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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain

November 2018 PPM Letters to the Editor from practitioner peers and patients
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain

MAT: Rejected by Most Recovery Centers

A recent NPR segment highlighted that medication-assisted treatment (MAT) is not always accepted in recovery houses for those fighting opioid addiction. We asked PPM Editorial Advisors for their take:

“I think you will find that most educated individuals in this field will say the same thing: treatment must be individualized. There are obviously certain patients that fall into some categories, such as repeat legal offenders, but most guidelines all point to pharmacotherapy (the term that we should use to replace MAT) as the way to go, with the top choices for addiction treatment being: buprenorphine, methadone, and vivitrol. The problem with the opioid epidemic is one thing: treatment. There is an incredible stigma against the addiction patient in all fields of life, but we need to treat those that want help.” –Frank A. Kunkel, MD

...

“The practice of medicine is extremely biased toward its namesake; medicine. So, of course, there are drugs to get off of drugs. And there are studies designed to show how beneficial the drugs to treat drug use are. In 2014, I became quite ill with gastroparesis. I’ll spare the details but I discussed it on a blog (www.stillexaggeration.com/#/testimonials/).

Board certification in pain management helps because I’m not afraid of pain, but it often surpassed my threshold. I’m so glad I was prescribed Fentanyl patches because they helped to reduce my ER visits and hospitalization over a couple of years. I also tried every healthcare approach I could think of to get well, such as acupuncture, homeopathy, nutritional medicine, and osteopathy (OMT). I was on 19 medications. My second attempt at OMT worked. Fortunately, I was referred to a highly skilled practitioner who used a specific technique.

I was able to get off most of the medications and desperately wanted to get off Fentanyl, but even at the lowest dose patch, I got what I referred to as the heebie geebies at about 73 hours after applying the 72-hour patch. I asked for help and so my osteopath consulted with a pain specialist who suggested OxyContin. I filled the prescription, went home, sat down and stared at the bottle for at least 10 minutes. Then I flushed the MAT down the toilet and went through 3 days of severe discomfort knowing I would soon be free of that terrible drug that helped me so much when I needed it.

Two years later, in December 2017, I had a relapse. Four months later, I went off Fentanyl again, cold turkey. The second time was easier because I knew what to expect. I did not sleep for 3 days and I couldn’t sit still so I did something productive — I cleaned out cabinets. My wife joked I should go through withdrawal more often. It was good to see her laugh as being my caretaker was taking its toll. Grant you withdrawal is not easy, nor for everyone, but there are a lot of people who no longer need the drugs they are on and another expensive and addicting drug is not the only answer.

That’s my experience as a patient in this matter. The experience was quite the reminder that doctors can be patients too. I made it past age 60 without any serious health issues, but sooner or later something happens to all of us. I hope not to have to remind myself a third time that I can withdraw without help. But if I relapse again, then go back into remission I will stop any painkiller the day I stop vomiting, again. One day longer than necessary on Fentanyl is too long.” –Daniel L. Kirsch, PhD, DAAIPM

...

“I have stopped referring pain patients to drug rehabilitation programs, especially if they endorse the Narcotics Anonymous model of treatment (ie, no opioid-based pain medicines, period). Further, I have found that many centers inform patients that pain medicine doctors are equivalent to the evil empire. It is an unreasonable approach, especially if the patient is well selected and monitored carefully. If the patient is not well controlled, I recommend an individual approach based on the pain physician and pain psychologist working together. After 30 years of practice, I still feel that opioid-based pain medicine can be a valuable tool in the pain manager’s toolbox. I address this issue in my new book (‘It Hurts’) and hope you will give it a look.” -Kern Olson, PhD

What’s your take? Email ppmeditorial@verticalhealth.com

 

Chronic Headaches: Cannabis and Other Treatments

Dear PPM,

I have had a chronic headache for four years, including signs of a benign growth in the clival region of the sphenoid. Treatment has included cannabis, which is not ideal for day-to-day function, and a combination of tramadol and gabapentin, which do not seem to be great for pain control.

I’d like to discuss alternatives. How do I get off these medications, and get my life back? I experience side effects from the headache, including lack of focus, fatigue, occasional loss of appetite, weight gain (which I believe is due to the gabapentin), lack of sex drive, and double vision (again, gabapentin). I look forward to starting a dialogue with someone who knows about pain. My current doctors seem to think the answer is more pills. –Andrew Hollis, New Zealand

Dear Mr. Hollis,

Daily headaches are common; the benign growth could be a factor, but usually benign growths are not the main cause of the headaches. We encourage all of the non-medication approaches, whichever are appropriate in your situation. These include exercise, physical therapy, psychotherapy, meditation, biofeedback, acupuncture, and massage. I have written several articles in this journal that discuss these approaches, such as: Deconstructing the Art of Headache Management and Migraine Therapy: What’s Old, What’s New (both published in June 2017).

As far as medication, we usually use a combination of daily preventives, and also abortive therapy. While cannabis may help, it is a third-line therapy, usually reserved for patients refractory (ie, unresponsive) to the usual preventives. Gabapentin is a safe drug, but may not be particularly effective for chronic headaches. Preventives we would consider include duloxetine (to help with headache and depression), low dose amitriptyline (note that weight gain and fatigue may occur), topiramate, sodium valproate, and onabotulinum toxin A (Botox). There are a number of others as well. Generally we would reserve tramadol for 1 or 2 days per week, as it is a mild opioid. Triptans (eg, sumatriptan, rizatriptan, and others) may be appropriate.

If these first and second line approaches do not help, we consider sphenopalatine ganglion blocks for anterior pain, and occipital nerve blocks for posterior pain. The best “natural” remedy is the herb Petadolex (not the parent compound, butterbur; it has to be the Petadolex brand). Cannabis may help, but it probably works better at treating anxiety, than headache pain.

You are in a large group, with millions of other chronic headache sufferers The American Migraine Foundation has an excellent Facebook page, with an attached support group. Good luck. –Lawrence Robbins, MD

 

Central Pain Recall

Dear PPM,

I appreciate the excellent article, New Insights in Understanding Chronic, Central Pain in the September 2018 issue by Dr. Goldenberg and would like to share a case that gave me insight into the profundity of central pain... A 63-year-old man was brought to our Level 1 Trauma Center with a spinal cord injury (SCI) following a car wreck. History revealed he was driving his grandson and, before impact, extended his arm to protect the boy since both were not wearing safety belts. His head struck the windshield. He was unconscious at the scene. CT revealed cervical spinal stenosis most severe at C5,C6.

As a physiatrist, I was consulted for the assessment of his rehabilitative potential. His chief complaint was low back pain. He was able to speak, but confused and agitated. He had strong elbow flexion and 3/5 wrist extension, but no triceps or more distal motor function. He was able to feel sharp in lateral antecubital area and thumb, but had no distal epicritic sparing and could feel no perirectal sensation of any type. I diagnosed complete quadriplegia with last normal level at C6 (graded A on the ASIA Impairment Scale).

Family shared the history that 10 years before, he suffered a severe lumbar spine injury and had intractable chronic low back pain ever since. Even though he had Complete C6 Tetraplegia and had a traumatic brain injury that kept him so confused that he could respond almost solely only to internal stimuli, he continued to complain of low back pain. He died a few days later of respiratory failure.

My colleagues and I feel this case represented one of the purest examples of central pain. Due to the SCI, he was no longer able to feel anything caudal to C6 – neither arms nor chest. Due to the TBI, he never became aware of what had happened to him. The presence of the head injury eliminated confounding factors such as secondary gain. –Jeffrey S. Hecht, MD

Dear Dr. Hecht,

Thank you for sharing your case. I agree with your conclusion that this was a striking, albeit, tragic example of persistent central pain. In a different but relevant setting, subjects with chronic neck pain after trauma had structural regional brain changes suggestive of central sensitization, not noted in those patients with idiopathic chronic neck pain (see Coppieters, et al, Hum Brain Map, 2018). Also, it may be of interest to review a paper in press in Arthritis and Rheumatology by Martucci, et al, that performed cervical spinal cord resting-state fMRI in fibromyalgia patients and healthy controls. Their results demonstrate spinal cord contribution to central sensitization. –Don Goldenberg, MD

A Patient’s Call to Action

“As a long-term sufferer of Crohn’s Disease, living in a hospital bed became all too familiar for myself as well as my children. Three years ago, I was introduced to pain management and my life changed for the better. I went on to achieve remission. A small daily dose of opioids, plus a proactive lifestyle, afforded me the chance to become a patient advocate/activist, author, and a fitness competitor.

Two years ago, millions of pain patients were cut off, abruptly, from essential pain medications and providers began to be targeted by governmental agencies. I couldn’t sit back, so I organized a nationwide protest and the Punish Pain Rally Organization was formed. We started with five members and are now at 7,000.

Hundreds of providers have reached out to me but are fearful to share their stories. I want them to be involved as well so we launched an online Doctors Collaborative, which affords providers a place to support one another in a confidential setting. We hope to work with providers and patients together on legislation to provide relief for the strict prescribing guidelines that have been created. We recognize that providers want to help their patients but have been forced to turn their backs on them. Please join us and be seen, be heard, as we work together in finding a solution. –Claudia Merandi, founder of dontpunishpainrally.com/docs

Last updated on: November 7, 2018
Continue Reading:
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
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