New study says opioids may make pain worse

WESTBOROUGH, MA April 2, 2018 Much has been written about the incidence of opioid-related death and debility. As of yet I have not directly published my approach to this contagion. 20 years ago we offered a pain management program at the hospital at which I consult.
pain level conceptual meter indicate maximum
 

Graphic from Harvard University Health Blog

 

  It was a coordinated and structured rehabilitation program with daily education, physical restoration, mindfulness exercises, aquatics, family support, and nutritional education – including weight management. What happened was referring physicians sent us all their chronic cases and treatment failures. There is no magic to pain management. There is no mysterious gating mechanism to turn off pain receptors in the brain.  As soon as people learned this we had difficulty filling the program with those who truly wanted to work at reducing their pain and strive to increase their functional independence. Our medical director cited current rehabilitation statistics from 1999-2002 indicating that if someone is out of work for greater than 6-12 months because of pain, the likelihood of their eventual return to work is almost nonexistent.  I found this news to be very discouraging but generally true.
Recently, I was reading the blog post of Vic Crain who is spot on when it comes to many current social issues.  He writes from New Jersey and does not hesitate to comment of a range of topics from guns to opioid addiction.  I enjoy seeing his writing and try to comment on his posts whenever he touches on an area about which I am knowledgeable or simply an area where we share a common interest.  In this case it is the use of pain medicine for chronic pain.  Pain management requires both a team approach and a shift in the current zeitgeist guiding the standard of care for those suffering with chronic pain and its psychosocial sequelae. According Harvard University psychologist Dr. Robert Edwards, “patient surveys also show that people with chronic pain care about more than just experiencing less pain. They care about enjoying life more, having a strong sense of emotional well-being, increasing their physical activity, improving sleep and reducing fatigue, and participating in social and recreational activities.” in an article published in 2015.
Each patient has his or her own story to tell and should be allowed the opportunity to express the frustration that is universal among those in pain.  At the same time the new standard must include a comprehensive review of medication and modalities that will address the pain from integrated approach that is derived from both the cycle of pain that is coupled with increased functional capacity. Regular education and review of team goals are essential.
There is no shut off switch for severe pain. Patients float from one physician or clinic to another spending thousands of dollars seeking the key to ending their discomfort and debility when often the answer is within their grasp.  The internet has allowed many patients to access information about new medications, test procedures, and sometimes obscure treatment methods like never before. Treatment need not be complex but certainly it must include a comprehensive pain management plan.
Reach for the hand of a loved one in pain and not only will your breathing and heart rate synchronize with theirs, your brain wave patterns will couple up too, according to a study published this week in the Proceedings of the National Academy of Sciences (PNAS). Vic Crain, 2018

Using Opioid Medications and Pain Relief

Mr. Crain’s recent post brought into focus the issue of opioid dependence and addiction.  Most of us are aware that deaths from opioid overdose have increased exponentially in the past 5 years largely due to physician-related practices – now thought to be over prescribing of pain medication.  Recently a study was published findings that indicate chronic pain patients’ are no better off when prescribed opioids or an OTC analgesic.  The study followed randomly controlled groups for 12 or more months of treatment.  Some patients were functioning even worse after the study period. Mr. Crain also cites a newly released study indicating that the source of underlying pain, know as small fiber polyneuropathy, may require alternative therapies and not respond to the typical opioid therapy (2017). These syndromes are directly linked to the long-term impact of poorly controlled diabetes mellitus, circulatory problems from DVT, poorly controlled cardiac arrhythmia, and more.
A common underpinning of these afflictions and more is elevated inflammation throughout the body and reduced autoimmune functioning.  The result is errant ANS functioning.  This is an automatic process of sympathetic arousal ramps us up as if to say “bring it on” – activating us to fight or fly the coop if needed to survive.  The problem is that over time an insidious elevation of normal baseline physiological values that create a sympathetic-parasympathetic mismatch adds to patient experience of pain and tension.  A key component to recovery is movement – regular exercise and a routine of progressive mindfulness coupled with a goal of increased functioning. This is a hard sell for many individuals suffering from pain.  Many fail to understand that the lack of movement – and lack of regular exercise, physical therapy, aquatic therapy, yoga, and or other treatments, is far worse than the initial injury they may have sustained sometimes years ago.
What people often do not know is that opioid medication is only one small piece of the pain management puzzle.  I am particularly interested in biofeedback protocols designed to reduce pain and the co-morbid conditions that are linked to it like irritability, tension, shortness of breath, and autonomic dysfunction.  I have had patients tell me they have tried “everything” to reduce their discomfort and often respond with incredulity when I suggest regular use of ice and 20 minutes of walking each day.  Biofeedback may be a useful modality for migraine headaches, anxiety, pain management, concussion, and stress. I have used a combination of physiologic biofeedback and neurofeedback for patients with chronic pain, failure to thrive, depression, post-concussion syndrome, and severe traumatic brain injury” (2014).  The results often bring down levels of stress and tension and have a corresponding lowering of physiological arousal – even blood pressure, pulse rate, and improved sleep and mood.
Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions.  Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is a licensed psychologist who is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist-Trainer (CBIST).

Edwards, R. (2015) The “right” goal when managing pain. December 18, 2015 Harvard Health Blog https://www.health.harvard.edu/blog/the-right-goal-when-managing-pain-201512188865 takenMarch 12, 2018.
Crain, V. (2017) A New cause and treatment for pain. November 10, 2017 Blog post: https://wordpress.com/read/blogs/69301418/posts/13770 taken March 12, 2018 citing Pavel Goldstein, Irit Weissman-Fogel, Guillaume Dumas, Simone G. Shamay-Tsoory. Brain-to-brain coupling during handholding is associated with pain reductionProceedings of the National Academy of Sciences, 2018; 201703643 DOI: 10.1073/pnas.1703643115
Crain, V. (2018) Pain therapy: Holding hands. March 7, 2018 Blog post: https://wordpress.com/read/feeds/21687647/posts/1787094734 taken March 12, 2018
Sefton, M (2014) Blog post: https://concussionassessment.wordpress.com/consultation/topics-in-neuropsychology/tbi/autonomic-dysfunction/ Taken 3-13-18.
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