Pain Management Demystified
In this post I am going to be talking about ketamine, a non-opioid pain medication that can be helpful in acute and chronic pain. I’ll first go over the pharmacology of this medication and explain why it is different from opioids, which can be useful…
In this post I will be focusing on dietary changes to manage pain. This is a very common thing that patients ask me about, as it is something they can take charge of at home. The relationship of diet and pain is a very complicated…
In this post I will be discussing another therapy used for chronic pain: medical marijuana. Since I practice in NY, and the state laws vary so much, I will only be discussing the program in NY. I’ll give a brief overview of how the program is set up here and the different types of medical marijuana products used. Then, I’ll talk about the evidence to support the use of medical marijuana for pain.
New York State currently has what is called a certificate program, meaning that physicians who undergo additional training in medical marijuana use are able to certify that patients under their care have qualifying conditions which allow them to enroll in the program. There is no prescription issued per se, which is important, because federally, marijuana is still considered illegal. The qualifying conditions in NY are similar to many other state programs, and importantly for my practice, include chronic pain and cancer. This past year, New York also added opioid replacement therapy as a qualifying condition, which is relevant to my practice as well.
Once a patient is enrolled in the program, they have access to specialized pharmacies called dispensaries, which sell medical grade marijuana products. Although there are many ways to utilize medical marijuana, in New York, all that is available currently are oils that are vaporized, liquid that goes under the tongue called a tincture, and capsules. Smoking and edibles are not approved in NY at this time. There is no insurance coverage for medical marijuana products.
There are two major chemicals in marijuana that are used for medical purposes: THC and CBD. They each have their own effect profile that makes them suitable for certain treatment goals. THC is a chemical that in high doses can have psychoactive effects (making people feel “high” or altered), but in low doses is a very powerful pain reliever, especially for nerve type pain. CBD is a different chemical with limited psychoactive effects, but appears to be a weaker pain medication and may have some benefits for anxiety.
Companies that prepare medical grade marijuana products are able to provide different blends or ratios of the two chemicals leading to different side effect profiles. Many of my patients wind up using two different types of products: a high CBD or pure CBD product during the daytime, and a higher THC or 50/50 ratio product at night.
I most often recommend to patients that they use vaporized products, as the onset of action is the most fast and reliable. Tinctures take slightly longer to kick in, but are also a good option. I rarely recommend capsules with any THC in them because the oral absorption is pretty unpredictable, meaning that patients cannot depend on reliable effects in a certain time frame.
There are multiple studies looking at and demonstrating the efficacy of medical marijuana. Associated pain conditions that can be treated by medical marijuana include neuropathic (nerve pain), cancer related pain and fibromyalgia. It can be tricky to study medical marijuana for many reasons. First, the illegal federal status can make it difficult to obtain for studies and also makes many researchers wary of conducting trials. Additionally, there is significant variation in CBD and THC levels depending on which strain of marijuana is used. More high quality research would greatly benefit the field.
I talk to my patients about the risks of medical marijuana, including small chance of addiction, potential to worsen mood issues, and the fact that we are not sure of the long term health issues relating to chronic vaporizing/use, although we believe it is safer than smoking the plant. The decision to certify someone is made after a thorough review of their medical history, physical examination and discussion of all of these factors. I also have my patients sign a controlled substance agreement, similar to my practice for opioids, and complete a urine drug screen. Patients remain actively under my medical care, and may be receiving other complementary pain therapies as well from me.
Medical marijuana can be a politically and socially fraught therapy, but as someone practicing on the frontlines of the opioid epidemic, I am grateful to have another tool in my toolbox to help patients with chronic pain.
In this blog post, I am going to be discussing a common complaint for my patients: shoulder pain. I’m going to mainly focus on muscle issues (rotator cuff pathology and biceps tendonitis) and in another post I’ll talk about some other issues affecting the shoulder.…
This blog post is going to be a little bit of a departure from my normal topics of pain conditions/treatments. I feel strongly that pain management doctors like me, on the front lines, need to share our experiences and thoughts regarding the opioid crisis. I…
In this post I will be talking about a pain disorder called spinal stenosis. This can occur either in the neck, known as cervical spinal stenosis, or in the low back, known as lumbar spinal stenosis. I will be mainly focusing on lumbar spinal stenosis.
Spinal stenosis is a generic term that is used to describe a narrowing in the spinal canal. Stenosis can occur either in the foramina, which are the holes that the spinal nerves come out of, or centrally, in the area where the spinal cord and fluid lies. I am not going to focus on foraminal stenosis in this blog post because it was already covered in my post on radiculopathy.
In the lumbar region, central spinal stenosis most often arises as a result of degenerative changes in the spine, which cause thickening in the joints and the soft tissues that then reduce the amount of space in the spinal canal. Some people are more predisposed to this than others because they are born with slightly smaller canals at baseline. In the neck, these same changes can cause spinal stenosis, but sometimes a disc herniation is enough to cause central spinal stenosis because there is so much less room in this area.
Patients with lumbar spinal stenosis most often feel leg pain or “heaviness”, particularly when they walk. The pain tends to get better after a short period of rest, and then it starts up again with movement. Patients can report a “shopping cart sign”, which is when they feel better bending over something while walking (like a shopping cart!). This motion opens up the space in the spine, so it isn’t surprising that it helps. The pain can be associated with numbness and tingling in the legs. Cervical spinal stenosis can present less specifically, but usually involves symptoms in the arms such as numbness, tingling and pain.
To make the diagnosis, after a good interview and examination, the pain doctor will normally order an MRI of the spine. Treatment options include pain medications, mainly ones that work on nerve pain, physical therapy to strengthen the back/condition the patient, and epidural steroid injections to reduce any inflammation from the compression. If the stenosis is very severe, I will refer patients to a spine surgeon to see if they are a candidate for surgery to relieve the compression.
I hope that helps to explain spinal stenosis! Remember, the best way to be evaluated for this condition is to see a pain management doctor in person. And don’t forget to subscribe to my blog here so you never miss a new post.
Today I will be covering the topic of migraine headaches. This post was a special request, and a little while coming, because to be honest, I am not a headache specialist! I do treat some headaches, but more often I see tension headaches arising from…
In this post I’ll be discussing Transcutaneous Electrical Nerve Stimulation (TENS), which is a therapy that falls under the heading of “other modalities”. I really like offering TENS as a treatment option because it is non-invasive, and not a medication or procedure. I’m going to…
Fibromyalgia is a condition that I see and treat often in my pain management practice. In this post, I will discuss an overview of fibromyalgia, including common symptoms and how it is diagnosed. I will also talk about different treatment options including lifestyle modifications, medications, other modalities and interventional procedures.
Fibromyalgia is a condition that is characterized by widespread pain and is associated with other symptoms such as fatigue, poor sleep, and poor concentration. We are still not exactly sure what causes fibromyalgia, but it is likely that there is an interplay of genetics, physical and emotional stressors that combine to cause the symptoms of fibromyalgia. There is probably an alteration in the way that the brain processes pain signals which leads to increased frequency and intensity of painful sensations.
Fibromyalgia is more common in women, and is associated with other conditions including anxiety, depression, TMJ disorders, and irritable bowel syndrome. I treat a lot of pelvic pain in my practice, and I have found that there is significant crossover with this condition as well.
In the past, we used to diagnose fibromyalgia by putting a specific amount of pressure over various points of the body. If more than a certain number were painful, this was considered positive. Now, we use a Widespread Pain Index, which is a way of assessing for diffuse pain that occurs for more than three months. The pain cannot be caused by another diagnosis, and is associated with other symptoms like fatigue, poor sleep, and poor concentration. We will often do blood tests to rule out other disorders before fibromyalgia can be diagnosed.
Some of the most important treatment options for fibromyalgia are lifestyle modifications. This is really hard to do because it involves changing habits, but it is also probably the most important aspect of a fibromyalgia treatment plan. Evidence shows that regular cardiovascular exercise is helpful in controlling the symptoms of fibromyalgia. I usually tell my patients that they may feel a little worse after each episode of exercise, but that the overall trajectory of their long-term pain patterns is one of improvement. It is also totally fine if the exercise is gentle walking for 20-30 minutes! Sometimes it can feel overwhelming to think that good exercise is something intense like running a marathon. Small steps are more achievable and just as good for the symptoms of fibromyalgia. I also discuss sleep hygiene measures like a regular bedtime, no screens one hour before bed and trying to limit alcohol before bedtime.
Medications that are helpful for fibromyalgia are typically taken daily as a preventative measure, and they include some anti-depressants such as Cymbalta and Savella. Lyrica is another medication that is approved for use in patients with fibromyalgia, and Gabapentin is an older cousin of Lyrica that I often use if patients can’t get Lyrica approved by their insurance company. I also discussed in another post the use of low dose naltrexone, which isn’t formally approved yet for fibromyalgia, but I think likely will be in the future.
I try to manage breakthrough symptoms with anti-inflammatory medications and muscle relaxants as needed, but these medications are not intended for daily use as they can have side effects. Opioids are not a good option for fibromyalgia because they can actually worsen pain over time.
I am very supportive of patients trying other modalities to control their pain from fibromyalgia including acupuncture and mindfulness based therapies (see my other post about mindfulness). Sometimes starting therapy can be helpful too, because the stress of a chronic illness like fibromyalgia can be really challenging to manage alone.
As far as interventional treatment options, I typically will offer patients trigger point injections if they have severe areas of spasm. You can find a discussion of trigger point injections in this old post. Unfortunately, there isn’t one fibromyalgia injection that fixes the all the symptoms of this disorder.
If you are worried that you might have fibromyalgia, the best thing to do is get evaluated in person by a pain management physician so that you can be assessed. If you do have fibromyalgia, a pain management physician can help to develop an individualized treatment plan for you.
Now that we’ve discussed radiofrequency ablation in this prior post, let’s discuss a particular application of the technique called genicular radiofrequency ablation. This procedure is done for knee pain, particularly knee pain from arthritis. This procedure is exciting because many people do not want to…