages to the brain.  They also alter your psychological reaction to pain.  Patients sometimes report still being aware of pain, but not having such an aversion to the feeling.

Side Effects:

  • sedation
  • nausea or vomiting
  • constipation
  • breathing difficulty at higher dosages

Issues with Narcotics…

1. Effectiveness
While narcotics are great for acute pain, they often don’t work so well for chronic pain, especially nerve pain.  The negative side effects can be greater than the good effects, making them not worth taking.

2. Tolerance
Over time, your body gets used to their effect.  So to get the same benefit, a higher and higher dose is needed.  Unfortunately, the side effects continue to increase too.  However, don’t mistake tolerance, which is simply a physical process, with addiction.

3. Addiction
True addiction is a disease in which people continue to use a substance (alcohol, street drugs or prescription drugs), despite bad consequences such as physical illness, relationship problems or inability to function at work.  Just because your body is tolerant to a medication, it doesn’t mean you’re addicted.  Addiction is a behavior; tolerance is a physical process.

However, a small percentage of patients who use narcotics will develop true addiction, with symptoms such as lying about how much medication they’re using, doctor shopping to get more prescriptions, obtaining narcotics illegally, and using the medication to get high rather than to control pain.  About 5% of patients who are prescribed narcotics for chronic pain develop addiction.  The risk is higher in people who’ve been addicted to drugs or alcohol in the past, and for those who have few other coping skills to deal with pain.

4. Side Effects
Side effects of narcotics can be significant.  The most bothersome ones are usually sedation, slowed thinking, and constipation, which can be severe.

5. Do Narcotics Increase Pain?
An under-recognized problem is that for some people, narcotics can set up a process where pain will increase over time, even if the medication initially decreases pain.  Narcotics can cause what’s call hyperalgesia, which is an increase in pain sensations.  When this occurs, sometimes doctors think the medication isn’t working and increase the narcotic, when in fact the narcotic itself is increasing pain.  A vicious cycle can develop.  As with all drugs, for narcotics to continue to be prescribed, it should be clear that they’re decreasing pain.

Conclusion…  Pain is bad, and sometimes narcotics are helpful and should be used.  Doctors and patients need to be sure that the benefits are worth the risks or are greater than the side effects.  When narcotics are used, it’s important to see if a person’s functioning is also improved, in addition to a decrease in pain.

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Medications for Pain Series: Blood Pressure Medication

June 2nd, 2014 · No Comments

This article is one in a series on Medications for Pain…  What are your choices?  How do various medications work?  Pros and cons?  How about side effects?

Today we’ll look at the medication category of Anti-Hypertensive Medication.  This class of medication includes drugs originally used to control high blood pressure.  A common medication from this class that’s used for pain is Clonidine.

Like muscle relaxants, anti-hypertensives indirectly decrease pain.  They would be considered supplemental medications for pain, rather than primary ones.

Effect of Anti-Hypertensives:
These medications work by decreasing the activity of your sympathetic nervous system.  This is the “fight or flight” system in your body, the one that’s responsible for getting your body going – raising your blood pressure and getting your heart beating faster.

Uses of Anti-Hypertensives:
In some pain disorders, it’s thought that an overactive sympathetic system may be partly responsible for symptoms.  CRPS (RSD) and other neuropathic pain disorders are some examples.  Using anti-hypertensives in pain isn’t “FDA-approved”, but there are some studies supporting the use of these medications for pain.

Side Effects:

  • a decrease in blood pressure (which is a direct effect of the medication, but is considered a side effect when the medication is used for pain control, as that’s not the effect that’s necessarily desired)
  • sedation
  • dizziness or lightheadedness

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Medications for Pain Series: Muscle Relaxants

May 27th, 2014 · No Comments

This article is one in a series on Medications for Pain…  What are your choices?  How do various medications work?  Pros and cons?  How about side effects?

Today we’ll look at the medication category of Muscle Relaxants.  Muscle relaxants are drugs which help muscles relax and prevent muscle spasms.  Common medications include Zanaflex and Baclofen.

Previous medications we’ve looked at, such as anticonvulsants and antidepressants, can directly reduce pain.  Starting today and over the next few weeks, most of the medications I’ll review work instead indirectly on pain, by affecting some other system and indirectly decreasing pain.

There are many categories of muscle relaxants, all working on different neurotransmitter systems in the body.  Most muscle relaxants work indirectly on pain, although Baclofen may also have direct pain-reducing effects.  We think of muscle relaxants as supplemental medications for pain, rather than primary ones.

Uses of Muscle Relaxants:
Muscle relaxants are used in conditions where these symptoms are a problem:

  • muscle tension
  • muscle spasm
  • dystonia (severe, long-lasting spasm)

These symptoms can occur in pain disorders such as chronic back pain and CRPS.

Side Effects:
Side effects include sedation and weakness.

You might also be interested in the article Dystonia Makes Movement Hard.

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Medication for Pain Series: Ketamine

May 19th, 2014 · No Comments

This article is in our series on Medications for Pain…  What are your choices?  How do various medications work?  What are the pros and cons?  Side effects?

The medication we’ll look at today is Ketamine, a specific anesthetic.  Anesthetics are drugs which prevent sensations, particularly pain.  Ketamine is an “NMDA-receptor antagonist.”  Also in this class is Dextromethorophan (which is an active ingredient in cough syrup).  These medications can be used:

  • Topically (through the skin)
  • By mouth in pill form
  • Intravenous (IV) low-dose or moderate-dose infusion
  • Intravenous (IV) at high doses – “ketamine coma”

One study showed that moderate-dose infusions give much better pain relief than low-dose infusions do, without additional side effects, and so moderate-dosages are now recommended (review here).

Effect of Ketamine:
Ketamine and others in this class are called NMDA-receptor antagonists.  This means they block nerve conduction at a specific (NMDA) neurotransmitter site.

Uses of Ketamine:
Ketamine is only approved as an anesthetic for surgical procedures, not for chronic pain.  In chronic pain treatment, it’s used on the skin for nerve pain, and by IV for CRPS (Complex Regional Pain Syndrome or RSD).  Dextromethorophan, when used for chronic pain, is given in concentrated pill form, as the amount in cough syrup is very low.

Side Effects:
Ketamine’s short term side-effects include anxiety and hallucinations.  There’s been concern over unknown longer-term consequences, including cognitive (memory) problems.  However, one study showed no decrease in attention, learning, and memory in 9 patients with CRPS who underwent a Ketamine coma.  Although we’re still at an early stage in learning how to use Ketamine more safely for chronic pain, I’m becoming a bigger fan of this treatment for use after other treatments have not been effective.

Also Interesting:
Ketamine’s other uses include in veterinary medicine, battlefield medicine, and as a recreational drug.  You might also be interested in these articles:

More information about drug treatment clinics in Washington state.

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