Ask The Doctor – Pain Control

When I had a kidney stone, I couldn’t think of anything else but the pain. It took over my priorities, all else faded from importance. I was a different person. This is common with severe pain. Pain causes release of stress hormones, causing increased heart rate and breathing rate; you look paler; you are weaker.

Anxiety can increase our sensitivity to pain and pain can cause anxiety. We must control our anxiety when in pain to reduce the pain.

We usually ask the patient to rate the pain on a scale of 0-10; 0 is no pain and 10 is the worst pain you can imagine. Many patients say they are having pain rated at 10 so they will convince the listener that they need help. They think they will be ignored if the number is not 10. I have seen very comfortable people who I am sure they can imagine worse pain.

There are many ways to reduce pain some of them are:
Physical Therapy
Topical Medication
Injected Medications
Injected Medications directly to the area of pain

I will concentrate on the medications:
There are several classes of medications:
Non-steroidals (ibuprofen, antiarthritics, aspirin)
Opiates (including Ultram, Morphine)

For mild to moderate pain we usually do not use the opiates since they are narcotics and may cause dependence, i.e. if the drug is abruptly stopped, the patient will experience withdrawal. All humans will experience this if they are on opiates continually for more than a month or so. We can wean them off, so if opiates are used for a good reason, there is no need to be scared.

At this point we must discuss addiction and adaptation. Most people on opiates develop more receptors so the same dose gives less effect and for a shorter time. It is as if the mother bird is bringing 3 worms for 3 babies and after a while a fourth baby pops up. All the babies will be hungrier and scream louder and longer.
Addiction is a group of behaviors that shows the patient is drug-seeking: visiting multiple physicians or pharmacies for narcotics, having multiple excuses for why more medication is needed. Seeking drugs becomes a major focus of their life and they will break rules to get some.

Pseudoaddiction is a person in severe pain who is not getting enough narcotic to relieve the pain and therefore is very insistent on getting the medication to meet this goal. It takes a skilled physician to discriminate between addiction and pseudoaddiction.

Most physicians do not want to deal with dependence, addiction, and pseudoaddiction so they shy away from prescribing narcotics. This keeps undesirable behavior and people out of the office. They will refer the patient to a pain specialist who has elaborate procedures to minimize the incorrect use of narcotics. Rarely does a pain specialist accept Medi-Cal or less. The lines are very long. Many pain specialists are mainly anesthesiologists seeking to help the appropriate patient with deep injections for which they have excellent training, and emphasize medication prescriptions less.

The non-steroidals are a large group, mainly used for arthritis and also other pains. They are effective. Most of them carry a risk of bleeding from the upper intestines or stomach. This is more riskier in the elderly.

Combining therapies in the large list works well for some: e.g. exercise, heat, visualization and medication can be a winning combination for some. I think of this like each is contributing 2 points to the total pain of 10, dropping the pain down to a 2 which is tolerable. Using the strategies that are not medication lowers the risk from medications. Opiates can cause mental dulling in addition to the problems mentioned above.

Ibuprofen and other non-steroidals can be made into an ointment which can relieve some muscle pains. Irritant creams, such as Ben Gay, can work for straight and gay patients. It works by sending a message to the spinal cord to jam the pain signal coming from deeper in the tissue. The brain senses the cream but not the pain while the cream is active.

Ultram works in the opiate receptors but rarely causes dependence, so it is preferred over opiates.

Muscle spasm can cause pain which sends a signal to the muscle to protect it and go into spasm, creating an endless loop which is hard to break.

Trigger point injections are a great way to help some patients who have them. A trigger point is the worst pain spot in the area of pain; the physician can press the painful area and find a trigger point in many patients who have a muscle spasm pain. A small amount of medication is injected into the area and the pain is much better in the trigger point and in the rest of the area almost immediately.