Causalgia (aka CRPS II or RSD) should be very high on your list of things that you do not want. If you're the sort who runs without being chased, come out this Sunday and support the USC Pain Center.
Also, MacGyver will be there!
Love,
Adam
Dear [Dr's assistant],
....The pharmacy has a prescription of Darvocet for me. But, I'd actually like to avoid both the propoxyphene and APAP in Darvocet. I'd appreciate it if you could ask Dr. xxxxxx to cancel that prescription and write me one for something different. He might find the following useful:
The Vicodin prescription [which I had been written for the initial pain of the injury] worked fine. Still, I had forgotten that there is some evidence of an interaction between acetaminophen and xxxxxx. See, for example, [3]. So I'd prefer something without APAP. It's not a big deal, but I'd prefer to keep on the safe side.
I'd prefer to avoid anything containing propoxyphene for two reasons. First, it's somewhat contraindicated with xxxxxxx (propoxyphene can potentiate the xxxxxxxxxx). Second, there are some concerns about its cardiotoxic metabolites. See [1] and [2]. I know it's a tiny risk. But, again, I'd prefer to stay on the safe side wherever possible.
To make things just a bit more complicated: I don't think anything with straight codeine will be very useful. I'm fairly certain that both my mother and my sister are poor metabolizes, so I don't want to trust my CYP2D6's any more than I have to. Moreover, according to Cochrane Reviews [7], with a NNT=12, codeine just doesn't seem very trustworthy.
Finally, just in case this is relevant, I'd prefer to use the narcotics to hit the acute pain hard for 1-2 days and then get off of them as quickly as possible. There seems to be evidence that early aggressive treatment helps cut the overall duration of post surgical pain and, more important to me, reduce the risk of chronic pain (see, e.g., [4], [5], [6], [8]). Thus I'd prefer very few doses of something strong to more of something weaker.
These are just some very weak preferences based on my rudimentary understanding of pain management protocols. I trust your judgment completely.
Thanks
Adam
References
[1] http://www.citizen.org/publications/publicationredirect.cfm?ID=7420
[2]http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm170268.htm
[3] Miners JO, Attwood J, Birkett DJ. Determinants of acetaminophen metabolism: effect of inducers and inhibitors of drug metabolism on acetaminophen's metabolic pathways. Clin Pharmacol Ther. 1984; 35:480-486.
[4] Leibeskind, J. C. (1991). "Pain Can Kill." Pain 44: 3-4.
[5] Merskey, H. (1999). Pain and Psychological Medicine. Textbook of Pain. P. D. Wall and R. Melzack. Edinburgh, Churchill Livingstone: 929-949.
[6] Harman, K. (2000). "Neuroplasticitiy and the Development of Chronic Pain." Physiotherapy Canada 52(64-71).
[7] Derry, S., R. A. Moore, et al. (2010) "Single dose oral codeine, as a single agent, for acute postoperative pain in adults." Cochrane Database of Systematic Reviews DOI: 10.1002/14651858.CD008099.pub2.
[8] Kehlet, H., T. S. Jensen, et al. (2006). "Persistent postsurgical pain: risk factors and prevention." Lancet 367(9522): 1618-1625.
Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain.
Patient Voices: Rheumatoid Arthritis
Oklahoma House gets bill restricting injections for chronic pain | NewsOK.com: "
Only physicians would be allowed to administer precise pain management injections under a bill approved Tuesday by a House committee.
The House Public Health Committee approved Senate Bill 1133 by a 14-5 vote. It now goes to the full House.
Rep. John Trebilcock, who took over authorship of the bill, said pain management injections into a patient’s spinal or neck area must be precisely administered.
'Chronic pain medication is medicine and should be practiced by doctors,’ said Trebilcock, R-Broken Arrow.
The measure was carried over from last year after it failed to win passage. Efforts to come up with a compromise among a hospital group, doctors and certified registered nurse anesthetists fizzled. Certified registered nurse anesthetists now administer spinal injections to manage pain.
Trebilcock said the practice of chronic pain management is 'extremely dangerous.’
An injection in the wrong spot could cause paralysis or not effectively treat the pain, he said.
Trebilcock said certified nurse anesthetists would be allowed to continue to give other injections. It’s estimated the chronic pain injections take up only about 4 percent of their duties, he said.
Marvin York, a lobbyist for the Oklahoma Association of Nurse Anesthetists, said the measure would be a hardship to rural patients, because few rural doctors practice in pain management.
'I can’t imagine why any rural legislator ... could possibly be for this bill,’ he said.
Victor Long of Norman, a certified registered nurse anesthetist, said about 80 percent of the spinal injections for pain are administered by certified registered nurse anesthetists. About 500 certified registered nurse anesthetists are in the state, he said.
Rep. Pat Ownbey, R-Ardmore, said he wondered why the bill was necessary because no complaints had been filed against certified registered nurse anesthetists administering chronic pain management injections.
'Is this a patient issue or a money issue?’ he asked fellow committee members. 'Make no mistake, this is a turf war.’
Trebilcock said doctors are willing to travel to rural areas to administer the injections.
'Rural Oklahoma shouldn’t have to settle for less than a doctor when they suffer from chronic pain,’ he said."
Treating Psychiatric Symptoms: "
Welcome to the continuing series Why You Should See a Pain Management Psychiatrist. Last week we learned that psychiatric symptoms - such as depression, anxiety, etc. - often accompany chronic pain. This week we’ll look at how to treat psychiatric diseases.
As we saw, depression (8-50% of patients with pain), anxiety (19-50%), PTSD (10%), sleep disturbance (50% or more), drug and alcohol problems (3-19%) are common in patients with pain. Let’s look at some important issues related to treating these problems.
1. Identifying symptoms
To be able to treat psychiatric symptoms, they first have to be identified. Your doctor should be asking about these common symptoms and referring you if appropriate. You should also report if you’re having such symptoms. Don’t be embarrassed or feel like you’re complaining. Getting help is important!
2. Taking symptoms seriously
If you’re having significant depression, anxiety or other symptoms, it’s important to report these to start to get treatment for them. These symptoms should not be dismissed as, ‘of course you have depression - it’s because of your pain.’ Chronic pain does not automatically mean depression, anxiety and disturbed sleep. There’s treatment for these symptoms.! And they should be treated!
3. Treat all the disorders that are present.
We know that if psychiatric problems are present along with pain, it’s crucial to treat both. Treating just 1 doesn’t make the other go away. For example, if someone has depression and pain, treating just pain doesn’t necessarily mean the depression will go away. And sometimes neither gets better unless you treat both.
4. Treatment
There are both therapies and medications to treat nearly all psychiatric diseases. Medication should be used only along with therapy. I strongly recommend trying therapy first, before medication, to see if just therapy alone can work. There are times, when psychiatric symptoms are severe, that both will be started at once, but that’s less common. Most people with pain disorders are already on several medications and sometimes already tolerating side effects, so trying non-medication treatment first makes sense.
Other articles in the series:
"
- Why comprehensive treatment works better
- Benefits of a psychiatric evaluation
- Treatment of psychiatric symptoms
- Using psychiatric medications for pain
- Learning psychological skills
- Making positive behavioral changes
- Making positive psychological changes
- Benefits of supportive therapy
- Benefits of a pain support group
- New brain-based treatments
(Via How To Cope With Pain Blog.)
Translating nociceptive processing into human pain models.: "
Exp Brain Res. 2009 Apr 29;
Schmelz MAs volunteers can easily communicate quality and intensity of painful stimuli, human pain models appear to be ideally suited to test analgesic compounds, but also to study pain mechanisms. Acute stimulation of nociceptors under physiologic conditions has proven not to be of particular use as an experimental pain model. In contrast, if the experimental models include sensitization of the peripheral or central pain processing they may indeed mimic certain aspects of chronic pain conditions. Peripheral inflammatory conditions can be induced experimentally with sensitization patterns correlating to clinical inflammatory pain. There are also well-characterized models of central sensitization, which mimic aspects of neuropathic pain patients such as touch evoked allodynia and punctate hyperalgesia. The main complaint of chronic pain patients, however, is spontaneous pain, but currently there is no human model available that would mimic chronic inflammatory or neuropathic pain. Thus, although being helpful for proof of concept studies and dose finding, current human pain models cannot replace patient studies for testing efficacy of analgesic compounds."
(Via HubMed - pain.)
ScienceDaily (Feb. 3, 2008) — UCLA and University of North Carolina researchers have found that women with irritable bowel syndrome (IBS) who have experienced sexual and/or physical abuse may have a heightened brain response to pain that makes them more sensitive to abdominal discomfort. IBS is a condition that affects 10 to 15 percent of the population and causes gastrointestinal discomfort along with diarrhea, constipation or both.Link
Researchers used brain imaging to show that patients with IBS who also had a background of abuse were not as able to turn off a pain modulation mechanism in the brain as effectively as were IBS patients who had not suffered abuse.
According to previous studies, more than 50 percent of patients with IBS have been physically or sexually abused at some time in their lives. The new finding may help explain why those in this subset of IBS patients experience greater pain and poorer health outcomes than others with the disorder.
Such insight provides a greater understanding of how the disorder develops and may offer new pathways for treatment. Brain imaging studies were performed at the UCLA Brain Mapping Center.
The research appears in the Feb. 1 online edition of the journal Gastroenterology. Authors include Dr. Emeran Mayer, professor of medicine, David Geffen School of Medicine at UCLA; Dr. Douglas Drossman, professor of medicine, and Dr. Yehuda Ringel, lead study author and assistant professor of medicine, both at the University of North Carolina at Chapel Hill.
The study was funded by the National Institutes of Health (NIDDK and NCCAM).
How To Cope With Pain: A guide to coping with pain.
http://www.howtocopewithpain.org/blog/51/your-name-isnt-aristotle-youll-still-find-this-info-about-pain-and-your-brain-intriguing/
http://www.howtocopewithpain.org/blog/53/no-one-understands-your-pain-heres-the-philosophical-reason-why/
Your Complete Guide to TNI'm looking for information on deep brain stimulator treatments of TN. Please email me if you have any links/articles/journals that might help.
TN Support Association
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