Category Archives: Pain Management

Personalized Pain Medicine

Personalized Pain Medicine – By Lynn Webster, M.D. – October, 2018

Here Dr. Webster explains how our genes control both pain sensitivity and drug sensitivity. Many of us with EDS find ourselves with the most unfortunate combination of high pain sensitivity and low drug sensitivity (due to metabolic issues).

Below is an edited excerpt from a chapter titled, Pharmacogenetics and Personalized Medicine in Pain Management, that Inna Belfer, MD PhD and I published in Clinics in Laboratory Medicine, Volume 36, Issue 3, September 2016.

Pharmacogenetic therapy in people with pain requires consideration of 2 different genetic substrates to determine the outcome of pharmacotherapy.

  1. The first is the genetic contribution to a variety of different pain types, and
  2. the second is the genetic influence on drug effectiveness and safety. Continue reading

Opioid analgesic tolerance without hyperalgesia

Analgesic tolerance without demonstrable opioid-induced hyperalgesia: a double-blinded, randomized, placebo-controlled trial of sustained-release m… – PubMed – NCBI – Aug 2012

Although often successful in acute settings, long-term use of opioid pain medications may be accompanied by waning levels of analgesic response not readily attributable to advancing underlying disease, necessitating dose escalation to attain pain relief.

How can a doctor determine whether a patient’s increasing pain is attributable to “advancing underlying disease” or tolerance to opioids?

It’s impossible for anyone except the patient to determine this. Even for myself, it’s difficult to distinguish between increasing pain versus increasing tolerance to the medication.   Continue reading

In excruciating pain, sickle cell patients shunted aside

‘Every time it’s a battle’: In excruciating pain, sickle cell patients are shunted aside – By Sharon Begley @sxbegle – Sept 2017

The U.S. health care system is killing adults with sickle cell disease. Racism is a factor — most of the 100,000 U.S. patients with the genetic disorder are African-American — and so is inadequate training of doctors and nurses.

And the care is getting worse, sickle cell patients and their doctors said, because the opioid addiction crisis has made ER doctors extremely reluctant to prescribe pain pills.

STAT interviewed 12 sickle cell patients who described the care they received and didn’t receive. They were old and young, men and women, scattered from coast to coast, some with jobs or attending school and some too sick to do either.   Continue reading

Opioid Policies Based On Morphine Milligrams

Opioid Policies Based On Morphine Milligram Equivalents Are Automatically Flawed – By Josh Bloom — October 23, 2018

  • Calhoun, who died in 1989 at age 55, was 6’4″ and weighed 601 pounds
  • Dinklage, who is 4’5″ tall, weighs 110 pounds.

Now imagine that both Dinklage and Calhoun have headaches and need aspirin. The recommended adult dose for Bayer Aspirin is two 325 mg tablets every four hours.

Will this dose be suitable for both men?   Continue reading

Psychotherapy for Chronic Pain

Chronic pain treatment: Psychotherapy, not opioids, has been proven to work – Vox – By Brian Resnick @B_resnick brian@vox.com – Aug 16, 2018

When pain settled into Blair Golson’s hands, it didn’t let go.

What started off as light throbbing in one wrist 10 years ago quickly engulfed the other. The discomfort then spread, producing a pain much “like slapping your hands against a concrete wall,” he says. He was constantly stretching them, constantly shaking them, while looking for hot or cold surfaces to lay them on for relief.

But worse was the deep sense of catastrophe that accompanied the pain. Working in tech-related startups, he depended on his hands to type.   Continue reading

Depression in chronic pain: opioids responsible?

This article made a big splash arguing that opioids, and not the pain we take them for, cause our depression.

Depression in chronic pain: might opioids be responsible? : PAIN – M.D. Sullivan and D.N. Juurlink – Nov 2018

Of course, the answer is “NO”, but this low-quality study with specious claims of “causal inference” tries to show a causal relationship that cannot be proven.

As usual, they are looking only at opioids with little concern for chronic pain, but if we substitute the words “chronic pain” everywhere they say “opioids” these studies make a lot more sense.   Continue reading

Questioning biopsychosocial treatments

Prickly issues: The biopsychosociality of pain might not necessarily mean biopsychosocial treatments work – Body in Mind – by Lorimer Mosely – October 10, 2018

A little while ago now, O’Keeffe et al published a systematic review and meta-analysis that showed little difference in effect between treatments they described as physical, psychological or combined.

The paper was vigorously criticised – arguing that the paper by O’Keeffe et al sets the pain field back by undermining the great advances in gaining traction for a biopsychosocial model of pain.

For some background, here are the broad definitions of the categories they used:  Continue reading

Can physical therapists identify malingered pain?

Can Physical Therapists identify malingered pain in the clinical setting? – August 2011

Background: Many physiotherapists use tools in an attempt to detect malingering; however, there are discrepancies within the literature as to their ability to identify patients who malinger.

Purpose: To survey the literature available on diagnostic tools that could be used in physiotherapy practice and their ability to detect malingering of pain.

This is the holy grail: to find an objective test for pain, one that can definitively determine its existence and, even more ambitiously, measure the “amount” of pain.

Of course, that can’t happen because the horrible feeling of being in pain is the brain’s interpretation of signals it’s getting from the body and other parts of the brain – a very intricate and convoluted process.  Continue reading

Spinal Cord Stimulators: Pulling out more than putting in

Spinal cord stimulators: ~ 10% are good candidates. Pulling out more than putting in | Pain Management Specialist in San Diego & La Jolla – 10/15/2018 — Nancy Sajben MD

PainWeek 2018 has a series of conferences in different cities. This weekend 10/13-10/14, it was in San Diego teaching pain management. Thank those who funded this 2 day program for doctors and healthcare providers to bring us up to date in the field.

Anesthesiology pain specialist Michael Bottros, MD, Associate Chief of the Division of Pain Medicine, Washington University St. Louis, made a comment on spinal cord stimulators:

“They are pulling out more than they are putting in.
Only 10% are good candidates.”

Spinal Cord Stimulators – Shortcomings of Evidence | Pain Management Specialist in San Diego & La Jolla – 09/25/2018 — Nancy Sajben MD   Continue reading

Daily Coffee May Help When You Hurt

Why That Daily Coffee May Help When You Hurt – Sep-2018 – Written by: Matt Windsor

This artilcle makes it sound like caffeine is an instant solution to our pain:

“it blocks receptors for the neurotransmitter adenosine, which interferes with pain-signaling”

Coffee has been known to slightly diminish pain and slightly enhance the effects of opioids merely through its stimulating properties, but it’s far from being a “pain reliever”, so this simplistic explanation doesn’t tell the whole story.  Continue reading