Category Archives: Pain Management

Pain management in the Ehlers–Danlos syndromes

Pain management in the Ehlers–Danlos syndromes – Chopra – 2017 – American Journal of Medical Genetics Part C: Seminars in Medical Genetics – Wiley Online Library

For those of us with EDS, this is a post we can show our doctors to explain all the various pains we have and to provide hard scientific evidence (from the National Institute of Health, no less) that our pain is absolutely “real”.

Because our pain moves and changes so much, we can seem a little crazy when we report all its varieties and change our reports from appointment to appointment.

INTRODUCTION

Pain is common in Ehlers–Danlos syndrome (EDS) and may correlate with hypermobility, frequency of subluxations and dislocations, soft tissue injury, history of previous surgery, myalgias, and may become chronic.   Continue reading

World’s most Popular Painkiller is Hazardous to Health

World’s most popular painkiller poses risk with long-term use: study | CTV News – Mar 2015

I find it baffling that despite knowing for years how damaging this drug can be, I read about it being recommended for just about any pain, anywhere, any time.

Doctors may be under-estimating the risks to patients from long-term use of paracetamol, also known as acetaminophen, the world’s most popular painkiller, researchers said Tuesday.

Chronic users of the drug — people who typically take large, daily doses over several years — may increase their risk of death, or kidney, intestinal and heart problems, they found.

So why is it still being pushed on patients at every turn?  Continue reading

Surgeons’ Estimates of Opioid Needs Highly Variable

Orthopedic Surgeons’ Estimates of Opioid Consumption Following Total Knee Arthroplasty Found Highly Variable – Pain Medicine News – Dec 2019

A survey has uncovered wide variability in how orthopedic surgeons interpret their patients’ postoperative opioid consumption after total knee arthroplasty (TKA).

I find it odd that the leading sentence of this article talks about the “interpretation” (not estimate) of their patients’ postoperative opioid “consumption” (not need).

the researchers surveyed 36 orthopedic surgery residents, fellows and attendings at the institution. Respondents were asked to estimate the percentage of patients using opioids in the month before undergoing their TKA, as well as one to three months postoperatively. Continue reading

Pain Needs Patient-Centered and Individualized Care

The HHS Pain Management Best Practice Inter-Agency Task Force Report Calls for Patient-Centered and Individualized Care – Jianguo Cheng, MD, PhD, FIPP, Molly Rutherford, MD, MPH, FASAM, Vanila M Singh, MD, MACM – January 2020

At least these folks see the reality: for pain, both acute and chronic, standard treatment with standard doses of standard medications is simply not medically appropriate. Pain treatment is not suitable for standardization.

Some healthcare services must be personalized to be effective, even when they become much more complicated and difficult (meaning, expensive).

The same people insisting on standard dose limits for opioids wouldn’t think of suggesting standard dose limits for blood thinners or insulin or cancer treatments.

The Pain Management Best Practices Inter-Agency Task Force (Task Force) was convened by the US Department of Health and Human Services (HHS), in conjunction with the Department of Defense, the Department of Veterans Affairs, and the Office of National Drug Control Policy. Continue reading

Individual Variation in Opioid Metabolism

Opioid Metabolism – free full-text /PMC2704133/ – Jul 2009

Though this article is a decade old by now, the biological processes of opioid metabolism haven’t changed, so it’s still entirely valid. It points out several reasons why prescribing standard doses of opioids is not a valid medical practice.

Clinicians understand that individual patients differ in their response to specific opioid analgesics and that patients may require trials of several opioids before finding an agent that provides effective analgesia with acceptable tolerability.

Reasons for this variability include factors that are not clearly understood, such as allelic variants that dictate the complement of opioid receptors and subtle differences in the receptor-binding profiles of opioids.   Continue reading

A Practical Approach to Opioid Weaning

A Practical Approach to Opioid Weaning in the Midst of an Opioid Crisis – Pain Medicine News – by Mary Milano Carter, MS, APRN-BC, RN-BC – Sep 2019

The expanse of chronic pain in the United States is incredible. According to U.S. government statistics, pain affects more people than diabetes, coronary heart disease or cancer.

Low back pain gets the gold medal here, affecting 27% of individuals with chronic pain, per the National Institutes of Health.

Approximately 26 million Americans between 20 and 64 years of age experience frequent episodes of low back pain, and it is the leading cause of disability in Americans under 45 years of age, according to the AAPM.

As providers, we struggled to treat our patients’ complaints of debilitating pain, and sales of prescription opioids quadrupled between 1999 and 2014.

Treating benign pain with opioids became an accepted part of the treatment plan, keeping in mind the need to satisfy the Joint Commission’s standards for pain management.

In 2016, the “CDC Guideline for Prescribing Opioids for Chronic Pain” stated that opioids should not be prescribed as first-line treatment for chronic pain, and that prescriptions should be kept to 90 mg of morphine or less daily, or the equivalent in another opioid

No, it did NOT say to keep rx at 90mg or less – it merely said to be more cautious.

Unfortunately, a guideline that was aimed at primary care providers became a standard of care to insurance companies. Providers had to comply with weaning patients on opioids to satisfy the CDC guideline

But the guideline never mentioned anything about weaning. In fact, it said nothing about patients already taking opioids.
It’s all the other people/agencies meddling with our meidcal care that unilaterally decided to wean current patients.

Pain management providers have been adept at weaning patients from opioids due to severe side effects, patient noncompliance with treatment, unsafe patient behaviors, lack of efficacy of the medication or just simply patient desire.

But most patient being weaned don’t exhibit these wigns of opioid use disorder. It seems Ms Carter is saying that while they’ve always had to wean people who had problems with using opioids or their efficacy, now they “had to” wean patients for no other reason than to satisfy bureacracy or managers they are working under.

The Process of Tapering

How long does it take for a patient to become opioid tolerant?

The FDA definition is a patient taking 60 mg of oral morphine daily, or the equivalent of that in another opioid, for at least one week.

If a patient discontinues abruptly or is tapered down rapidly, withdrawal symptoms can occur.

The National Institute on Drug Abuse states that the length of withdrawal symptoms is dependent on

  • how long the drug was taken,
  • the dosage of the drug,
  • the half-life of the drug,
  • the patient’s age and
  • comorbidities.

And NIDA (the agency with extensive history and expertise on drug abuse) helpfully explains the journey through withdrawal:

  • The typical onset of withdrawal is approximately 12 hours, starting with myalgias and excessive yawning.
  • By day 2, hyperhidrosis, anorexia, diarrhea, runny nose, and anxiety and panic attacks can occur.
  • By the third or fourth day, the patient can experience abdominal cramping and vomiting while the myalgias begin to subside.
  • By days 5 to 6, most of the physical symptoms will resolve, but the psychological symptoms can be long-lasting (Table).

Table. Opioid Withdrawal Symptoms 

When initiating an opioid taper, alert the patient that the process typically takes two weeks to six months—and sometimes up to 24 months, depending on opioid usage.

The total daily dose of opioids can be reduced 10% to 20% every one to two weeks, and reduced up to 50% at a time if the dosage is low or truly as needed.

Dies this mean opioids were used when they were *not* needed?

If the dose of a medication is taken truly “as needed”, this statement means the patient is suffering from symptoms that medication can ameliorate.

This seems a clear medical reason to continue the medication. Otherwise, a doctor is literally deprescribing a medicine that was medically needed.

When the total daily dose becomes very low, it should be reduced by 5% at a time.

It is important to monitor the patient closely for withdrawal symptoms, and individualize the plan of care.

When performing an opioid taper without a medical reason, only because of outside influences, how can that be individualized? When a patient needs a medication, treating them as an individual would mean continuing to prescribe the needed medication.

If the patient is reporting withdrawal symptoms, you can use the Clinical Opiate Withdrawal Scale.

Eleven symptoms are graded and tallied, and total score will indicate mild to severe opioid withdrawal (Figure).

Figure. Clinical Opiate Withdrawal Scale.
Based on J Psychoactive Drugs. 2003;35(2):253-259.

Medication therapies to assist with weaning and withdrawing opioids include:

  • lonidine (physical withdrawal symptoms, decreases sympathetic activity)
    – mg po bid; Catapres TTS1 patch
  • nonsteroidal anti-inflammatory drugs/acetaminophen (pain)
  • loperamide (diarrhea)
  • melatonin or trazodone (sleep)
  • prochlorperazine (nausea and vomiting)
  • hydroxyzine (anxiety)
  • oxybutynin (sweats)
  • antidepressants
  • antiepileptics

The patient should be reassessed every three to seven days. It is not recommended to treat withdrawal symptoms with other opioids or benzodiazepines.

How is a patient, crippled by pain, going to get to the doctor every 3 to 7 days? How can a disabled patient afford so many appointments?

Most of the suggested drugs have already been prescribed to pain patients to lower the dose of opioids needed.

There are also adjuvant therapies to assist with opioid weaning.

Nondrug management can include

  • support groups and counseling,

What if your pain doesn’t respond to talk therapy because it has a physical cause?

  • Referrals to detox/addiction medicine/psychiatry, 

No matter how prettily they dress it up we see here that they think we’re all more addicted than in pain.

  • nutrition and hydration counseling, 

So now our disabling chronic pain might be due to not drinking enough water? To not eating the right food?

  • good sleep hygiene, 

What if your sleep is horrible *because of* your pain? What if you can’t sleep because you’re no longer given proper pain relief?

  • relaxation and meditation, 

The modern “cure-all”: you’re hurting because you’re stressed and if you’d just learn to relax, you wouldn’t be having so much pain. Condescending, minimizing, 

  • Reiki therapy, 

Now a medically trained doctor is expected to promote “mystical” alternative therapies? Seriously?

  • aromatherapy, 

If a patient has pain severe enough to need opioids, aromatherapy will not be effective.

  • an exercise regimen. 

What if you can’t exercise *because of* your pain? What if tapering causes your pain to increase, and then you can no longer exercise? (that’s my case: the less opioid, the more pain, the less exercise – I doubt I’m unique in that aspect.)

Also, most of these non-opioid therapies are already being used on pain patients in addition to their opioids.

The American Society of Addiction Medicine also has guidelines for opioid withdrawal. 

Again, patients are assumed to be addicted.

Recommendations include the use of:

  • clonidine to support opioid withdrawal;
  • methadone for patients who may benefit from daily dosing;
  • oral buprenorphine, initiated after withdrawal, although it has poor medication adherence;
  • oral buprenorphine-naloxone, initiated until 12 to 18 hours after the last dose of a short-acting agonist; and
  • naltrexone for extended-release injectable suspension (Vivitrol, Alkermes) for those with difficulty adhering to oral daily doses.

In conclusion, clinicians should be aware that there are many options for safely weaning patients from chronic opioid therapy.

I wish they’d explain more about the basic assumption that all patients on opioids MUST be tapered. 

There are many patients who use opioids responsibly and only use them as needed for pain, but they are never mentioned. It’s as though it’s no longer legal to treat legitimate pain with effective medication.

Author: Ms. Carter is a member of the Pain Medicine News editorial advisory board.
Director of Nursing Education, Chronic Pain Service/Anesthesiology, North Shore University Hospital, Manhasset, N.Y.

Effectiveness and Risks of Long-Term Opioid Tx

The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. – PubMed – NCBI – Sep 2014

I originally found this in a government-sponsored Research Review, from the Effective Health Care Program (Helping You Make Better Treatment Choices) under the Agency for Healthcare Research and Quality (AHRQ).

But now in 2019, I can’t find it there anymore. I can only find the abstract of what used to be a 219-page report, which had reached the same non-conclusion as all other studies of the last couple of decades: “more research is needed”, used when the study doesn’t find the results they wanted.

I think this increasingly common “conclusion” to studies of opioids is a pathetic evasion of the full truth.  Continue reading

Post-op Pain Unaffected by IV Acetaminophen

Post-op Pain Unaffected by IV Acetaminophen After Minimally Invasive Spine Surgery – Pain Medicine News —Chase Doyle – Nov 2019

A study of perioperative IV acetaminophen in patients undergoing minimally invasive spine surgery has found no effect on postoperative pain.

However, that finding does not rule out its use for other surgeries, particularly more painful spine surgeries.

If it didn’t work for mild pain, how can they claim it would be useful for more severe pain? If opioids were studied and evaluated like this, they would be found effective for all kinds of pain.  Continue reading

Effects of opioids on cognition in older adults

The effects of opioids on cognition in older adults with cancer and chronic non-cancer pain: A systematic review. – PubMed – NCBI – J Pain Symptom Manage. Oct 2019

CONTEXT:
Opioids are prescribed to manage moderate to severe pain and can be used with older adults; however, they may lead to several adverse effects, including cognitive impairment.

OBJECTIVE:
To identify, appraise and synthesise evidence on

  • i) the impact of opioids on cognition in older adults with cancer/chronic non-cancer pain, and
  • ii) screening tools/neuropsychological assessments used to detect opioid-induced cognitive impairment.

Continue reading

Tylenol/acetaminophen/APAP is a Dangerous Drug

Is Tylenol ‘By Far the Most Dangerous Drug Ever Made?’ By Josh Bloom — September 11, 2017

Aric Hausknecht, M.D. July 30, 2017:

“Each year a substantial number of Americans experience intentional and unintentional Tylenol (acetaminophen) associated overdoses that can result in serious morbidity and mortality. Analysis of national databases show that acetaminophen-associated overdoses account for about 50,000 emergency room visits and 25,000 hospitalizations yearly.   Continue reading