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Understanding Chronic Pain & How Best to Manage It

Hint: Painkillers Kill More Than Pain

pain Medications on Plate

pain medications on plate

A recent article on pain drugs in The Wall Street Journal (“Journal”) read like an expose of medical misinformation from pain specialists at America’s leading medical centers. It had all the makings of a medical soap opera…

  • A repentant physician advocate for broader prescribing of opioid painkillers – primarily Vicodin, Oxycontin and Percocet – for not just acute medical conditions (e.g., cancer and post-surgery), but for chronic pain as well. This advocacy is described by one of its former adherents as having “the makings of a religious movement”;

  • A pharmaceutical company that introduced a timed-release version of the opioid derivative Oxycontin admitting it “misbranded” Oxycontin as less addictive and less likely to be abused than other pain medications – and paying $635 million in fines for doing so;

  • The national Federation of State Medical Boards going so far as to reassure doctors they’d face no penalty for prescribing large amounts of narcotics in the course of treatment – making aggressive opioid prescribing for chronic pain as mainstream a medical practice as possible; and

  • Substantial financial underwriting of all these acts by pharmaceutical companies that manufacture what many experts now describe as dangerous drugs responsible for more deaths every year in America than all illegal drugs combined.

Here’s how Dr. Russell Portenoy – the pain specialist the Journal article focuses on for his leadership role in promoting widespread opioid prescribing – described his prior advocacy:

“‘I gave innumerable lectures in the late 1980s and ’90s that weren’t true’…Dr. Portenoy said it was ‘quite scary’ to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths. ‘Clearly, if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do’.”

As the Journal noted, “Recent research suggests a significantly higher rate of addiction than previously thought, and questions whether opioids are effective against long-term chronic pain…Many of these experts now say (their prior) claims weren’t based on sound scientific evidence.”

Drinking Their Own Koolaid

Dr. Portenoy, the pain specialist highlighted in The Wall Street Journal article, noted his own mother has been on opioids for many years. So he presumably believed his own lectures – ill-informed as they were.

But after correcting what he admitted wasn’t “true” and was “clearly the wrong thing to do”, he defends himself  against charges the millions he received from opioid pharmaceutical manufacturers may have biased him. He states in the Journal that these financial relationships, while benefiting him financially, did so “without producing in me any tendency to engage in…misinformation”.

So although he admits to engaging in medical misinformation and regrets doing so now, he then states that he didn’t engage in misinformation.

This is a classic example of how easy it is to rationalize our behaviors and overlook what may be inducing us to behave that way.

“Only in America” could those who misled doctors – whether purposefully or not – about the very real risks of a class of drugs responsible for more deaths every year than all illegal drugs combined turn around and disavow it all, avoid penalty and manage to make a new career out of disavowing their previous mistaken advice.

The following video from Physicians for Responsible Opiod Prescribing shows Dr. Portenoy and others describing the risks of opioids for chronic pain in their own words…

What Can YOU Do?

Opioids are a reasonable option for select cases of acute cancer pain (although they may accelerate the spread of tumors [1]) and after surgery. But for chronic pain – like nerve and back pain – their use is more problematic.

Some people are able to benefit with long-term opioid use without becoming addicted, but there’s no research identifying who they are beforehand. So it’s a bit of a crap shoot as to whether you’re likely to become addicted or even die – as over 16,000 Americans do every year from opioid medications.

Your best bet is to limit opioids to only short-term use as a transition to a less risky long-term approach to managing your chronic pain. America’s medical system isn’t well-equipped to help you in this journey, however.

The Institute of Medicine estimates that 116 million Americans suffer with chronic pain – more than heart disease, all cancers, and diabetes combined. Yet it also reports that we have no well-informed or coordinated system for treating chronic pain.

Instead, patients with chronic pain are viewed as a nuisance and a legal liability because most doctors simply don’t know what to do with them. Doctors don’t have the time to conduct the thorough exam and interviews needed to really determine the cause of chronic pain and explore treatments that might help relieve it.

So patients are referred to specialists. And the specialists generally have no idea what to do either.

There’s much that modern medicine still must learn about relieving chronic pain without harming patients. Its default solution remains dangerous medications – not just opioids, though those are the most dangerous – that may temporarily mask pain symptoms while causing other, often more dangerous medical conditions.

This is not unlike the broader misuse of medications described in Our Healthcare Sucks.

The Vicious Cycle of Pain

Pain is part of life. But chronic pain can come to dominate your thinking and behavior such that pursuing an active lifestyle may be out of the question.

It’s pretty near impossible, for example, to get the kind of restful and restorative sleep your body and brain require if chronic pain interferes with your sleep process.

Pain – and worrying about pain – interferes with a good night’s sleep; and lack of a good night’s sleep makes you more vulnerable to pain sensations – increasing your perception of pain – during the day.[2]

A similar vicious cycle occurs with stress. Pain is a form of stress. The hormonal dysfunction caused by chronic pain contributes to your experiences of pain by promoting fatigue, depression, sleep deprivation, weight changes, and irritability.

Depression is common among those suffering chronic pain. It also magnifies pain and makes it harder to cope with pain, especially if it’s limiting your independence.

The link between pain and depression is so strong because they share many of the same chemical messengers that connect nerves in the body (neurotransmitters) and some of the main nerve pathways.

This has led to the use of antidepressants to reduce the brain’s perception of pain. The so-called “dual-uptake inhibitors” (Cymbalta/duloxetine and Effexor/venlaxafine) have a host of side-effects, however, that include…

  • Increased blood pressure,

  • Possible liver and/or kidney toxicity,

  • Worsening of depression,

  • Possible increased suicide risk, and

  • Increased risk of unsteadiness and falls in older adults taking Effexor/venlaxatine.

The following video from our friends “Down Under” succinctly explains why drug-based approaches to chronic pain are best employed only as a transitional measure.

Drug-Free Approaches to Pain

Exercise releases the same brain chemicals as antidepressants and offers a lower-risk alternative that naturally stimulates production of chemical messengers in the brain considered central to pain management.

But physical exercise, of course, is severely limited by physical pain. This causes many people to regress into a low-activity mode that leads to physical deterioration, increased risk of injury and – you guessed it – more pain.

Fear of pain is a normal reaction that’s actually protective when it causes you to avoid harmful physical activities like running and other activities that stress your joints.

But excessive fear of pain causes many people to avoid healthful physical activity as well. As a result, many regress into a sedentary lifestyle that generally worsens the cause of pain (e.g., arthritis). It also increases your risk for other life-threatening diseases like cardiovascular disease, diabetes, and cancer.

Resolving this “chicken and egg” problem is essential because the ultimate “treatment” regimen for pain management is the same as it is for health promotion generally: an anti-inflammatory lifestyle incorporating as many healthful behaviors as possible for maximum benefit.

Lower Your Medical Bills

Pain is a major cause of physician office visits, medication use and abuse, and emergency room visits and hospitalizations.

It is a prime driver of healthcare system use and a prime obstacle to the kind of healthful lifestyle behaviors that can reduce dependence on that healthcare system.

It’s essential, therefore, to employ measures to resolve chronic pain with the best evidence of a favorable risk-to-reward profile. Which is why I’m working on an eBook outlining a transitional plan to help wean readers off dangerous anti-inflammatory painkillers and onto a more active anti-inflammatory lifestyle.

If you’d like to be notified when it becomes available, click here.

And in any event, be cautious in relying on medications to cope with chronic pain. Whether opioids or aspirin, none of them are risk-free. And they may just perpetuate the vicious cycle of pain without real resolution.

[1] Morphine May Help Tumors Spread in Cancer Patients. 11/18/09.

[2] Sleep restriction attenuates amplitudes and attentional modulation of pain-related evoked potentials, but augments pain ratings in healthy volunteers. Pain. Published online 10/28/09. DOI: 10.1016/j.pain.2009.10.013.

What’s YOUR experience with chronic pain? Leave a comment below

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