Many people with chronic pain take daily medication to manage their suffering. The most commonly used medications are opioids, otherwise known as narcotics. While a large percentage of those using opioids improve with treatment, some do not- and others get worse.
There are many potential causes for this worsening. Progression of the underlying painful disease, new or worsening depression and tolerance to pain medications are among the most likely. Another concern is opioid-induced hyperalgesia.
To understand this controversial problem, one must first understand how the body processes pain. Normally the body sends pain signals to the brain and the brain sends signals back to block the pain. A balance exists between pain causing and pain blocking activity in the nervous system. Sometimes this system fails, though, such as in the case of fibromyalgia. A major cause of fibromyalgia is inadequate activity of the pain blocking system.
Scientists have long known that opioids can disrupt this balance as well. The most definite studies are in animals given continuous narcotics. These animals develop more pain causing and less pain blocking nerve activity over time.
Whether this effect occurs in humans, though, has been controversial. It appears after much research that an imbalance in the pain processing system (opioid-induced hyperalgesia) can happen in those who take regular opioids.
Since many potential causes exist for increased pain in those taking narcotics, how do you know that opioid-induced hyperalgesia is the problem? Several steps (under the supervision of your doctor, of course) may help:
1. Make sure there is not a change in the disease causing the pain.
2. Make sure other factors such as stress, anxiety and/or depression are not increasing the pain.
3. Try increasing the dosage of the opioid to see if tolerance is the problem.
4. Consider increasing the dosage again.
If the above steps do not identify a cause or improve the pain, then opioid-induced hyperalgesia is a reasonable concern.
Optimal treatment of this problem is unclear. Some experts recommend changing to a different opioid. Others recommend other types of pain medications. Still others advocate stopping the medication through a detoxification process. What is clear is that treatment requires an open and honest conversation with your pain management physician.
For more information, try this textbook entry: http://books.google.com/books?hl=en&lr=&id=ZwPIjKg0XukC&oi=fnd&pg=PA171&dq=opioid-induced+hyperalgesia&ots=J7dVhl5IfK&sig=1HsBXpLRwrROVMicTc2nMTicdao#v=onepage&q=opioid-induced%20hyperalgesia&f=false.
Sunday, January 29, 2012
Wednesday, January 18, 2012
Building tolerance
I attended a pain management lecture given by a prominent physician a few weeks ago. As expected given the presenter and the audience of doctors who treat pain, the conversation covered many topics.
The most interesting subject, though, was the philosophy of pain managment. Patients and doctors all think about reducing pain. There are, in fact, dozens of ways to decrease overall pain level. Our focus often seems to be on eradicating pain with medications.
Perhaps instead we should consider not just reducing pain but also improving tolerance. There are many ways to increase resistance to pain using both medications and other techniques.
One of the biggest recent advances in pain is the concept of treating pain with seizure medications such as gabapentin and pregabalin. While these drugs do decrease pain levels somewhat, their main mechanism of action is to increase the resistance of the pain nerves in the brain and spinal cord. Norepinephrine medications such as milnacipran and duloxetine similarly improve the brain's ability to resist pain signals.
Exercise and physical therapy also improve pain levels, partially by increasing tolerance. This effect is most clearly seen in patients with fibromyalgia. Other similarly effective techniques include meditation, biofeedback and even simple positive thinking.
With the recent advances in the understanding of pain regulation in the brain and the spinal cord, I suspect improving pain tolerance will become a much more prominent component of pain managment over the next few years. Keep an eye out for more options to improve your ability to resist pain!
The most interesting subject, though, was the philosophy of pain managment. Patients and doctors all think about reducing pain. There are, in fact, dozens of ways to decrease overall pain level. Our focus often seems to be on eradicating pain with medications.
Perhaps instead we should consider not just reducing pain but also improving tolerance. There are many ways to increase resistance to pain using both medications and other techniques.
One of the biggest recent advances in pain is the concept of treating pain with seizure medications such as gabapentin and pregabalin. While these drugs do decrease pain levels somewhat, their main mechanism of action is to increase the resistance of the pain nerves in the brain and spinal cord. Norepinephrine medications such as milnacipran and duloxetine similarly improve the brain's ability to resist pain signals.
Exercise and physical therapy also improve pain levels, partially by increasing tolerance. This effect is most clearly seen in patients with fibromyalgia. Other similarly effective techniques include meditation, biofeedback and even simple positive thinking.
With the recent advances in the understanding of pain regulation in the brain and the spinal cord, I suspect improving pain tolerance will become a much more prominent component of pain managment over the next few years. Keep an eye out for more options to improve your ability to resist pain!
Welcome
This is the introduction of the new blog Manage Joint Pain. I intend for this to be a source of information for those living with chronic pain and arthritis. Stay posted for updates every 1-2 weeks.
Pendleton Wickersham, M.D.
Pendleton Wickersham, M.D.
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