How can I avoid chronic pain?

The best way to avoid chronic pain is to treat acute pain aggressively and appropriately. For example, when a person first experiences severe pain, anti-inflammatory medications like Ibuprofen help promote healing and prevent abnormal pain impulses from developing. Prolonged, severe pain can cause anxiety, depression and insomnia which in turn decrease a person’s pain tolerance. Pain causes depression, which causes more pain. This “Cycle of Pain” can be very difficult to break once it starts. This is why it is important to see a Pain Management specialist when the usual treatments aren’t working.

I’ve been having back and leg pain for a long time and my medication is not helping very much. My neighbor has the exact same symptoms and he’s taking a different medication which helps him a lot. Why isn’t my doctor giving me the same medication?

Even if your symptoms sound exactly like your neighbours, it is most likely that the two of you are still having different problems. Patients often ask me if they can take the same medication that their friend is taking, but it’s not that simple. Doctors treat the problem, not just the symptoms. Different problems often times cause similar symptoms, but because they are different problems, each person needs to be treated individually. Talk to your doctor about other options for your problem, or ask to be referred to a Pain Management specialist.

I have chronic pain and my pain gets worse when I increase my activity. I’m taking pain medication which helps me to do more, but how do I know that I’m not causing more damage?

In Acute Pain problems, such as a sprained ankle or a burn, the pain is a “signal” to the person that something is wrong and alerts that person to stop doing a certain activity. In Chronic Pain problems, the pain is no longer a helpful tool. Because of an abnormal process within the nerves, pain is being produced even though there is no longer ongoing injury to a particular body part. Using medication in order to decrease the pain and increase activity is a very important part of getting better. As a person moves around more, those abnormal pain signals can “die out”. You should always talk to your physician for specific directions regarding your condition.

Will Pain Management turn me into a drug addict?

No! Effective pain management allows people to be relieved of pain using different therapies so that they don’t rely solely on narcotic painkillers. The incidence of addiction to narcotic or morphine-like medications is about 3-5%. In people who use these medications for the treatment of chronic pain, the rate is about 1-3%. So, although the risk of addiction is present, it is a relatively low risk, and for people who are suffering, the benefits greatly outweigh the risks. It is very important, though, that such medications be used under the direction of an experienced doctor who is able to identify and treat any problems.

It is extremely important to realize; however, that prescription painkiller abuse is now the #1 type of abused substance surpassing marijuana. It is your responsibility to ensure that your medication isn’t taken by anyone else but you.

Once I start using pain medications will I always have to take them or will my pain eventually go away?

The answer to this question is different for everyone. In some cases, the medication allows the painful areas to “calm down” or heal after which time the medication can be discontinued.  My goal for all patients is to incorporate other pain management therapies, such as physical therapy, to allow people to more easily discontinue their medications.

There are other types of pain problems called “degenerative or progressive” such that the abnormality is expected to continue and therefore medication will need to be continued on a long-term basis. Sometimes it’s difficult to predict who will need long-term treatment and who won’t. This is why regular assessment of pain issues, and adjustments in therapies and medications as symptoms change are important.

My doctor says that I’m addicted to Vicodin because I need it for my arthritis pain. How do I know if I’m addicted?

“Addiction” is the irrational use of drugs or medications despite harmful consequences. Addiction is a biophysiopsychological phenomenon which is diagnosed based on a dangerous behavior pattern. If you are not misusing your medication, such as taking more than has been prescribed or using it for reasons other than pain relief, it is unlikely that you are addicted.

There is a phenomenon called “Physical dependence” which is the natural effect of using narcotic medications. Essentially, over time, your body gets used to the medication, and if you abruptly stop taking it, you will experience withdrawal side effects. Withdrawal side effects are avoided by slowly weaning the medication off, and are not an indication of addiction. Many other types of non-addictive medicines can produce withdrawal effects if abruptly discontinued.

I have chronic back and leg pain. What can a Pain Management specialist do to help me? What is a Pain Management specialist?

Anyone who has a pain problem which has not been eased with the help of your primary care doctor and the usual medications should be evaluated by a doctor who is specially trained to treat various pain problems. As with any type of physician, you should seek a doctor who has completed a fellowship program and is Board Certified in Pain Management. The doctor will devise a plan to ease the pain and improve your ability to enjoy activities which the pain may have been preventing. This plan is very individualized and may consist of medications, special pain relief injections or specific exercises to ease the pain. People who suffer from chronic pain may develop sleep problems or depression. A Pain management specialist is trained to treat all aspects of your health which may be affected by your pain problem.

Which pain medication is the most effective?

The most effective medication depends on what is causing the pain. For example, narcotic medications are very helpful for certain severe pain problems, but may do very little to help pain which is due to chronic tissue inflammation, muscle spasm or nerve irritation. All pain problems cannot be alleviated with the same medication. To make matters more complex, different people may respond to the same medication in different ways. One person may have great pain relief with medication A and another person may not have any relief with the same medication. This is why a doctor’s full evaluation is necessary before prescribing any pain medication in order to identify all of the possible factors which may be causing the chronic pain situation.

Can pain be relieved without taking pills or medications?

Yes, especially if the pain problem is addressed early. Oftentimes, pain can be alleviated or stopped by using specific exercises and stretches. Physical therapy offers a variety of non- medicinal treatments which are effective in reducing pain. This helps people to get back to a previous level of activity following an injury and also decreases the chances of a repeat injury. Weight loss, smoking cessation and proper posture/ lifting techniques can especially help back, knee, hip and neck problems.

I’ve been told that there are certain “injections” that could help my pain. What are these?

Pain management specialists use injections to quickly alleviate multiple types of pain. The most common type is the epidural injection, for back or neck pain, but many other types are available to ease the pain. The injections consist of local anesthetic, aka numbing medication, with or without a steroid. The local anesthetic provides immediate pain relief by blocking the nerves that carry the pain signal and the steroid decreases inflammation and helps the tissues to heal. The injected steroid is much more effective than a steroid pill because it is placed directly onto the inflamed tissues. Also, because it doesn’t have to be absorbed into the bloodstream to get to the site of pain, the risk of side effects is much less.

I’ve had neck pain for many years. Recently, my pain became so severe that I was referred for an epidural steroid injection at the hospital. The injection helped the pain for 3 weeks, but now I can feel my symptoms returning. What do I do now?

Unfortunately, patients are often referred to doctors who will perform an injection and never see them again for follow- up pain management instructions or long term treatment options. The difference between these “injectionists” and a Pain Management specialist is that the specialist will “blend” several therapies so that the person receives the best chance at long term pain relief. Epidural injections are highly effective, but only if they are used within a specific treatment plan with close follow-up after the injection. You should ask your primary care doctor for a referral to a Pain Management specialist for long term treatment options.

My mother was diagnosed with metastatic cancer and she is suffering from uncontrolled pain. She is either screaming in pain or “zonked out” after she takes her medication. We want to be able to spend quality time with her before she passes, so what can we do?

Cancer related pain is notoriously difficult to treat. This type of pain is most effectively treated with a combination of two or three types of pain medications which work together to relieve pain without causing excess sleepiness. Some cancer patients are candidates for the “morphine pump”. This allows the patient to receive very small doses of morphine directly into the spinal fluid. This technique gives the best pain control without sedation and removes the need to take pills altogether. A Pain Management specialist can evaluate your mother and devise a plan to help control her pain without the side effects which are currently affecting her quality of life.

What is the Spinal Cord Stimulator that Jerry Lewis has been talking about?

A spinal cord stimulator is a devise which is very helpful for pain that involves damaged nerves. It is most commonly used for pain in the arms or legs. Essentially, this device “turns off” the pain signals which are sent out from damaged or abnormal nerves. The pain sensation is replaced by a gentle “electrical massage” sensation. The person undergoes a temporary trial use to ensure that the stimulator will relieve at least 60% of the pain. After a successful trial, the stimulator is permanently implanted under the skin, like a pacemaker.

“My doctor prescribed Neurontin but I’m too afraid to take it because of all of the negative information about it on T.V. and the internet. What should I do?”

It’s very important that you discuss your concerns with your doctor who prescribed it. Neurontin is a good medication for many pain problems. There is no medication that is perfect for everyone, but your doctor prescribed the Neurontin because she/he believed that it is right for you. Always discuss your concerns with your doctor before making any changes to his/her recommendations. The T.V. and internet are NOT the best sources for your medical advice.

Why do I feel better when I use ice?

Ice is a natural pain reliever because it slows nerve conduction and numbs the tissues. In this way, it prevents the pain information from reaching the brain. Ice also slows the inflammatory response to injury by decreasing swelling. Ice tends to be more helpful for acute injuries and pain although it can also help with chronic pain.

Why do I feel better when I use heat?

Heat can be very helpful for chronic pain for two major reasons. One, it causes increased blood flow to tissues. This allows more oxygen to reach the tissues and also flushes out toxins. Two, it allows muscles and ligaments to stretch more easily which will help alleviate painful spasms.

How often will I need to see a pain management doctor?

It depends on the plan of care that your doctor has in mind for you. Some patients need only one visit for treatment suggestions that their family doctor can carry out. Other patients may need to see their pain management doctor 2 to 4 times per month depending on the severity of their pain. For example, if I prescribe a patient a strong pain medication, I oftentimes reevaluate them after 2 weeks in order to ensure that they are doing well without any side effects and that no adjustment in the medication is needed.

“What are the side effects of pain medications?”

The most common side effects include sleepiness and constipation. People who are very sensitive to these types of medications may also experience itching, nausea, dizziness, hallucinations or changes in memory and thinking. Alcohol and sedatives and even allergy medications make these symptoms worse. Anyone who needs pain medication should never drink alcohol or use similar medications without their doctor’s knowledge.

Can a person’s pain be all “in their head”?

Pain that is “all in the head” is not very common. The medical term is Somatization. Some people do turn the emotional symptoms of anxiety or depression into the physical symptom of pain. It is more common; however, for people with physical pain to have more intense pain because of their anxiety or depression. Anxiety and depression lower people’s pain tolerance. Although it’s not all in their head, emotional disturbances definitely worsen the pain problem. This is why it is important for people with chronic pain to also see a psychiatrist to have those emotional issues treated at the same time as their physical pain issues.

Why do some people continue to have pain after back surgery?

There are many reasons. Sometimes after surgery scar tissue or adhesions can form. This can cause pain by pinching or pushing on the nerve tissue in the back. Also, some surgery can cause adjacent areas of the back to degenerate or weaken over time. The spine is a very complex network of ligament, muscle, bone and nerve tissues all of which may cause pain due to injury alone or in combination with each other.

What is the difference between regular pain medications and “slow- release” pain medications?

Most pain medications are meant to be used for short term pain problems such as after surgery or for an acute injury. Those medications typically provide pain relief for only 3 to 4 hours and then they wear off. Medications that provide pain relief for 8 to 24 hours at a time are better for chronic pain problems. One pill is slowly released into the blood stream to provide superior pain relief that lasts longer. Studies have also shown that slow-release pain medications cause a lesser incidence of tolerance and work very effectively at the same dose for years.

I’ve been told that there is a difference between physical dependence and addiction to pain medications, but I don’t understand. Can you explain the difference to me?

It’s very common for people to be confused about the difference between physical dependence and addiction.  The main difference is that addiction includes a psychological (or mental) craving for the medication that can lead to self-destructive behavior.  Physical dependence only means that your body needs the medication and you have symptoms when you do not take it.  People become physically dependent on many kinds of medicines, including insulin, antidepressants, and others.  It is a normal part of using some medications.

When you use a pain medication, after a while your body becomes used to having that chemical on a regular basis.  Your body needs that medication to function normally.  If you stop taking it or lower the dose, your body reacts badly, with physical withdrawal symptoms like headaches, nausea, shakes, and other more serious problems.  This is physical dependence, and it is not at all the same as addiction.

Addiction is a psychological problem that causes people to lose control over their use of a medication.  People with this problem sometimes think the drug is the most important thing in their lives.  They might raise their dosage or continue using the medication without their doctors’ permission, or seek other sources of medication that their doctors don’t know about.  They take the medication even when they know it is not good for them, and they might do risky and irresponsible things to get the medication.

Depending on the type of medication you use, physical dependence might be unavoidable.  Talk to your health care professional if you are concerned about dependence or if you feel you might need to increase or decrease your dosage.

Addiction is avoidable.  If you think that you might be taking a pain medication that you do not need for pain, talk to your doctor about safely reducing the dose.  Also, if you become preoccupied with the medication, thinking about how soon you can take more or worrying excessively that you might run out, that can be a warning sign to talk to a health care professional about changing your treatment.

Why did my doctor give me an antidepressant for my pain? I’m in pain, not depressed! Can’t he see that the only problem is my pain? I need help now!

It is a little confusing, but a number of antidepressants have actually been found to help ease chronic pain. The effect these medicines have on pain is separate from their effect on mood.  There are many things about chronic pain that we do not understand.  However, it seems that imbalances in chemicals involved in pain perception and transmission may play a role.  In low doses antidepressants seem to adjust these chemicals. As a result, they are a common and useful way to treat chronic pain.  As with all medicines, unwanted side effects can occur.  For this reason you should always talk with your doctor about how well the medicine is working in your body and any side effects you may have.

I’ve been prescribed narcotics because of chronic pain, and the bottle says I should avoid operating heavy machinery and driving when I take them. Can you tell me why? Is there anything else I should avoid, like herbal supplements?

Narcotic pain medications (also known as opioids) tend to make people dizzy and drowsy.  That is why people taking them are warned not to do things that could be dangerous if you were not 100% alert.  Many people who use narcotic medications for chronic pain report that these side effects lessen or go away after a few days or weeks on the medication.  However, even if you feel alert, driving might not be safe or legal in your area.  Consult your health care team about whether you should restrict your activities while taking narcotics.

You should avoid other things that can make you sleepy or dizzy while taking this medication.  Sleeping pills, tranquilizers, muscle relaxants, antihistamines, and even alcohol can make the side effects worse.  Even if you usually do not have these side effects, you can get them when you add another medication or alcohol to your routine.  Also remember that even over-the-counter medications and herbal supplements might cause these problems when taken with narcotic medications.

In particular, the herbal supplements kava and valerian should not be used with narcotic medications.  Kava is typically used as a pain reliever, muscle relaxant, anti-anxiety treatment, or anticonvulsant.  Valerian has similar uses as a mild sleep aid, pain reliever, and muscle relaxant.  Both of these supplements can intensify the drowsiness and dizziness of narcotic medications.

Tell your doctor about all medications and herbal supplements you take, including over-the-counter medications and vitamins.  Read the labels of your medications and consult your health care team if you have concerns.  If you have any side effects, be sure to tell your doctor—you might just need a different dose of the medication.

I have a difficult time swallowing large pills, and in the past, I’ve crushed the pills up and mixed them into food to make them easier to take. Are there any medications that I shouldn’t do this with?

You should be very cautious about crushing pills. Many pills have a special timed-release coating that allows small doses of the medication to be absorbed over time as the coatings dissolve. Crushing a pill destroys its coating, and releases a much larger dose all at once, which can lead to dangerous side effects or even death.

 Talk to your pharmacist about whether your medications are available in a different form. Your doctor might be able to change the prescription to a liquid, or to several smaller pills that are easier to take. If you have to use a large pill, ask your doctor or pharmacist if it is safe to crush it or dissolve it in food. To be safe, it’s important to ask about every medication, and even for refills if the pill changes from one manufacturer to another.

I have been told by pain management specialists that I have a naturally opioid blockers that prevent any and all pain medication from relieving the severe pain that I suffer from. My doctors have said that the only option left for me is methadone and I don’t want to do that. Isn’t that a medication that they give to heroin users or drug abusers in general?

Methadone is a medication which has  two FDA approved uses:

Management of moderate to severe pain

Detoxification and management of opioid addiction

While it is true methadone can be used to help individuals addicted to opiates, including prescription medications (e.g., oxycodone, fentanyl, morphine) and non-prescription (e.g., heroin), it is also a very powerful pain reliever. As a pain reliever, your doctor may have you take it every 8 hours (for treatment of dependence it is taken one time every day).

Many side effects of methadone are similar to other opioids including constipation, nausea, and respiratory depression (trouble breathing).  With prolonged use, you may become tolerant, meaning you may require higher doses to achieve the same analgesic effect.  Methadone, especially at higher doses, can cause irregular heartbeats (arrhythmias).  Much of the negative press surrounding methadone in recent years is related to the potential to cause arrhythmias. Current research indicates that your risk of developing arrhythmias may be predictable.  Your doctor may perform tests (like an ECG) prior to initiating therapy to help determine if you are at risk for developing this complication.  In addition, your doctor may perform follow up monitoring of your heart’s response to the medication.  While you are taking methadone, it is important to have your prescriptions filled at a pharmacy which is aware you are taking methadone: there are medications that can increase the likelihood of developing arrhythmias which you should avoid while taking methadone.  In addition, it is important to let your doctor know what medications you are already taking to determine if methadone is an appropriate medication for you.

There are benefits to using methadone as an analgesic. Methadone may offer benefits in the treatment of chronic pain over other opioid medications. While most opioids offer pain relief by acting at “mu” receptors, methadone is also thought to act at “NMDA” receptors. By also working at the NMDA receptor, methadone may offer these benefits:

Suppress nerve sensitization which helps to decrease your response to painful stimuli

Help to prevent tolerance to the pain relieving effects of opioids

It is important to take this medication as your doctor prescribes it.  The full effects of this medication may not be apparent immediately; do not take additional doses if you do not think it is providing adequate relief.  If you miss a dose, do not take an extra dose. Your doctor will adjust your dose slowly to make sure that you tolerate it well. This medication is generally safe to use to treat chronic pain conditions, however, you must

Make sure your health care provider is aware of your entire medical history

Make sure your pharmacy is aware of all medications you are taking so they can perform a complete check for potential drug interactions

Keep this medication away from children and pets and never give your medication to anybody for whom it was not prescribed

Seek medical attention if you believe you are experiencing any side effects