In the latest issue of JAMA (Journal of the American Medical Association) Aug 9, 2016 there is an article proposing what a physician should do if a patient wants medical marijuana. As usual the American medical establishment is way behind on assessing a situation and coming up with some thoughts since medical marijuana has been around for a long time. But, better late than never, which is a poor statement for any kind of medicine. In the article there is reference to the different stages—1) first time it is brought up by the patient—-this visit should be well documented. If marijuana is being considered for this patient, a full evaluation should take place if one has not been done recently. During this eval the risks and benefits of marijuana for THIS patient should be discussed. 2) Other treatments that have been tried should be documented for success or failure. 3) The fact that the quality and concentration of marijuana is extremely variable should also be discussed. Cannabis Use Disorder and the potential for a psychotic disorder need to be mentioned in the side effects discussion. 4) It should be documented that it was discussed that the marijuana should be safeguarded against others using it. 5) There could be room for wider based discussions depending on the practitioners expertise in the area of marijuana.
The above is what your physician who writes you a letter of recommendation for marijuana should discuss with you. This is only the initial stage of preparation to use marijuana–if you are new to it. At this point in time all physicians should be knowledgeable on this subject but they are not–so you need to advocate for yourself and be informed.
Several situations have arisen recently that have changed the focus of chronic pain control. The main consideration is that the FDA has come out against using opioids for chronic pain–thus making prescribing physicians more vulnerable to being a causal agent (overdose, death etc.). This FDA ruling stems from the huge number of patients that are overdosing and dying from opioids–usually in combination with some other depressant. This has been going on for years –someone finally decided to do something about it. Unfortunately, they didn’t give many options for severe pain or patients already on opioids for years. Abuse of legal and illegal drugs is rampant in the US. In a normal lifespan, about 50% of people will have abused drugs. It was no surprise that over-prescribing of opioids by physicians, uneducated in pain control, would lead to massive abuses by patients. So–here we are–pain control without opioids–can it be done? Of course it can. Opioids were just the easy way out–at least in the beginning. Let’s look at it from this point of view–the view that almost every patient has a high potential for being an addict. A pain plan would need to keep this in mind and avoid highly addictive/high abuse potential medications.
The concept of multimodal therapy is inherent to not using opioids. This means that several different medications and treatment therapies will be used to replace the opioids. The usual ones are optimization of NSAIDS, acetaminophen, anti-convulsants and anti-depressants. Exercise regimens that include Yoga or Tai Chi are also considered standard (stretching and relaxing muscles and joints). Marijuana, with low levels of THC and high levels of CBD, has shown promise when in a multimodal treatment regimen. Newer to complimentary medicine in the US are Moringa and Andrographis Paniculata. Both of these herbs show promise in the area of musculoskeletal and arthritic pain. I believe physicians will need to become more familiar with complimentary medications along with exercise options if they are going to continue treating chronic pain patients and not use opioids. Also, psychiatric co-morbidities cannot be overlooked and need to be aggressively treated in the setting of chronic pain.
There are many books written about pain control without opioids (I wrote one called 21 Broken Bones)–as a patient,read a book and get to know your options. Always be aware of possible drug interactions. The more meds you are on the more potential for negative interactions. Ask your physician or pharmacist about you meds, if you have a question. You can control your pain without opioids–in the long run it will be a better alternative
Some chronic pain can’t be managed without opioids. This is less than 5% of all patients and even these patients can take LESS opioids with a good multimodal plan.
February and March of this year(2016) give us 2 good articles to review. The first is from the Journal of Comparative Neurology entitled ” Positive emotions and brain reward circuits in chronic pain” We have been aware for quite sometime that negative emotions can make your pain worse. It makes sense then that positive emotions could make it better. Why? Though the understanding of brain circuits and the apparent crossover of emotions and pain are not perfectly clear some answers have been forthcoming. The negative aspects of pain have a location that overlaps with areas that process reward and motivation. Pain relief is rewarding and can activate positive circuits. Lack of treatment or under treating chronic pain can maintain the activity of negative circuits making their feedback strong. Reinforcing the positive feedback can be done with good pain relief or possibly other methods of stimulation of this brain area.
Take advantage of this positive treatment loop and mentally reinforce it to increase the size and strength of the feedback. Get on top of your pain!
The second article is from the Br Journal of Pharmacology “Identification of A3 adenosine receptor agonists as novel non-narcotic analgesics” We are well aware that the treatment modes currently available are not adequate. This is the discussion of a novel therapy. Adenosine is a purine nucleoside and is everywhere in nature best known for its combination in energy transfer, ATP. It is also used in treatment of irregular heartbeats. It has 4 receptors of which the one important to us is the A3 receptor. This pain relief by stimulating the A3 receptor alone does not have cardiac effects. This target also uses our own intrinsic systems to give us pain relief.This gives us the thought that the effect on our bodies will be gentle and easily cleared from our system. Though in it’s infancy, early studies are very promising. Hopefully the research will continue to be funded.
Complex Regional Pain Syndrome (CRPS) has had many names prior to it’s current name. It has been called causalgia, Sudeck’s atrophy or reflex sympathetic dystrophy. The current name reflects the region nature of the disease and the many complex signs and symptoms that make up the disease. There are 2 methods used for diagnosis–the IASP and the Budapest criteria. It has been shown that the Budapest criteria is best for both clinical and research work. Inside of this is a group having chronic refractory CRPS–this is the most severe form of CRPS. It appears to effect women exclusively. The challenges related to CRPS have mostly to do with the fact that the numerous name changes and previously unvalidated criteria made research difficult. Now using the Budapest criteria this will change.
Pharmacologic management can be from IV, oral or topical sources. IV treatment would be with ketamine (a dissociative anesthetic or biphosphonates (usually used to prevent bone loss). Subcutaneous or IM doses of calcitonin have also shown some success. Calcitonin is usually used in calcium regulation or for osteoporosis. The specific goal would be for treatments that are all oral for ease of patient use.
Budapest criteria for CRPS: 1) Continuing pain that is disproportionate to any inciting event
2) Must report at least one symptom in 3 of the 4 following categories
-sensory: reports of hyperesthesia and/or allodynia
-Vasomotor: reports of temperature asymmetry and/or skin color changes or color asymmetry
-Sudomotor/edema: reports of edema and/or sweating changes
-Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or tropic changes (hair, skin, nails)
3) Must display at least one sign at time of evaluation in two or more of the following categories
-Sensory evidence of hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure)
-Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or sweating asymmetry
-Sudomotor/edema: evidence of edemas and/or sweating changes and/or sweating asymmetry
-Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
4) There is no other diagnosis that better explains the signs and symptoms
The biopsychosocial model for care may be the best. Yes, it is as it seems–you need to come from all the different sides of the problem. The possible biological origin which may or may not still be present, the psychological effects need to be addressed as well as the social changes that occur with chronic pain.
The whole patient needs to be assessed and treated. Begin treating the pain (pharmacologically) at the same time-modify maladaptive behaviors, improve coping skills, physical reconditioning to allow functional restoration, and stress management with relaxation techniques.
Careful titration of the pharmacological agents to minimize side effects, but under dosing can be a negative due to lack of full treatment potential.
Many therapies such as back fusions seem to have outpaced the research as to whether they actually are better–head to head studies do not show a great advantage from many types of fusions
A well rounded pain program involving all the biopsychosocial areas appears to be the best approach to controlling chronic pain. ASK to be included in this type of program
My book 21 Broken Bones has finally been published. It is a handbook on how you take the lead in your own care if you have chronic pain. It is short and to the point.
Almost all pharmacological agents are insufficient as single therapies in chronic pain. The goal is to start somewhere and look for a 30 % improvement in the pain score. When this is arrived at then each added agent should be held to the same standard–a specific reduction in pain. If it cannot deliver, then another agent should be trialed.
Antidepressants have been used for years in aiding pain relief. Their mechanisms for relief are complicated and varied. The most important aspect of these medications is that the ones with non-selective mechanisms work the best. For example SSRI’s (selective serotonin re-uptake inhibitors) do NOT work well to give pain relief. In general the mechanism of action of these non-specific anti-depressants in pain relief has to do with re-uptake inhibition of various neurotransmitters. Especially in the descending bulbospinal inhibitory pathways. One of the TCA’s (tricyclic anti-depressants) can be used preemptively in patients know to have a diagnosis of herpes zoster, which can be extremely painful. Cannabinoids (from cannabis) have also been used to inhibit descending pathways of the spinal cord to moderate pain. The antidepressant Duloxetine has been used successfully in fibromyalgia and neuropathic pain. It is particularly effective in nighttime pain relief.
Anti-convulsants are also used in pain. Their effector areas are more “at the site” of the pain as opposed to somewhere in the spinal cord. Examples of these medications include carbamazepine, valproate, gabapentin and pregabalin. Another anti-convulsant, topiramate, can be used in migraines. Many of the mentioned medications can also be used topically.
We must not forget some of the most commonly used non-prescription medications– Tylenol (acetaminophen) and NSAIDs such as Advil. The use of NSAIDs deserves a quick discussion of how it works, which could help keep you out of trouble while using it. NSAIDs work on COX 1 and COX 2 enzymes. Tylenol may work at a COX 3 site. They inhibit them. Most over the counter NSAIDs inhibit both COX 1 and COX 2. COX stands for cyclo-oxygenase. These enzymes are involved in the synthesis of prostaglandins. Prostaglandins are involved with inflammation but are also involved in protecting the lining of the stomach. Continued use of these NSAIDs could cause the breakdown of the stomach lining called an ulcer (with potential internal bleeding). Alternating Tylenol with NSAIDs is an option,if you are going to use them frequently. There are specific COX 2 inhibitors but they are not without their problems also. They can activate platelets and cause heart attacks if they are not taken with an aspirin. COX 3’s are probably somewhere in the cerebral cortex.
As you can see, having many options available helps keep the side effects down and still give you the pain relief you deserve.
We have COX inhibitors–Tylenol, NSAIDs—–antidepressants, anti-convulsants, cannabinoids from cannabis, and of course opioids—all can be delivered in various formats.
In acute pain, tissue damage can lead to a sensory aspect of pain with possibly some superimposed cognitive response. In chronic pain tissue damage may not be apparent or even present. In spite of this, symptoms can be magnified and affective distress and illness behavior take the lead. This is why chronic pain patients need a multi-modal approach—medications (prescription and/or herbal), Behavior therapy, Physical modalities such as exercise and potentially some invasive procedures. Thoughts of re-injury and just plain fear of injury can undermine the success of any of the therapies. The use of opioids MUST be tempered by the multi modal approach to treatment, this allows for less chance of overdose, tolerance, and opioid induced hyperalgesia. It must be remembered that all chronic pain does not follow the same initiation nor is it maintained by the same mechanisms. The development follows a similar, shall we call it blooming, period————–PHYSICAL PROBLEM—PSYCHOLOGICAL DISTRESS—ILLNESS BEHAVIOR—-SOCIAL INTERACTIONS Good pain treatment programs are composed of several physicians, allied health therapists (physical therapy, nutritionists, herbalists, exercise specialists)–leading to functional improvement and behavioral change
History <______________________ Evaluation and Management_______________________> Assessment
pain hx physical exam
medical hx mental exam
psychosocial hx function
Diagnostic/therapeutic/ medications/Physical rehab/ psychological techniques
It seems that medicine is asking more and more of the pain patient. In a recent article in PAIN (Jan 2016) pain acceptance is the topic. If we accept our pain (measured by willingness to engage in activities in spite of the pain) then this would result in less increase in pain intensity. The goal here is to develop ideas that are positive and have a positive feedback. It relates that if you actually move ahead with an activity when you are in pain that this act in itself will help decrease you pain. The pain is not going away–>>you accept this and continue activity in spite of the pain–>> your symptoms will decrease. This all necessitates a skill set to not try to control your pain if it interferes with an activity. The participants in the study were re-examined 3.5 years later and still showed a positive effect from the learned pain acceptance.
Another recent article looked at heart rate variability (HRV) and found it to be decreased in chronic pain. Who cares you say? well decreased heart rate variability is associated with cardiovascular diseases, mood disorders, and increased morbidity. This is a form of dysfunction of the autonomic nervous system. It is unclear whether the chronic pain leads to this or a down regulation of the parasympathetic section of the autonomic nervous system is the cause. Either way it leads to an impact of chronic pain past the actual pain ares. WE know chronic pain is bad for you in many ways–this is a further explanation why.
Why don’t overdoses of marijuana die like can be the case with narcotics or alcohol. It could be as simple as that there are no cannabinoid receptors in the medulla of the brain–the medulla spends its time regulating cardio and respiratory aspects of the body. This a protective mechanism for marijuana users that can’t figure out the correct dosages of their marijuana.
We all know how pain can cloud our brain and fill it with anxiety, anger, fear, depression, cloudy thinking and many other things that take up a lot of our brains ability to get OTHER things done. If you don’t have chronic pain you are not aware of the drain on our system. Well, after a lot of years talking about it some folks in the UK (Univ of Bath-Nina Attridge) have sat down and come up with a cognitive intrusion scale–its actually called the Experience of Cognitive Intrusion of Pain (ECIP)—–pain becomes attention grabbing—pulling us away from our task at hand It’s a 10 item question set–each 0-6 pts for a worse case scenario of 60 pts You take it an then you can see what pain is doing to your brain capacity—it reminds you the pain needs to be taken care of –it’s a big monster messing with you–you need to win this battle==look at all the time you’d save focusing on the task at hand and not the pain
The other thing I want to discuss for a second is a new (trial) internet based Pain Course (by Australians of course–Macquane Univ-Sydney) which uses various levels of clinician support–I love the possibility of internet connections to education, health care and support This is how pain management can be delivered to everybody–not just those with good insurance or access to pain specialists–we need this in the US desperately It’s focused on cognitive behavior and lasts 8 weeks–no big deal and very helpful
GET THAT PAIN UNDER CONTROL SO YOU CAN THINK!—-Take the lead in your cognitive therapy!