Pain: Are Narcotics the Answer?

Just back fro the annual meeting of the American Academy of Pain Management in Phoenix, AZ. It was a meeting well worth attending, with many experts from a variety of related fields sharing their knowledge and experience. Here is a very brief overview of some of the current issues in pain management.

Approximately 110 million Americans suffer from acute or chronic pain; of these 100 million suffer from chronic pain, which generally lasts more than 6 months. Examples of pain which can become chronic include sciatica, neck strain, myofascial pain, osteoarthritis, knee and hip arthritis, fibromyalgia and migraine headaches. The cost to the economy of chronic pain alone is more than 600 billion dollars a year, almost equally divided between actual medical cost and the cost of loss of productivity. According to an article in The Journal of Pain this is more than the yearly costs for cancer, heart disease and diabetes.

Many people have felt that the mainstay of treating chronic pain is narcotics. Some of the better known ones include Percocet, Vicodin, oxycodone and Oxycontin. But many others exist, Opana, Dilaudid, Duragesic (fentanyl), tramadol, Nucynta, and Butrans, to name just a few.

While the use of opioids is sometimes necessary, this should hardly ever remain the only mode of treatment (an exception to the rule might be the terminal cancer patient). Long term use of opioid medication frequently leads to opioid-tolerance and addiction, and sometimes to dreadful medical and legal consequences. Furthermore, long term use of opioids can, by itself, lead to an increased awareness of pain, where a person begins to have more pain without actually having a worsening of his/her physical condition.

Occasionally, pain becomes chronic because it was not immediately treated. There are numerous cases where pain was inadequately treated just because of a law suit, or just because an insurer refused to allow, delayed, or limited the treatment. Or maybe someone just decided to “drag the case.”

The answer to the treatment of chronic pain is simple in principle. It involves a multidisciplinary approach. There is no one treatment that fits all. Each patient must be individually evaluated, and a course of treatment designed. Treatment may involve one or more elements of physical therapy, massage therapy, acupuncture, chiropractic, yoga, nutrition and special diet design, psychologic/psychiatric support, drug counseling, and the use of non-narcotic medications.

And, yes, as the pain subsides, the use of opioids has to be adjusted. And if tolerance and addiction interfere, then these have to be carefully handled in order to help prevent relapses and uncomfortable narcotic withdrawal.

One great way to treat the opioid addiction is the use of Suboxone. Prescription of Suboxone is by special license. To my knowledge, I am the only internist between Darien and Bridgeport who is licensed to do so. For information about Suboxone click here.

Weight loss - the old and the new

We all know the facts: Over two thirds of Americans are overweight. Half of them (one third of Americans) are medically obese, which places them at high risk for the development of premature heart attacks and a variety of other serious medical conditions.

The main cause of obesity is overeating, even more so than lack of physical activity.

The most effective way to lose weight is portion control, and with it comes the control of caloric intake.

But portion and calorie intake control is a tough job. It’s a “full time job,” and it takes willpower and discipline.

So what do you do when the brute force approach doesn’t work for you?

The New York Times Business section of February 16^th had an interesting article on the possible approval by the FDA of a new appetite suppressant, Qnexa (U.S. to Review Diet Treatment Once Rejected).

The use of appetite suppressants for the treatment of obesity has a long history. Medications like phentermine, Tenuate and Xenical have been used for years (we all remember the fen-phen period, of which phentermine emerged as the surviving drug…).

More recently, metformin (used in diabetes) has been used in some cases, and a combination of phentermine and certain antidepressants has been shown to be more effective than phentermine alone.

What’s new about Qnexa is not really new. The proposed drug is a combination of two well known medications now widely used: phentermine, the familiar appetite suppressant, and topiramate (Topamax) which is most commonly used for migraine prophylaxis.

Topamax, like most other drugs has a long list of side effects, one of which is weight loss. So physicians who treat obesity, have now begun using Topamax “off label” for it’s weight loss side effect, in combination with phentermine. The combination appears to be very effective.

Diabetes and memory loss – If I were a mouse…

In diabetics, blood sugar levels that are persistently high, low, or widely fluctuating are an indication that the diabetes is not under control. Diabetes, especially when uncontrolled, is a known cause of progressive memory loss. Besides making sure that your diabetes is under control, what else can you do to protect against memory loss?

Many of us drink coffee to feel more energetic, help us think more clearly,  or work more efficiently. But does regular coffee, or decaffeinated coffee help memory or prevent memory loss? 

Studies in specially bred mice, done several years ago, suggested very strongly that coffee enhanced memory. When mice drank the equivalent of five caffeinated cups of coffee a day over several weeks, their memory was far superior to those who drank plain water.

For those who think 5 cups of caffeinated coffee a day is too much, what about decaf?

A more recent study done on the same type of mice, showed similar results.

So what about man?

Several uncontrolled studies in man suggest that caffeine slows age-related memory loss. One study, done in Portugal, showed that people with Alzheimer’s had consumed less coffee than their non-Alzheimer counterparts.

So where do we go from here?

Meet you at Starbuck’s tomorrow morning, and bring your mouse with you.

Think prevention and early detection

We now answer our phone as “Doctor’s office” rather than “Doctor Staw’s office,” and there’s a reason.

As of Monday, January 16, a new physician in town is sharing office with me. His name is William Sanchez, specializing in family practice. Dr. Sanchez was born in the Dominican Republic, where he also attended medical school. He did his medical training at Columbia Presbyterian in New York City and at the University of Arizona, Tucson, AZ.

While Dr. Sanchez and I will each maintain our separate practices, both of us expect to be working closely together; we firmly believe in the value of early detection and preventive medicine. Office cost sharing will allow both of us to give our patients the type of service which is only available in a “solo practice.”

Our office is now in the midst of implementation of our newly acquired EMR (electronic medical records) system. It takes a little while to get used to it, but I know it will be worth it at the end. More about it in the next blog(s).

Don’t forget to request your renewals by email at renewals@drstaw.com. You can also contact me for non-urgent matters at istaw@drstaw.com.

Stay warm.