Posts Tagged ‘Chronic pain’

This article appeared first in “The Conversation” on April 25, 2018, under the title “Why it’s so hard for doctors to understand your pain”. 

We’re all human beings, but we’re not all alike.

Each person experiences pain differently, from an emotional perspective as well as a physical one, and responds to pain differently. That means that physicians like myself need to evaluate patients on an individual basis and find the best way to treat their pain.

Today, however, doctors are under pressure to limit costs and prescribe treatments based on standardized guidelines. A major gap looms between the patient’s experience of pain and the limited “one size fits all” treatment that doctors may offer.

Concerns about the opioid epidemic make the problem worse. Opioids – including heroin and fentanyl – killed more than 42,000 people in the U.S. in 2016. Four in 10 of these deaths involved prescription painkillers such as hydrocodone and oxycodone. Physicians are increasingly reluctant to prescribe opioids for pain, fearing government scrutiny or malpractice lawsuits.

Where does this leave the patient whose experience of pain is outside the norm? How can physicians in all specialties identify these patients and do our best to manage their pain, even when their needs don’t match our expectations or experience?

Pain differences

Some pain is a natural part of healing. But that pain can vary depending on who is experiencing it.

Let’s start with a question that for years perplexed physicians who specialize in anesthesiology: Do redheads require more anesthesia than other patients? Anecdotally, many anesthesiologists thought they did, but few took the question seriously.

Finally, a study examined women with naturally red hair compared to women with naturally dark hair when under standardized general anesthesia. Sure enough, most of the red-haired women required significantly more anesthesia before they didn’t react in response to a harmless but unpleasant electric shock. DNA analysis shows that nearly all redheads have distinct mutations in the melanocortin-1 receptor gene, which is the likely source of the difference in pain experiences.

Cultural norms also can determine how different groups of people react to pain. In the U.S., for instance, boys playing sports and young men in military training traditionally have been encouraged to act stoically and “shake it off” when hurt, while it has been more socially acceptable for girls and women to react emotionally in comparable circumstances. As a result, medical personnel may subconsciously take male complaints of pain more seriously, assuming that a man must be in severe pain if he’s complaining at all.

Many people believe that women’s pain is consistently undertreated, and often blamed on “hormones” or “nerves.” Women more commonly suffer from fibromyalgia, autoimmune diseases including lupus and inflammatory arthritis, and migraine headaches, among other painful conditions that can be hard to control. Recently, research has identified genetic explanations for why these conditions strike women more often than men.

More women than men had at least one prescription for opioids filled in 2016. Though women are less likely to die of opioid overdose, they may become dependent on prescription opioids more quickly than men.

Race and ethnicity, too, can play a role in the experience of pain. The unequal treatment of pain, even cancer-related pain, among minority patients is part of the tragic legacy of racial discrimination in the U.S. In 2009, a major review article concluded that “racial and ethnic disparities in acute pain, chronic cancer pain, and palliative pain care continue to persist.” For example, minority patients who presented to emergency departments with abdominal pain are 22 to 30 percent less likely to receive analgesic medications than white patients with similar complaints.

In spite of research showing that non-Hispanic white patients show less sensitivity to pain than do black patients and patients of Hispanic ancestry, these inequities persist. The stereotype of the stoic Northern European patient may have a basis in genetics more than personality. The minority patients demonstrated a lower threshold for experiencing pain and a lower tolerance for acute pain, suggesting that they need more medication for adequate pain relief.

The hope of genetic research

My guess is that the next decades will bring an explosion in research illuminating the genetic mechanisms behind pain experiences. Genetic differences can help explain why some patients develop certain diseases while others, exposed to the same environmental factors, never do. Some patients undoubtedly are more sensitive to pain from the start than others, based on genetic factors that the medical community doesn’t yet understand.

At UCLA, where I work, the Institute for Precision Health obtains a sample of blood from nearly every surgical patient. By analyzing each patient’s genetic data, we hope to explain why patients often respond so differently after the same type of surgery, injury or illness.

Furthermore, chronic pain is associated with long-lasting changes in gene expression in the central nervous system. Simply put, the experience of pain changes a patient’s nervous system at the molecular level. These changes are linked to behavioral expressions of pain. Emotional factors – including a history of previous traumatic stress or depression – increase the chances that a patient will become dependent on opioids after experiencing pain.

The best physicians can do in the short term is to respect what patients tell us and try to gain insight into any of our own biases that could lead us to underestimate a patient’s experience of pain.

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Fame and fentanyl

Poppies, the original source of opium…  

A fentanyl overdose led to the recent death of musician and singer Prince, according to the medical examiner’s report released June 2. The drug seems likely to become as notorious as propofol did after the death of Michael Jackson in 2009.

For all of us in anesthesiology who’ve been using fentanyl as a perfectly respectable anesthetic medication and pain reliever for as long as we can remember, it’s startling to see it become the cause of rising numbers of deaths from overdose.  Fentanyl is a potent medication, useful in the operating room to cover the intense but short-lived stimulation of surgery. The onset of action is very fast, and the time that the drug effect lasts is relatively brief.

But fentanyl was never intended for casual use. Fentanyl is many times more potent than morphine; 100 micrograms, or 0.1 mg, of IV fentanyl is roughly equivalent to 10 mg of IV morphine. In March, the LA Times reported that 28 overdoses — six of them fatal — occurred in Sacramento over the course of just one week. The victims had taken pills that resembled Norco, a common pain reliever, but in fact the pills were laced with fentanyl. Even tiny amounts were enough to be lethal.

Like all opioids, fentanyl reduces the drive to breathe, and after a large enough dose a patient will stop breathing entirely. In addition to its effect on respiratory drive, fentanyl may also produce rigidity of the muscles in the chest and abdomen, severe enough to hamper attempts to ventilate or perform CPR.

What exactly is fentanyl?

Fentanyl is an inexpensive member of a class of drugs called “opioids”, which are powerful pain relieving medications. The word “opium” is derived from the Greek word for juice, because the juice of the poppy flower was the original source of opium. Starting in Mesopotamia, the opium poppy has been cultivated since at least 3000 BC. The term “opiate” is used to designate drugs derived from opium. Morphine was the first of these, isolated in 1803, followed by codeine in 1832.

The development of techniques to synthesize drugs in a laboratory, as opposed to the cultivation of poppy fields, has led to the use of the term “opioids” to refer to any and all substances that treat pain by acting on opioid receptors in the central nervous system. The term “narcotic” is often used as a synonym. It’s derived from the Greek word for stupor, and is used to refer to any morphine-like drug with the potential for addiction.

Fentanyl is cheap, and the powdered form is being synthesized in clandestine laboratories in the U.S. and Mexico according to news reports. What’s leading to the spate of new overdoses is the fact that some dealers are quietly adding fentanyl to heroin to increase the “high”. A user injects what he thinks is his usual quantity of heroin, not realizing that it may be mixed with fentanyl. The mixture is far more potent and may be deadly.

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It’s amazing how quickly my role switched from physician to patient, thanks to a silent assailant: osteoporosis.

I went to the gym in the morning before work 12 days ago, as I often do now that my children are all grown up and out of the house. First, a couple of light sets of leg exercises served as a warm-up, and then I started a set with a barbell on my shoulders. I’ve been doing weight training for years, since my mother suffered badly from osteoporosis and I knew I was at risk. Weight training, along with calcium and Vitamin D, can help maintain bone density.

The weight was average for me, and I was halfway through my second set of 12 repetitions when suddenly there was a loud noise, like a sharp crack or pop, that people in the gym heard 10 feet away. I felt my mid-spine collapse downward what seemed like an inch, accompanied by sharp pain. The trainer grabbed the weight, helped me lie down, and called my husband.

I did a quick self-assessment.

Can I move everything? Check.

Is anything numb? No.

Can I do a straight leg raise without more pain? Yes.

This confirmed that I didn’t have any spinal cord injury and probably didn’t have a herniated disk. The most likely diagnosis was a spinal compression fracture, which turned out to be exactly what happened.

Off to the emergency room

My husband insisted on driving immediately to the emergency room, which gave me a little time to reflect.

By coincidence, September is “Pain Awareness Month”, and I had been wanting to write a piece in support of the American Chronic Pain Association and the American Society of Anesthesiologists‘ recognition of pain as an endemic problem. Chronic pain ruins lives, and inappropriate treatment of pain with narcotics too often leads to addiction, overdose, and death.

But what to write?? I treat acute pain in my daily work as a physician anesthesiologist looking after patients in the immediate recovery timeframe, right after surgery. Sometimes I take Aleve for a headache, but that’s about it. Now, of course, it seemed much likelier that I would have a story to tell.

Luckily for me, the Cedars-Sinai Medical Center emergency room was relatively quiet at 6 a.m. The staff whisked me off to X-ray, and the technician quickly took supine and lateral films. He said, kindly, “Ma’am, I’m not a doctor, but it looks to me like you have a compression fracture.” He printed out the films for me to see, and of course he was right. A nurse gave me some morphine, which eased the pain considerably, and then it was time to consider next steps.

Conservative treatment or intervention?

My fracture was at the level of the 12th thoracic vertebra or “T12”, the commonest site for compression fractures. This is hardly a rare problem. One in four American women will have a vertebral compression fracture during her lifetime, and men can suffer them too. The most common cause is osteoporosis, a condition in which bone loss over time results in weak, brittle bones.

The emergency room physician ordered a CT scan to see the extent of the fracture in more precise detail, and to see whether or not any bone fragments were endangering the spinal cord. Then he called a neurosurgeon, Dr. Khawar Siddique, to see me.

The neurosurgeon outlined treatment options. Basically, there were three:

Conservative treatment: a back brace, pain medications, and 6-8 weeks of rest, with gradual mobilization;

Surgery: thoracic fusion;

Kyphoplasty: a less invasive procedure to stabilize the fractured vertebra.

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