Sorry, i keep doing this.
I posted something on Suparempe on Van's Forum in error.
you may justly chastise me.
John T
oops --> Hijacked to fibromyalgia
Moderator: Available
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JOHN THURSTON
- Posts: 2445
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- Location: MARSHFIELD, MA. USA
- Contact:
oops --> Hijacked to fibromyalgia
"All Enlightenment Gratefully Accepted"
-
Bill Glasheen
- Posts: 17299
- Joined: Thu Mar 11, 1999 6:01 am
- Location: Richmond, VA --- Louisville, KY
-
JOHN THURSTON
- Posts: 2445
- Joined: Sat Nov 28, 1998 6:01 am
- Location: MARSHFIELD, MA. USA
- Contact:
I'm Retired
Well:
In a way. It turns out that as a victim of the new 'buzz" occult disease heretofore never mentioned and rarely diagnosed, FMS.
I believe that i was struck down with massive pain attacks via fibromyalgia because I refused my nervous system's warnings to have a genuine nervous breakdown on my own.
so, when i failed to assent to this request, brain ordered its synaptical SS into action and did it for me.
brain
--------- 
me
But i have missed seeing you at the camps.
do read the post as I do not have the knowledge to transfer it over.
In a way. It turns out that as a victim of the new 'buzz" occult disease heretofore never mentioned and rarely diagnosed, FMS.
I believe that i was struck down with massive pain attacks via fibromyalgia because I refused my nervous system's warnings to have a genuine nervous breakdown on my own.
so, when i failed to assent to this request, brain ordered its synaptical SS into action and did it for me.
brain
--------- meBut i have missed seeing you at the camps.
do read the post as I do not have the knowledge to transfer it over.
Last edited by JOHN THURSTON on Thu Nov 12, 2009 9:46 pm, edited 1 time in total.
"All Enlightenment Gratefully Accepted"
Not so rare...
John,
Not so rare at all; occult in the sense that the cause is still unknown...
Not all that long ago, Fibromyalgia was dismissed by the medical establishment as essentially a manifestation of psychological problems/distress. More recently with better quality studies the data seems to point to some subsets of fibromyalgia-like disorders having some symptoms in common with problems like depression and anxiety but not that there is a causal link between depression e.g. and fibromyalgia (although certainly one could argue that in many cases, suffering from fibromyalgia can lead one to depression).
Part of the dismissal of fibromyalgia and similar problems has been due in my opinion to frustration on the part of the medical establishment with the inability to neither determine etiology nor develop effective treatment strategies. Unfortunately medicine often dismisses problems that fall into these categories (admittedly a shocking admission...).
The most recent research describes a set of disorders termed Central Sensitivity Syndromes (CSS), which are disorders where the brain 'misinterprets' nerve messages. Another example of this is irritable bowel syndrome (IBS) which also was considered a manifestation of psychological distress. Turns out that while this may well play a part, it is the fact that the gut of patients with IBS is 'wired differently' to interpret intestinal stretch (which normal folks receive as "I need to use the bathroom") as pain that primarily causes the problem.
In any event, very possibly information you already had, but I've become much more interested in the subject in the past year or so as the result of having had several patients with the diagnosis. I'm ashamed to admit that initially I also accepted without question the notion that this was 'all in the heads' of my patients; I've come to realize that while on some level that may be the case (i.e. brain dysfunction on some interpretive level), it's not simply a matter of 'snapping out of it'...
Please excuse the diatribe...my apologies if I hijacked your post!
Not so rare at all; occult in the sense that the cause is still unknown...
Not all that long ago, Fibromyalgia was dismissed by the medical establishment as essentially a manifestation of psychological problems/distress. More recently with better quality studies the data seems to point to some subsets of fibromyalgia-like disorders having some symptoms in common with problems like depression and anxiety but not that there is a causal link between depression e.g. and fibromyalgia (although certainly one could argue that in many cases, suffering from fibromyalgia can lead one to depression).
Part of the dismissal of fibromyalgia and similar problems has been due in my opinion to frustration on the part of the medical establishment with the inability to neither determine etiology nor develop effective treatment strategies. Unfortunately medicine often dismisses problems that fall into these categories (admittedly a shocking admission...).
The most recent research describes a set of disorders termed Central Sensitivity Syndromes (CSS), which are disorders where the brain 'misinterprets' nerve messages. Another example of this is irritable bowel syndrome (IBS) which also was considered a manifestation of psychological distress. Turns out that while this may well play a part, it is the fact that the gut of patients with IBS is 'wired differently' to interpret intestinal stretch (which normal folks receive as "I need to use the bathroom") as pain that primarily causes the problem.
In any event, very possibly information you already had, but I've become much more interested in the subject in the past year or so as the result of having had several patients with the diagnosis. I'm ashamed to admit that initially I also accepted without question the notion that this was 'all in the heads' of my patients; I've come to realize that while on some level that may be the case (i.e. brain dysfunction on some interpretive level), it's not simply a matter of 'snapping out of it'...
Please excuse the diatribe...my apologies if I hijacked your post!
-
Bill Glasheen
- Posts: 17299
- Joined: Thu Mar 11, 1999 6:01 am
- Location: Richmond, VA --- Louisville, KY
Why don't we just hijack the thread and be done with it? I'll transfer John's stuff over in a bit.
From what I understand about fibromyalgia, Greg, it may indeed be a neurotransmitter issue, albeit a more complex one. Typically in the past depression was treated by preserving serotonin in the synapses via SSRIs. However a new class of antidepressants have come on the market (SNRIs) which address both serotonin and norepinephrine. To some extent, dopamine may also be involved.
Other than the genes and biochemistry that we bring to the game of life, chronic stress can trigger this. Hmm... Good thing most people don't have that to deal with these days. (jk)
Not surprisingly, people respond well to (drum roll...) regular exercise. In other words, get your booty in the dojo, John. And find some weights to throw around a bit. It'll help you prime the pump and get you in the right direction. Don't be surprised if you're aching a lot (muscles, joints) when you start. But the right combination of diet, exercise, and a little Rx can be very helpful.
There's an interesting special going on that looks at cultures where people live a long time. One of them focused on Okinawa, and followed Tomoyose Ryuko into his Uechi dojo. They also interviewed him afterwords. It's very instructive.
- Bill
From what I understand about fibromyalgia, Greg, it may indeed be a neurotransmitter issue, albeit a more complex one. Typically in the past depression was treated by preserving serotonin in the synapses via SSRIs. However a new class of antidepressants have come on the market (SNRIs) which address both serotonin and norepinephrine. To some extent, dopamine may also be involved.
Other than the genes and biochemistry that we bring to the game of life, chronic stress can trigger this. Hmm... Good thing most people don't have that to deal with these days. (jk)
Not surprisingly, people respond well to (drum roll...) regular exercise. In other words, get your booty in the dojo, John. And find some weights to throw around a bit. It'll help you prime the pump and get you in the right direction. Don't be surprised if you're aching a lot (muscles, joints) when you start. But the right combination of diet, exercise, and a little Rx can be very helpful.
There's an interesting special going on that looks at cultures where people live a long time. One of them focused on Okinawa, and followed Tomoyose Ryuko into his Uechi dojo. They also interviewed him afterwords. It's very instructive.
- Bill
-
JOHN THURSTON
- Posts: 2445
- Joined: Sat Nov 28, 1998 6:01 am
- Location: MARSHFIELD, MA. USA
- Contact:
FMS
For the benefit of the readers. Yes, FMS has been the author of much frustration in the medical communities and patients because the pain is quite real and excruciating to the victim. But the the diagnosis is "by default" , it is not, as i undertand it, detectable by any test.
It appears, from my non medical background, to be an as described CNS disorder which I believe is pretty much caused in the manner i noted. Absorbing too much stress.
Despite two classes a week that I taught In Uechi, and the one T'ai>Chi Class once a week.
I also Usually ,took instruction one to three classes a week in TC.
The Water Boxing does not seem to be on Sifu's radar at the moment and I could not find my print out of the movements. I post this last only to show Bill Sensei that I have folled his advice in advance of the gift thereof-except during my cancer problems (
(sob sob) and dealing with two smashed ankles.
Despite this active presence in the Dojo and Kwan, FMS prevailed.
Have you ever sat in a doc's office qquittly for two or more hours with just tears running down involuntarily, or stood screaming after 5 hours of pain in your office of home (neither of which helped)?
I any event the matter was diagnosed a FMS in 2000, but no successfull course of treatment worked.
I thought I knew what WOULD have worked and I finally convinced the staff at a very fine pain clinic to give my thoughts a try-with a not so small tweaking on their part.
Medications and treatment: Fenatil 3 day pain patch, Lyica 2ce a day, Xanax thrice a day, one medication to deal with RLS symptoms created, in my view, by the insufficient use of Lyica in conjunction with neurontin. They don;t agree with each other, so stay clear of that mix unless you like stuttering..
The "Expert " in the field sat me down in his office at a prestigious hospital associated with B & W (Brigham and Womens) and, at a non insured cost of 1250 simolians sent a letter to my Primary . In the sit down and the letter he said I had FMS. Gee-duh-thanks. But he did go on to say that the neurontin and lyrica might 'conflict'.
This last was ignored and last landed me in the hospital about 18 months ago for what i hope was the last time.
TMI I know, but if there are any FMS sufferers out there I would be happy to commiserate with them and make suggestions.
Trust me Bill Sensei, when you have an actual Chronic fatigue plus pain (to 7 level attacks----you would not make it to the dojo because you could not stand much less drive a car thereto. It i s not that I could not stand the pain, but the duration of that level pain and the thoughts that it might NEVER stop, spiraled matters out of control many a time.
In between attacks I highly recommend exactly what you suggested--get the old booty down to the Dojo------if you don't---it just gets hardeer to bear the pain.
Although i feel accupunture is contraindicated, my practitioner, a fine man, did note after I said "look at me-the proud martial artist"--he consoled me with the thought that "if you weren't a martial artist you would be hanging from the rafters here, or somewhere else"
J
It appears, from my non medical background, to be an as described CNS disorder which I believe is pretty much caused in the manner i noted. Absorbing too much stress.
Despite two classes a week that I taught In Uechi, and the one T'ai>Chi Class once a week.
I also Usually ,took instruction one to three classes a week in TC.
The Water Boxing does not seem to be on Sifu's radar at the moment and I could not find my print out of the movements. I post this last only to show Bill Sensei that I have folled his advice in advance of the gift thereof-except during my cancer problems (
(sob sob) and dealing with two smashed ankles.Despite this active presence in the Dojo and Kwan, FMS prevailed.
Have you ever sat in a doc's office qquittly for two or more hours with just tears running down involuntarily, or stood screaming after 5 hours of pain in your office of home (neither of which helped)?
I any event the matter was diagnosed a FMS in 2000, but no successfull course of treatment worked.
I thought I knew what WOULD have worked and I finally convinced the staff at a very fine pain clinic to give my thoughts a try-with a not so small tweaking on their part.
Medications and treatment: Fenatil 3 day pain patch, Lyica 2ce a day, Xanax thrice a day, one medication to deal with RLS symptoms created, in my view, by the insufficient use of Lyica in conjunction with neurontin. They don;t agree with each other, so stay clear of that mix unless you like stuttering..
The "Expert " in the field sat me down in his office at a prestigious hospital associated with B & W (Brigham and Womens) and, at a non insured cost of 1250 simolians sent a letter to my Primary . In the sit down and the letter he said I had FMS. Gee-duh-thanks. But he did go on to say that the neurontin and lyrica might 'conflict'.
This last was ignored and last landed me in the hospital about 18 months ago for what i hope was the last time.
TMI I know, but if there are any FMS sufferers out there I would be happy to commiserate with them and make suggestions.
Trust me Bill Sensei, when you have an actual Chronic fatigue plus pain (to 7 level attacks----you would not make it to the dojo because you could not stand much less drive a car thereto. It i s not that I could not stand the pain, but the duration of that level pain and the thoughts that it might NEVER stop, spiraled matters out of control many a time.
In between attacks I highly recommend exactly what you suggested--get the old booty down to the Dojo------if you don't---it just gets hardeer to bear the pain.
Although i feel accupunture is contraindicated, my practitioner, a fine man, did note after I said "look at me-the proud martial artist"--he consoled me with the thought that "if you weren't a martial artist you would be hanging from the rafters here, or somewhere else"
J
"All Enlightenment Gratefully Accepted"
Neurontin (gapapentin) is a seizure medicine that was not that effective. It also required large doses (many grams a day). The makers figured out that there was much more money to be had elsewhere and so they encouraged trials of neurontin for all sorts of things and then handed the articles out to doctors--this was promotion of off-label use, and they were heavily fined.
Lyrica (pregabalin) is largely viewed as a patent extender for the blockbuster Neurontin. It is a similar drug with minor improvements but is new and thus much more expensive. It HAS received an indication for fibromylagia, but it's not clear if it's better than neurontin. Because they are related, they should not be used together. See blurb from a review article:
If patients are unable to tolerate or symptoms are insufficiently controlled by AD drugs, anticonvulsants may be used. In a recent RCT, gabapentin was shown to be effective in the treatment of FMS in daily doses between 1200 and 2400 mg, with a median dose of 1800 mg/d.3 A multicenter, double-blinded RCT of pregabalin, a drug targeting the α2-δ subunit of calcium channels, 3 doses (150, 300, and 450 mg/d) were studied in an 8-week trial in 529 patients. At 450 mg/d, pregabalin had a significant effect on pain, fatigue, sleep, and health-related quality of life when compared with placebo. Side effects included dizziness, somnolence, and rarely, peripheral edema.13 A follow-up open-label, dose-optimization study examined the durability of response to pregabalin in patients who had 50% reduction of pain and described themselves as much or very much improved: Two-thirds of pregabalin responders maintained this benefit for 6 months.1 American College of Rheumatology Annual Meeting, Washington, DC, 2006.1 Pregabalin was recently approved by the FDA for treatment of FMS. Other anticonvulsants have not been specifically studied in FMS. In the patient under discussion, adding either gabapentin or pregabalin to her antidepressant therapy may be helpful in managing her pain as well as improving sleep.
Xanax (alprazolam) is about your fastest acting, shortest duration benzodiazepine. Librium, Klonopin and Valium are other examples from the class. Because Xanax is short acting, it is best suited for RARE use for acute anxiety, eg before plane flights or something. It also is decent for sleep, but there are less habit forming substances. It is poorly suited to chronic pain conditions because of the short action. Thus, I (almost) never prescribe it, encourage patients to avoid it, and use one of the three mentioned above in its place. I'm not making any specific recommendations for anyone here, and there are always exceptions, but that's a prudent general approach.
Milnacipran, the other drug I know of with an indication for fibromyalgia, is mentioned in the following blurb from a review article:
As noted in the previous commentary, antidepressants are the primary pharmacologic therapies used to treat FMS, despite studies that demonstrate varying degrees of efficacy. Given the lack of clarity in study outcomes, the challenge for the clinician is selecting the most appropriate agent: Tricyclic, selective serotonin reuptake inhibitors, or mixed agents. Arnold et al5 in a meta-analysis of tricyclic AD drugs found moderate effectiveness in patients with FMS. Sleep quality, tenderness, and stiffness were the most affected measures. A significant response was found in 25% to 36% of patients studied.
Evidence supporting the use of selective serotonin reuptake inhibitors (SSRIs) in FMS is inconsistent. In a study of 42 patients with fibromyalgia treated over a 6-week period with fluoxetine (20 mg), no significant effect was found over placebo.35 In contrast, a randomized, placebo-controlled, double-blinded, dose-optimization trial with FMS patients found a significant difference in the Fibromyalgia Impact Questionnaire (FIQ) total score, pain score, fatigue score, and depression score when conducted over a 12-week period with doses of fluoxetine ranging between 10 and 80 mg (45 ± 25 mg/d). The McGill Pain Questionnaire also differed significantly between the fluoxetine and placebo groups. Tender point and myalgic scores did not differ between the 2 treatment groups.4 Studies using even more highly selective SSRIs have not been beneficial.35
Dual-acting serotonin and noradrenaline reuptake inhibitors have been studied in patients with FMS with varying results. Ninety patients were studied in a randomized controlled trial (RCT) of venlafaxine (75 mg) versus placebo. No significant difference was found between the 2 treatment groups.37 In contrast, a double-blinded RCT of 125 patients treated for 8 weeks with up to 200 mg twice daily of milnacipran, another dual-acting drug, found a significant difference in overall improvement compared with placebo. Twice-daily dosing also resulted in a significant decrease in pain intensity.34 Similarly, 2 multicenter RCTs comparing another dual-acting agent, duloxetine, reported significant improvement in female patients in FIQ total score, FIQ stiffness, Brief Pain Inventory pain score, and number of tender points.[6] and 7 L.M. Arnold, A. Rosen, Y.L. Pritchett, D.N. D’Souza, D.J. Goldstein, S. Iyengar and J.F. Wernicke, A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder, Pain 119 (2005), pp. 5–15. Article | PDF (264 K) | View Record in Scopus | Cited By in Scopus (141)[7] Men were found to receive no significant effect from treatment.6
As far as the existence and cause and so on from the medical community, we do tend to have difficulty (eg, being kind, and not getting stressed out) with pain patients especially when there is no evident cause. In part, this is because of the massive contamination of our pain patient populations with people who are seeking disability or narcotics, or just want to cover up their issues with drugs / are "woe is me" types. Obviously there is a lot of real suffering out there and it is difficult to sort out who should get the strong stuff and who should not. In general, my belief is that monitoring effectiveness in (as Freud put it) "love and work," is the key. If someone tells me they need more oxycontin and they've only been less active, not working, fighting with spouse over use--then it's no. If the drugs have put them back in karate class? Enthusiastic yes.
A major worry is creating a monster. Case in point, I recently admitted someone with diffuse body pain after an accident (years ago). He was having so much nausea from the drugs he was vomiting and had to be admitted to get IV drugs (still causing nausea apparently). Instead of pressing the button when pain occurred he sat motionless with a watch and stabbed the button every 8 minutes to get the max dose. Despite enough narcotics to kill a horse, his pain was still 9-10 out of 10 (ie, no better, just addicted to narcs). Additionally, he was getting much more medicine overall due to the easy availability in hospital and the overnight doctors' inability to say no when constantly paged. Only "bolus" meds worked, not infusions (go figure). His pain got worse from not walking. His posture was terrible and he wouldn't consider adjusting it. He noted the pain was constant and severe and unchanged by working but still wouldn't work, or do anything. When the pain doctor said he wouldn't get a pain pump until he got to clinic, suddenly the nausea improved (go figure) and someone who cried when I said he should start taking sips was able to to drink 5 liters that night. The entire life revolved around narcotic doses and, again, no function or real relief was to be seen. In short, we'd created a monster. Huge drug addiction and not any more functional or happy. Another issue is the act, shown in nauseating detail on an episode of Intervention, when a small child noted, "mommy seems fine until she goes to the doctor then she is sobbign and can barely walk" or something to that effect. There's nothing like treating "pain" and getting a letter from a pharmacy that your patient has gotten 26 controlled substances from 10 doctors in the last few weeks. Or when my patient starts calling me drunk for vicodin and becomes verbally abusive when I won't prescribe it for someone with other substance problems, a contraindication to the tylenol part, and no indication (garden variety low back pain only--I've had it, it was bad, meds didn't help, narcs are not the answer).
In contrast, my experience with cancer patients is that they frequently have to be talked INTO taking medications or increasing their doses and they don't have similar apathetic spells until they're suffering from advanced disease, and they frequently give me goals such as travel, work, doing things with loved ones. I'm not saying real pain doesn't deserve powerful medications at all. I am just relating that it is very tricky to sort out whether we're helping people or giving them new problems or whether the person we're dealing with has ulterior motives or larger issues. It's very unfortunate that humans are predisposed to abuse these drugs, **because it sure makes life more difficult from those who really need them.** Meanwhile I work with my trainees to explain that pain is important to treat, sometimes you have to trust people even if you get burned, and even an active heroin abuser needs morphine (at high doses due to tolerance) when there's real pain happening.
Good luck out there... posture and core work has mostly managed my back pain, I wish it were that easy for all.
Lyrica (pregabalin) is largely viewed as a patent extender for the blockbuster Neurontin. It is a similar drug with minor improvements but is new and thus much more expensive. It HAS received an indication for fibromylagia, but it's not clear if it's better than neurontin. Because they are related, they should not be used together. See blurb from a review article:
If patients are unable to tolerate or symptoms are insufficiently controlled by AD drugs, anticonvulsants may be used. In a recent RCT, gabapentin was shown to be effective in the treatment of FMS in daily doses between 1200 and 2400 mg, with a median dose of 1800 mg/d.3 A multicenter, double-blinded RCT of pregabalin, a drug targeting the α2-δ subunit of calcium channels, 3 doses (150, 300, and 450 mg/d) were studied in an 8-week trial in 529 patients. At 450 mg/d, pregabalin had a significant effect on pain, fatigue, sleep, and health-related quality of life when compared with placebo. Side effects included dizziness, somnolence, and rarely, peripheral edema.13 A follow-up open-label, dose-optimization study examined the durability of response to pregabalin in patients who had 50% reduction of pain and described themselves as much or very much improved: Two-thirds of pregabalin responders maintained this benefit for 6 months.1 American College of Rheumatology Annual Meeting, Washington, DC, 2006.1 Pregabalin was recently approved by the FDA for treatment of FMS. Other anticonvulsants have not been specifically studied in FMS. In the patient under discussion, adding either gabapentin or pregabalin to her antidepressant therapy may be helpful in managing her pain as well as improving sleep.
Xanax (alprazolam) is about your fastest acting, shortest duration benzodiazepine. Librium, Klonopin and Valium are other examples from the class. Because Xanax is short acting, it is best suited for RARE use for acute anxiety, eg before plane flights or something. It also is decent for sleep, but there are less habit forming substances. It is poorly suited to chronic pain conditions because of the short action. Thus, I (almost) never prescribe it, encourage patients to avoid it, and use one of the three mentioned above in its place. I'm not making any specific recommendations for anyone here, and there are always exceptions, but that's a prudent general approach.
Milnacipran, the other drug I know of with an indication for fibromyalgia, is mentioned in the following blurb from a review article:
As noted in the previous commentary, antidepressants are the primary pharmacologic therapies used to treat FMS, despite studies that demonstrate varying degrees of efficacy. Given the lack of clarity in study outcomes, the challenge for the clinician is selecting the most appropriate agent: Tricyclic, selective serotonin reuptake inhibitors, or mixed agents. Arnold et al5 in a meta-analysis of tricyclic AD drugs found moderate effectiveness in patients with FMS. Sleep quality, tenderness, and stiffness were the most affected measures. A significant response was found in 25% to 36% of patients studied.
Evidence supporting the use of selective serotonin reuptake inhibitors (SSRIs) in FMS is inconsistent. In a study of 42 patients with fibromyalgia treated over a 6-week period with fluoxetine (20 mg), no significant effect was found over placebo.35 In contrast, a randomized, placebo-controlled, double-blinded, dose-optimization trial with FMS patients found a significant difference in the Fibromyalgia Impact Questionnaire (FIQ) total score, pain score, fatigue score, and depression score when conducted over a 12-week period with doses of fluoxetine ranging between 10 and 80 mg (45 ± 25 mg/d). The McGill Pain Questionnaire also differed significantly between the fluoxetine and placebo groups. Tender point and myalgic scores did not differ between the 2 treatment groups.4 Studies using even more highly selective SSRIs have not been beneficial.35
Dual-acting serotonin and noradrenaline reuptake inhibitors have been studied in patients with FMS with varying results. Ninety patients were studied in a randomized controlled trial (RCT) of venlafaxine (75 mg) versus placebo. No significant difference was found between the 2 treatment groups.37 In contrast, a double-blinded RCT of 125 patients treated for 8 weeks with up to 200 mg twice daily of milnacipran, another dual-acting drug, found a significant difference in overall improvement compared with placebo. Twice-daily dosing also resulted in a significant decrease in pain intensity.34 Similarly, 2 multicenter RCTs comparing another dual-acting agent, duloxetine, reported significant improvement in female patients in FIQ total score, FIQ stiffness, Brief Pain Inventory pain score, and number of tender points.[6] and 7 L.M. Arnold, A. Rosen, Y.L. Pritchett, D.N. D’Souza, D.J. Goldstein, S. Iyengar and J.F. Wernicke, A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder, Pain 119 (2005), pp. 5–15. Article | PDF (264 K) | View Record in Scopus | Cited By in Scopus (141)[7] Men were found to receive no significant effect from treatment.6
As far as the existence and cause and so on from the medical community, we do tend to have difficulty (eg, being kind, and not getting stressed out) with pain patients especially when there is no evident cause. In part, this is because of the massive contamination of our pain patient populations with people who are seeking disability or narcotics, or just want to cover up their issues with drugs / are "woe is me" types. Obviously there is a lot of real suffering out there and it is difficult to sort out who should get the strong stuff and who should not. In general, my belief is that monitoring effectiveness in (as Freud put it) "love and work," is the key. If someone tells me they need more oxycontin and they've only been less active, not working, fighting with spouse over use--then it's no. If the drugs have put them back in karate class? Enthusiastic yes.
A major worry is creating a monster. Case in point, I recently admitted someone with diffuse body pain after an accident (years ago). He was having so much nausea from the drugs he was vomiting and had to be admitted to get IV drugs (still causing nausea apparently). Instead of pressing the button when pain occurred he sat motionless with a watch and stabbed the button every 8 minutes to get the max dose. Despite enough narcotics to kill a horse, his pain was still 9-10 out of 10 (ie, no better, just addicted to narcs). Additionally, he was getting much more medicine overall due to the easy availability in hospital and the overnight doctors' inability to say no when constantly paged. Only "bolus" meds worked, not infusions (go figure). His pain got worse from not walking. His posture was terrible and he wouldn't consider adjusting it. He noted the pain was constant and severe and unchanged by working but still wouldn't work, or do anything. When the pain doctor said he wouldn't get a pain pump until he got to clinic, suddenly the nausea improved (go figure) and someone who cried when I said he should start taking sips was able to to drink 5 liters that night. The entire life revolved around narcotic doses and, again, no function or real relief was to be seen. In short, we'd created a monster. Huge drug addiction and not any more functional or happy. Another issue is the act, shown in nauseating detail on an episode of Intervention, when a small child noted, "mommy seems fine until she goes to the doctor then she is sobbign and can barely walk" or something to that effect. There's nothing like treating "pain" and getting a letter from a pharmacy that your patient has gotten 26 controlled substances from 10 doctors in the last few weeks. Or when my patient starts calling me drunk for vicodin and becomes verbally abusive when I won't prescribe it for someone with other substance problems, a contraindication to the tylenol part, and no indication (garden variety low back pain only--I've had it, it was bad, meds didn't help, narcs are not the answer).
In contrast, my experience with cancer patients is that they frequently have to be talked INTO taking medications or increasing their doses and they don't have similar apathetic spells until they're suffering from advanced disease, and they frequently give me goals such as travel, work, doing things with loved ones. I'm not saying real pain doesn't deserve powerful medications at all. I am just relating that it is very tricky to sort out whether we're helping people or giving them new problems or whether the person we're dealing with has ulterior motives or larger issues. It's very unfortunate that humans are predisposed to abuse these drugs, **because it sure makes life more difficult from those who really need them.** Meanwhile I work with my trainees to explain that pain is important to treat, sometimes you have to trust people even if you get burned, and even an active heroin abuser needs morphine (at high doses due to tolerance) when there's real pain happening.
Good luck out there... posture and core work has mostly managed my back pain, I wish it were that easy for all.
--Ian
-
Bill Glasheen
- Posts: 17299
- Joined: Thu Mar 11, 1999 6:01 am
- Location: Richmond, VA --- Louisville, KY
Me? My secret, magic, ancient Chinese medicinal agent is... ice. I find the specific point on the specific muscle that's giving me problems, and slap on a zip-lock bag of the stuff. At least an hour. A day or two of that on-and-off followed by occasional heat and resistance training rehab and I'm good to go.IJ wrote:
posture and core work has mostly managed my back pain, I wish it were that easy for all.
Second best ancient secret? A great massage of the affected area by a professional masseuse. The better looking SHE is and the better our conversation during the session, the more likely the pain status will improve. It's a mind-body thing you know...
Worst thing for all of this? Stress. Again, it's the mind-body thing.
- Bill
But no significant side effects to either!