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Doctors' Answers to "Frequently Asked Questions" - Chronic Pain

These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

Treatment of Chronic Pain with Narcotics [posted 1/14/99]
Question: My husband has been in chronic, debilitating back pain for 10 years. He has had many back and knee surgeries (Failed back) and now is disabled. He is only 43. He is on the duragesic 75 mcg/hr patch, ms contin 100 mg, msir 30 mg. I'm concerned that he is over medicated and what will happen long term with this kind of medication in his system? i.e. - organs, etc. Can you shed some light on this for us?

Answer: Well, they're all narcotics. If he isn't sedated, he isn't receiving too much. That does not mean that he will not become dependent, he will. However, there are few other options for treatment for chronic pain.

Compression Fracture [posted 1/13/99]
Question: In 1989 I suffered a compression fracture and soft-tissue damage to the T5, T6, and T7 vertebrae. This as a result of a fall when I landed on my buttocks in a sitting position. At the time I heard a distinct crunch and tear. Treatment was 3 months bed-rest. Although I went back to work after that for 6 months I eventually gave in to chronic pain, muscle spasms, and fatigue. I have since received the various treatment, the best being a specialized exercise program and chiropractic care. To help cope with the chronic pain my doctor prescribes codcomol (250 mg paracetamol, 250 mg aspirin, 8 mg codeine). Although the fracture is in the thoracic area I suffer headaches, neck, mid and lower back pain, and muscle spasms in those areas as well as the back of my legs and at times the back of the arms. My condition can vary from day to day and week to week. I had an MRI two years ago, no conclusion and various blood tests. Can you offer your opinion on what is wrong and possible treatment before I go crazy?

Answer: You have had trauma and damage to the back and lower nerves of the body. This is probably permanent and treatment is limited at best.

Chronic pain - hip, waist, knees [posted 1/8/99]
Question: I have chronic pain in my hip and waist and it has moved to both knees. I have had a very traumatic illness with gall bladder surgery, acute pancreatitis with a cyst on my pancreas that is still there and gives me some discomfort. I have been to several doctors and a pain clinic. I have been given all sorts of antidepressants and they all have given me side effects, which are unbearable. Stiffness in my jaw, stomach cramps, diarrhea. The pain clinic said I didn't have fibromyalgia, which was good, but she also said she couldn't find anything. I have real pain and it is every day, all day. Some of the antidepressants helped relieve the pain, but the side effects were terrible. My family doctor is limited in what to do next. Can you please help me? Here are all the drugs I have been on: Effexor, neurontin, Trazadone, Amitriptyline, and paxil. The amitriptyline made the pain go away, but after 2 months on the drug my tongue twisted and my jaw was so rigid I clenched my teeth so hard they hurt.

Answer: Chronic pain following pancreatitis is fairly common. See a pain specialist for consideration of a nerve block

Neuropathy - Chronic Pain [posted 8/5/98]
Question: I had an ependymoma taken out of the spinal chord at L2 - L5. I now suffer from neuropathy, which could have been brought on by the surgery or the radiation treatments. What treatments are available to deal with the chronic pain? I teach school and sometimes it is very difficult to make the day. I am being treated with Neurontin, Tegretol XR, and Pamelor. This still is not getting me through many of the days. What can I expect?

Answer: Well, someone has started you on the usual treatments. Others that are of occasional help are acupuncture, TENS electrical stimulators, steroid injections, and last but not least Morphine - addicting, but effective. If you are going to suffer chronic pain, I would try all of these to see what is effective. A pain specialist will need to administer the steroid injection.

Debilitating Pain [posted 7/27/98]
Question: Patient is 44, male, presents chronic generalized muscle and joint pain. History of hyperuricemia, depression and asthma. Present condition: blood in urine, general FMS/CFIDS, chronic pain in muscles, bones, joints worse when pressure is applied. Sedentary occupation. Present medications include: Oruvail, Doxyfene, Molipaxin 100 mg, Zyloprim 300 mg, Lanzor 30 mg, Flixotide, Ventolin, Papaverin/Prostin inj. Pain therapy does not provide any relief. Rheumatologist at a loss to know what to prescribe next. Pain and discomfort leads to tears, defensiveness.

Answer: Unfortunately, I'm not familiar with Doxyfene or Molipaxin. These are either not available in the US or go by different names, which is unfortunately a common practice with drug companies. However, sounds like either pain from depression or fibromyalgia or both. I assume a work up has been done to exclude Addison's Disease and Thyroid Disease. Next, I would work with massage therapy and/or acupuncture. Sometimes very helpful if the patient can afford it. Also, if he is not on an antidepressant I would try several different ones for both pain relief and possible treatment of depression.

Medications for Chronic Inflammation and Pain
Question: If I can no longer take NSAIDS for chronic inflammation and pain, what are my alternatives. Is there an antiinflammatory patch?

Answer: Acetaminophen, Ultram, Duract, will help with the pain, but not the inflammation. There is no patch currently. If your problem is due to gastritis (hence the patch, but not the oral) have you tried using Cytotec with the NSAIDS? It is protective in most patients.

Chronic Pain Treatment
Question: I've suffered from daily chronic pain related to crohns and rheumatoid arthritis since March 1997. Before the specialists had discovered the cause, I was given Talwin (50 mg) every six hours. Now that my doctor realizes that the condition is chronic, he no longer wants to treat the pain for fear of causing addiction (but the pain is just as bad as before). He has taken me off the Talwin, and given me only 2 Tylenol #3 per day, and said he will not even be refilling that. Well, this does nothing for me. First of all, is Talwin really addictive if used properly? Second, is there any other pain reliever I might be able to convince him to prescribe (that will work) that he would be less concerned about addiction?

Answer: Are you taking any non-steroidal anti-inflammatories? This is the usual treatment. Yes Talwin is addictive-Tylenol much less so, but somewhat. There are several new potential drugs to try. Ultram and Duract are the newest and so far don't seem addicting. Failing this, a pain clinic might be the next place to try.

Chronic back pain
Question: I had a partial discectomy (L4-L5) about two years ago and am plagued by chronic back pain. I have heard that research in Europe is being done on a medication that blocks low level chronic pain signals from reaching the brain. How close is this research to being completed? Is there similar work being done in the Untied States? If so, are there clinical trials being done? Can I get information about participating in a trial? Are there similar medications available in the US today? What is the name of the drug?

Answer: Sorry, no data about this nor any guesses about who to contact other than the FDA.

Chronic pain
Question: I had back pain that occurred on the job in 1992. In the State of Washington there is no "Safety Net" for injured workers and I have managed to work after 4 months of disability. The case has been closed and this in no way was an attempt to gain information for purposes other than self help in pain management to continue working. This inquiry does relate to problems with my HMO, Group Health Northwest and my doctor. The problem, pain management, is becoming more of an issue with me.

When I was first returning to work in 1993, most of the work I was able to get was temporary, with no medical benefits. The most economical way to control pain was Tylenol 3 and Feldine. Depending on the type of work I found, I am a Computer Specialist by trade. When I had to sit for long periods of time, I required more medication. If mobile less medication, and in one position no medication. I have been subjected to all "Managed Care" has to offer in their arsenal for readily available drugs. I have been with my current doctor, for almost 2 years now. I was able to convince him to have more testing done via a Neurosurgeon. The prognoses after all these tests was not to operate, although degeneration in the original injury area is very evident. I agreed to have another epidermal steroid injection, and I’ve had this done this several times before. I had a epidermal steroid injection last month that caused problems, including more pain.

Last year I went in to get a Cortisone injection because I had to work out of town for a couple of weeks. My doctor said that he did not want to do the injection, but prescribed 60 Tylenol #3 x 4. I have never had more than 90 in a month prescribed to me before, but I quickly got used to taking this amount. About 3 months later I saw my doctor and he said this was too many, and suggested I had a problem. I told my doctor I was aware of the problem and was willing to do what ever was needed to decrease the amount of medication. His attitude towards me, the patient is now obvious contempt, disgust and dislike. I am still trying to figure out what do because I know the doctor - patient relationship is gone. I just had this injection in my spine by another doctor who claims to be autonomous in the whole matter. I have to fly out to Salt Lake City Tuesday and drive 200 miles to a town called Box Springs, Wyoming and smile at the customer while I install his entire computer system. I have a doctor who claims I’m now a dope addict and he will only prescribed 90 Tylenol #3 per month. What am I suppose to do about leg cramps, moving and sleeping?

Answer: You have a common problem. This problem is common to patients with chronic pain who experience the social paranoia caused by the anti-drug campaigns of the last thirty years. Patients who experience chronic pain will need pain medications. Usually, some type of non-steroidal anti-inflammatory and/or narcotics. Unfortunately, many physicians do not understand chronic pain and the appropriate treatment. I would ask for a opinion from a pain specialist. Also, have you tried a TENS unit? Sometimes this is very helpful.

Pain Managment
Question: I am doing a assigment on Pain Management. Can you tell me the meaning of Pain Perception, pain threshold and pain tolerance? Also, can I know what are the types of Pain Management?

Answer: Pain and its management comprise an entire subspecialty of medicine, and is a very complex problem from which a great many individuals suffer. It would be difficult to even summarize appropriately all the many facts we now know about the bodily production of pain, how it is perceived, and how it is treated. To answer the definition questions, pain perception is that ability of our nervous system, to detect pain, and hopefully act to remove its cause. An example of this would be stepping on a nail; most of us would know about the nail in an instant, drop to the floor and proceed to inspect the area where the pain is “perceived”. This is due to the pain perception ability of the nerves in our foot communicating to the spinal cord, and in turn to our brain, to notify it of a problem. The brain in turn, sends a command for action- to do something to remove the problem causing the pain. Pain threshold is that level or intensity of pain required for our nerves to be able to detect it. You may not be aware that a mosquito is biting you, for example, until the pain reaches your pain threshold. Pain tolerance is as the term describes, our ability to endure pain. This tolerance increases for example, with chronic pain. Also, at the level of the individual nerve, for example in the skin of our foot, tolerance to chronic pain occurs, allowing persistent painful signals to impart less of a “conscious” effect on the brain and thus diminish our awareness of it. There are many modalities, or ways that pain is managed. In the acute setting, the health care provider will often provide medication to ease pain until whatever problem caused the pain is corrected, such as a fracture, kidney stone, or gallbladder stone. Since the injury, and therefore its pain are temporary, there is less (but not none) concern for dependency on pain medication, or for lasting effects of the pain medication. Chronic pain conditions however, have been the subject of an entire discipline of the medical field. Regardless of cause, chronic pain can become a disease unto itself, with all of the physical, emotional, and psychological problems that arise from its presence. Effective pain management on a chronic basis requires a team effort from the patient, his or her health care provider, as well as the patient’s friends, family, and if necessary, a physician specializing m pain management. From medications and physical therapy, to nerve and spinal devices, the health care provider can do more for the patient with chronic pain than ever before, and hopefully in the not-to-distant future, no one will have to live with chronic pain.

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