An individual with chronic disabling pain will naturally request pain killers, so why are some physicians reluctant to prescribe narcotics?
- For thousands of years, narcotic pain killers have been used for pain. When we break a bone, have a heart attack or after a surgery, it is comforting to know that these medications will relieve our pain and suffering. Similarly, for those dying from cancer narcotics can give excellent pain relief.
- Everyone seems to have an opinion on the use of narcotics for chronic pain. With the scale of prescription drug abuse in Missouri, most families are aware of someone who has been affected by this epidemic.
- There is no doubt that narcotics are effective in patients with acute pain or cancer related pain.
- There are no good quality studies to show that narcotic pain medications work in the long-term for musculoskeletal pain alone, but may be beneficial in combination with behavioral therapy, interventional techniques, and physical therapy.
- There are studies to indicate that narcotic pain medications can be effective in the short to mid-term for bone and joint pain. Such an indication might be for three months of pain control while awaiting a knee replacement.
- Research studies show that patients on chronic opiate therapy have increased depression, reduced function and decreased activity.
Opiates can cause multiple problems. We have highlighted some of the complications associated with opiate therapy in the sections that follow on addiction, tolerance, hyperesthesia and hyperalgesia, immune and hormonal changes, withdrawal and detoxification.
- Hyperesthesia and Hyperalgesia
- Immune and Hormonal Changes
We may ask you to undergo psychological or psychiatric evaluation and/or counseling sessions because of your chronic pain. Chronic pain affects not only the body, but also the mind. It is beneficial to have someone to whom you can talk about the pain and its impact on your life. The therapist provides information to the pain management physician on the psychophysiological effects of the chronic pain. We provide psychophysiological therapy, family therapy, group and individual psychotherapy to assist in controlling and coping with the pain. Depending upon the cause and type of pain, as well as the type of therapy, we also sponsor community support groups in the St. Louis region. If you are considering a permanent implantable device, such as a Dorsal Column Stimulator (DCS) or Intrathecal Pump, we will require you to have psychological screening, to make certain you fulfill the criteria for implantation. Patient’s who have pre-existing psychiatric conditions such as bipolar disorder, borderline personality, schizophrenia, major depression, or any history of substance abuse should notify us immediately upon patient intake. Successful treatment of chronic pain in these particular patient groups depends upon a coordinated approach, especially in these specific conditions.
Pain medications are an important part of you care. We want to ensure that you are on an appropriate medication regimen for your specific pain. All patients who are prescribed narcotic pain medication must sign a narcotic agreement with The Center for Interventional Pain Management. This agreement is to ensure that we are the only physicians prescribing you pain medication, and that all narcotic pain medications are filled at a designated pharmacy. This will provide greater relief from the pain and also help prevent possible serious drug interactions. If you break this agreement, you will no longer be prescribed narcotic pain medication from the Center for Interventional Pain Management. The Center for Interventional Pain Management does not view running out of pain medication to be an emergency. You are responsible for taking your medication in the manner in which it is prescribed. No refills or medication changes will be given after hours, on weekend or holidays. Narcotic pain medications will not be refilled without physically seeing you in the office, on at least a monthly basis. Please remember, it is your responsibility to monitor your medication usage and to plan for your follow-up visit if you need a refill.
- Unless specifically stated otherwise, all prescriptions are written as a full thirty-day supply. If you have been prescribed a narcotic pain medication on an as needed basis, it must last you a full thirty days, the instructions on the bottle are the maximum permitted amounts, you should ration your medication to last a full thirty days.
- Don not take medications other than prescribed without consulting your health care providers. Even over the counter medications, such as Benadryl or Tylenol, can significantly interact with prescribed medications and cause serious complications.
- Do not combine sedatives or anti-anxiety medications with alcohol or with pain medications.
- Do not use pain medications as sleeping aids.
- Never give your pain medications to someone else.
- Do not suddenly stop taking your pain medications.
- Make a full list of all medications you are taking, including any over the counter medications or supplements, and bring this list with you to each appointment.
- Lock up all painkillers to keep them out of other people’s hands.
Chronic pain can be caused by several conditions, such as arthritis, fibromyalgia, migraines, nerve damage (neuropathy), and injuries that don’t heal properly. Sometimes, the source of chronic pain can be difficult to determine. Pain is the body’s signal that something is wrong, and in the case of chronic pain, this signal continues long term. Chronic pain can lead to a cycle of pain, stress, and physical deconditioning that further exacerbates the pain and can negatively impact overall health. It can disrupt sleep, decrease physical activity, reduce the ability to perform tasks, contribute to depression and anxiety, and affect relationships. Furthermore, chronic inflammation associated with some types of pain can affect metabolic health, potentially leading to conditions like heart disease and diabetes. Addressing both the source of pain and these downstream effects is an important part of comprehensive pain management.
Interventional pain treatments aim to directly address the source of pain, often by blocking the pain signals from the affected area to the brain. Common interventional pain treatments include epidural steroid injections, nerve blocks, radiofrequency ablation, spinal cord stimulation, and intrathecal pump implants. Physical therapy can also be considered an interventional treatment as it helps improve function and reduce pain. The type of treatment recommended will depend on the cause and location of your pain, your overall health, and how you’ve responded to previous treatments. I encourage a multidisciplinary approach, including psychological support, nutritional advice, and lifestyle modifications along with the interventional procedures to manage the pain effectively.
Opioids can be an effective tool for managing certain types of pain, particularly acute pain such as that experienced after surgery. However, for chronic pain, the picture is more complicated. While opioids can provide short-term relief, they do not treat the underlying cause of the pain. Additionally, long-term use of opioids can lead to tolerance (needing more of the drug to achieve the same effect), dependence, and even addiction. There are also other potential side effects, such as constipation, drowsiness, and suppressed breathing. Therefore, I generally consider opioids as a last resort and focus primarily on other pain management strategies such as interventional procedures, physical therapy, and lifestyle modifications. However, in cases where these strategies are not effective, and the pain is severe, opioids may be considered under careful monitoring.
Lifestyle changes can play a crucial role in managing pain and inflammation. Regular physical activity can strengthen muscles, reduce joint pain, improve flexibility and boost mood, all of which can help manage pain. Diet also plays a key role in inflammation; certain foods can promote inflammation while others can reduce it. For instance, foods rich in omega-3 fatty acids, like fish, and those high in antioxidants, like fruits and vegetables, can help reduce inflammation. In contrast, processed foods and those high in sugar and unhealthy fats can promote inflammation. Maintaining a healthy weight can also reduce pressure on joints and decrease pain. Lastly, smoking and excessive alcohol can exacerbate pain and should be avoided. Sleep and stress management are also vital; both poor sleep and high stress can worsen pain and inflammation.
Metabolic inflammation, also known as metaflammation, is a chronic, low-grade inflammation that can occur in response to excess nutrients and energy. It is commonly associated with obesity and sedentary lifestyle, and it’s thought to contribute to the development of metabolic syndrome, type 2 diabetes, and cardiovascular disease. Research has also shown a link between metabolic inflammation and pain. This may be due to pro-inflammatory molecules, called cytokines, which can be produced in excess in conditions of metabolic inflammation and can trigger pain signaling pathways. Chronic pain conditions, such as fibromyalgia and osteoarthritis, have also been linked with metabolic inflammation. Management of metabolic inflammation involves lifestyle modifications, such as diet changes, increased physical activity, weight loss if overweight, and stress management. Anti-inflammatory medications and certain dietary supplements, such as omega-3 fatty acids, may also be used.
Physical therapy is a crucial component of the multidisciplinary approach to pain management. It aims to improve mobility, restore function, decrease pain, and prevent further injury, which in turn helps enhance overall health. Physical therapy might include exercises to strengthen muscles and improve flexibility, posture corrections, manual therapy techniques, and modalities like heat, cold, and electrical stimulation. It can help patients manage conditions like back pain, arthritis, fibromyalgia, and neuropathy effectively. Physical therapists can also educate patients about the biomechanics of their bodies, helping them to minimize or avoid activities that might exacerbate pain.
Pain is not just a physical sensation, but is significantly influenced by emotional and psychological factors. Stress, anxiety, and depression can exacerbate pain, and living with chronic pain can, in turn, increase psychological distress, creating a vicious cycle. Cognitive behavioral therapy (CBT), a type of psychological therapy, has been shown to be effective in managing chronic pain. CBT helps individuals identify and change negative thought patterns and behaviors that can amplify pain and lead to mental health struggles. Techniques such as mindfulness, relaxation, and biofeedback are also used to help manage the perception of pain and reduce associated distress.
The specifics of what you can expect during an interventional pain procedure depend on the type of procedure you’re having. However, in general, these procedures are done under local anesthesia or mild sedation to ensure you are comfortable. They involve the use of imaging technologies, such as X-ray or ultrasound, to guide the procedure and ensure precise treatment. You might experience some discomfort during and after the procedure, but severe pain is uncommon. Most procedures are done on an outpatient basis, meaning you can go home the same day.
The timeline for improvement varies depending on the specific treatment and individual patient characteristics. Some patients may experience immediate relief, while others might take several days or weeks to notice significant improvements. In some cases, a series of treatments might be needed to achieve optimal pain relief. It’s important to note that interventional pain treatments are often only one part of a comprehensive pain management plan. Ongoing physical therapy, lifestyle modifications, and possibly medications will continue to be important for long-term pain management.
As with any medical procedure, there are potential risks and side effects associated with interventional pain treatments. These can include infection, bleeding, allergic reactions to the medications used, nerve damage, and worsening of pain. However, these risks are generally low, and the procedures are considered safe when performed by experienced physicians. Side effects from the procedures, such as soreness or bruising at the injection site, are typically temporary. We will discuss the potential risks and benefits of any proposed treatment in detail before proceeding to ensure you make an informed decision about your care. It’s also essential to remember that while risks exist, these procedures can offer significant pain relief when other treatments have failed. They can play a crucial role in restoring function, improving quality of life, and reducing reliance on medications like opioids.