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Particularly for these neuropathic pain conditions, we are finding that what most people think of as a pain medicine: aspirin, Ibuprofen, morphine, codeine, Vicodin. These do not work well. We need something that alters the way the nervous system functions. And so there’s a whole different group of medicines that we use to treat neuropathic pain. Very commonly it’s the antiseizure drugs or the anticonvulsants or the antidepressant medications. And then again it’s not because the patient is depressed or it’s not because they’re having seizures. It’s because of the properties these medicines have and their ability to alter nervous system function, which often we can use to reduce the abnormal firing and therefore the pain signals that the patient is getting.
So for neuropathic pain, and maybe I’ll use the example of CRPS as a pretty typical example. We need to first prevent the body from deteriorating because people are not using their body appropriately. Often people will stop moving a painful part or just go to bed. So fairly frequently we need to make sure that the body is staying strong and fit, and we’ll use physical therapy. But in addition, physical therapy provides normal input to the nervous system, and normal input is a counterbalance to the abnormal pain signals. So physical therapy is really one of the key treatments for neuropathic pain and CRPS in specific.
Pain psychology is another very important part of what we do. When patients are stressed, upset about their condition, fearful about their condition, it makes everything much worse. So we have to help patients overcome that. Teach them stress management techniques. Teach them a certain amount of mind over body techniques. These can make a big difference in the quality of life.
What are some of the problems that we run into? Well, certainly the one that’s making the papers is addiction. A fairly large number of people are susceptible to becoming addicted to opioids when their body is exposed to them because that’s how they’ve been treated. And the addiction can be very hard to fight. And even after the pain problem has gone away, which hopefully it has, even then, the patient may still be driven by a feeling of need and craving to use these medications, and it can become a very destructive addiction. The end result for some patients with addiction is overdose. And sometimes overdose happens even when there’s no addiction. It’s just because the patient took too much medicine in an effort to treat their pain, even when no addiction is present. So overdose with opioids is often fatal. It leads to the brain losing its drive for breathing. And patients basically die from lack of breathing because of an overdose on these medications, these opioids. And we’re seeing, unfortunately, that this is a huge epidemic in this country
You can’t pick up a paper these days without at least once a week seeing a headline about the opioid crisis, certainly in America and to some extent throughout the world. We’re finding that opioids, the medicines that have traditionally been used to treat pain: morphine, coding, dilaudid, hydromorphone, fentanyl, percocets, vicodins, that these medicines, which are all part of the opioid family, they all come from the opium structure, the opium poppy plant that this whole family of drugs, which is effective in the short term reduction of pain has caused many problems. When we use these medications chronically. They are not very good tools for the treatment of chronic pain.
In really difficult cases, we have to kind of pull out, if you will, big gun therapies. These might include implanted electrical stimulators. Sometimes we implant the wires into the spine on top of the spinal cord, or we might implant wires under the skin and the areas of pain. At other times we might implant a pump, that can on a continuous basis infused medicine into the spinal fluid, which of course is sitting right on top of the nervous system and can have a big impact on pain signals. We also at times may use nerve blocks. These are injections where we will inject anesthetic medicines on top of nerves to shut down the function of the nerve. Now this is temporary. It’s never permanent solution, but it almost acts like rebooting a computer. And so even after the effect has worn off, we often see that the pain, when it returns is not as severe, not as intense. And so sometimes a series of blocks can provide significant relief to a patient.
So one of the things that people often don’t understand is that there are very different kinds of pain and in our field we tend to categorize them in two kinds. One is when the nervous system is doing what it should do, it sounds the alarm appropriately because something is damaging the body. But in addition, we can have pain when the nervous system is malfunction, but our nervous system is sounding the alarm for no good reason like a car alarm that might be going off for no good reason. It can be a very painful response that we get from the malfunction of the nervous system. Examples might be somebody who has nerve damage from diabetic neuropathy or a classic example is phantom limb pain. If somebody has suffered an amputation, the part of the body that isn’t there, can be hurting and that’s because again of a malfunction of the nervous system that’s sounding the alarm and the patient perceives pain in a body part that isn’t there. There are many examples of this that in my specialty we deal with all the time where people are having what is often called nerve pain, and it’s, again, it’s from a malfunction of the nervous system rather than the traditional bodily injury.
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