Pain Management: | Arthritis Information

Hi! My Dr. suggested I see this other Dr. that specialies in pain management. Have anybody here seen this type of Dr. before? I had a cortizone shot in my right hip and it didn't work. Thanks for any replys.. Take Care! Paul

A doctor once suggested I see a doctor specialising in pain management but I never went ahead with it. I believe they vary with some teaching you techniques for coping with pain using means besides medication while in bad cases they may use drugs and techniques such as deadening of nerves by giving an injection that the comon GP would not be likely to use.

I'd imagine that some might be very good at what they do while others might do more harm than good. Given that like a lot of people I tend to take the easy way out and rely soley on medication it's certainly worth considering as there must be other ways besides routinely swallowing pills that might help.

Only today I posted at the RA Friends site about pain clinics in Australia and invited people to read an article about them and say what they thought.

I'll post the article here so people can read it and maybe respond to it:

Pain in the Brain-We can expect more of it
As people live longer, many may have to come to terms with enduring pain. Pain can arrive out of a clear blue sky through accident, operation or even a dental procedure, but if it is not treated with due respect it will be followed by a host of compounding and debilitating reactions. These create a whirlpool that can tear a person's world apart, capturing their health, relationships, work and future.

Four million Australians are living with chronic pain that interferes with their daily lives and, according to research published in the journal Pain, they've been living with it for three months out of the past 12. Their pain will cost the nation more than billion a year in treatments, welfare payments and days off work. The social, familial and emotional costs are beyond measure.

The treatment of acute pain also leaves much to be desired, according to some of Australia's leading practitioners. However, in this area it is not new drugs that are needed so much as new attitudes, education and a huge injection of funding.

The really bad news is that the chronic pain load will increase as life expectancy grows, and drugs will be of next to no use in the long-term treatment of such pain, for any but the aged. And there's the rub. For generations that have been brought up to believe that science and medicine make the experience of pain optional, the idea that they may have to deal with it as part of their daily lives is tough medicine.

Unfortunately, our instinctive reaction to acute pain only makes the treatment of chronic pain more difficult. Humans have adapted a survival tactic for acute pain that has stood us in good stead for 60,000 years. When traumatised, like all animals we contract into ourselves, nurse the damaged area and go to ground to wait for the healing to begin. Acute pain is smart pain. It signals that something is wrong and the body responds accordingly. This response enables the body to heal.

It is also the kind of pain that Western medicine should be good at treating because opiates such as morphine and pethidine are extremely effective in the short term. According to Michael Ashby, professor of palliative care at Monash Medical Centre, Melbourne, the problem is one of priority and culture.

"Health-care professionals appear to have a high pain threshold on behalf of their patients," Ashby says. "There is an obvious element of subjectivity in pain assessment - except in cases of cancer - and people are scared of pain management. They're afraid of creating addiction and afraid that patients may be overstating their pain in order to get drugs."

He believes the solution is as simple as it is expensive. "Healthcare professionals need to take the issue of pain seriously. It's not a high priority, so it's not funded and there is very little education given at all levels of health care. To do this we need real dollars."

Managing chronic pain has an even worse prognosis, beginning with the nature of the pain. Michael Nicholas, clinical psychologist at the Adapt pain management clinic, Royal North Shore Hospital, Sydney, says:
"Chronic pain serves no useful function and is, in a sense, stupid pain. The damage has already been done. The pain response will not promote any more healing, so it's useless."

It is not new drugs that are needed so much as new attitudes, education and a huge injection of funding.

Nevertheless, as life expectancy grows, so will the number of people living with such pain. The most common sources of chronic pain relate to arthritis, back pain, neuropathic changes (nerve pain) and post-operative pain. (Pain caused by cancer is in a category all its own and is not included here as chronic pain.)

Unfortunately, people experiencing chronic pain follow their instincts. They slow down, stop moving painful areas of their body, nurse themselves, take pain killers, and begin to see themselves as sick. In the end, their families collude with this dynamic and begin to see them as fragile and disabled. The result is a host of secondary problems that, if left untreated, could prove more damaging than the original trauma.

"By the time we see someone for assessment," Nicholas says, "they're usually on a cocktail of powerful drugs, there has been a lot of deconditioning, they've lost their fitness, they've started self-medicating with alcohol and marijuana, they're very depressed because they've tried a host of treatments before they get to our centre, and they may have become unemployed as a consequence of all of this."

It is in this state that the patient is asked to make a very difficult decision: how willing are they to take responsibility for their own pain management? And no, that management program does not include drugs. Nicholas compares this approach with the way asthma sufferers or diabetics are asked to treat their illness.

"It's a choice between being active in your own treatment and management or passively waiting for some new medication to save you - which isn't going to happen," he says.

Before starting the program, which runs for three weeks, patients are given a thorough assessment to ensure that everything that can be done to relieve the pain has been done. They are also asked to take themselves off all prescribed medication and to ease back on self-medication.

The first week is spent coming to grips with the fact that their pain is not negotiable - it is here to stay. The only choice they have is how they deal with that reality.

The difficulty of accepting the situation cannot be underestimated. After all, this is the 21st century, when sheep are cloned and Mars is filmed. Every day consumers are bombarded with advertising that shows the comforting effect of the latest drug on that niggling or severe pain.

On day one, patients leave their crutches and braces at the door and begin the work of setting goals, stretching limbs and learning the rudiments of cognitive behaviour therapy, or CBT.

"When people first arrive, they're prone to catastrophising their lives," Nicholas says. "That is, they will constantly tell themselves, 'I can't go on, I can't survive, if such and such happens I wouldn't be able to take it'. We challenge those thoughts - that's what CBT is all about."

Patients and their families are encouraged to stop identifying themselves with their pain. Yes, their pain is real; no, it is not the sum total of who they are. Curiously, this can be just as hard for other family members, who may be getting a good feeling from the power they have over the "sick" person. And the pain affected person may get a secondary benefit from being seen as fragile.

The intersection between mind and body becomes a contested place when pain enters the picture. While accidents and cancer create solid evidence of the existence of and reason for pain, many causes of chronic pain are hard to locate and even harder to see. Back pain, nerve pain and, in rare cases, phantom limb pain are extremely difficult to locate. That doesn't make the pain any less, but it does make the sufferer sensitive to allegations of malingering. It becomes hard to avoid the guilt-inducing notion that "it's all in your head".

Of course, that's where all pain resides - no head, no pain. However, current research is examining the idea that constant chronic pain may be able to change the way the brain is wired.
"The longer you feel pain, the harder it is to get rid of," says Charles Brooker, anaesthetic specialist at RNSH.

"There is, so far, limited evidence of pain rewiring the brain, but it appears its chemical composition changes. It looks as if the neurotransmitters that receive pain actually grow."

If pain enhances the brain's sensitivity to pain, and therefore creates more pain, it would follow that relief in the form of drugs should be used early and often to prevent the brain from becoming sensitised.

Not at all, says Brooker. "Drugs work better over a short period, but long term they create problems of tolerance and reduced efficiency. There are also some kinds of pain, like nerve pain, that can't be controlled with any kind of drugs."

Both Brooker and Nicholas have enormous regard for people's capacity to deal with high levels of pain while having a good quality of life.

"Human adaptation is amazing," Brooker says.
"I have seen people control pain very effectively using relaxation and those kinds of techniques. They move through the pain and stop identifying with it."

However, Barbara Workman, the head of the pain clinic at Melbourne's Kingston Centre, believes drugs can play a vital role in the treatment of chronic pain in the elderly.

`Chronic pain serves no useful function and is, in a sense, stupid pain. The damage has been done.'

"In the age group of my patients [55 years and older], chronic pain is more likely to be physically based than psychological," Workman says.

"So, while we use psychological tools like bio-feedback, we also use physiotherapists and community-based services. The issue of tolerance and efficacy is not such a problem because if the patient is in their 80s, they're looking for comfort right now, and tolerance and loss of effect is a secondary issue."

She sees pain as a complex issue and shies away from any one-size-fits-all approach, saying: "The kind of pain management used has got to depend on a variety of facts and must include the stage of life the person is in."

Of course, whether it is CBT or drugs, all these techniques are predicated on the patient's ability to communicate what is wrong, where it hurts, how much it hurts, and when they have had enough medication to stop the pain.

But what about people who can't communicate at all: babies, the cognitively impaired and those suffering advanced dementia. As recently as 20 years ago, health professionals believed infants could not feel pain. This is one reason painful procedures such as circumcision were performed without any pain relief.

According to John Collins, a physician at Westmead Children's Hospital Sydney pain in infants and the cognitively impaired has, been one of the most marginalised areas of pain study. Fortunately, as a result of advocacy on the part of parents and committed health workers, "there is a cultural revolution under way in pain management and paediatricians are leading the way", Collins says.

Evidence of that change can be found on the observation charts used at Westmead. The hospital is now using a Canadian technique called the Neonatal Facial Coding System to gauge infant's pain.

"The pain severity assessment chart means that everyone working with the child has got to be as aware of the child's pain situation as they are of the child's blood pressure and pulse," Collins says.

"So it forces the issue of pain management to consciousness."

As baby boomers move into their 60s and 70s, pain consciousness promises to be a growth area. While pharmaceutical companies spend millions on research and development in the area of pain management, Adapt's Nicholas offers some sobering advice.

"Ultimately, drugs don't offer a long-term solution to pain because when we drown out the pain signals, we also drown out signals that tell us how to live."
Story Julie Macken

I'm not sure I agree with the last sentence. The Tramadol I take lessens my pain down to a level where the pain doesn't debilitate me greatly and stop me living normally but I'm not aware that it 'drowns out signals that tell me how to live' as it's not that powerful a painkiller. Certainly because of the Tramadol I sometimes do things I probably shouldn't like work on my car for hours contorting my body in all sorts of ways that without the Tramadol would be quite painful and I usually suffer increased pain for the next few days.

The person making the statement might have meant that pain signals warn us to take it easy or stop doing whatever is causing us pain but as was pointed out earlier in the article a lot of pain associated with conditions like arthritis is totally useless. Stopping that sort of pain if anything enables us to live with a better quality of life rather than drowning out 'signals that tell us how to live'.

Someone high on heroin might be so high that they can't function normally and live with sensitivity to situations and people they encounter but most painkillers just take the edge off the pain without making us feel and act as if we were doped up.

A pain clinic like the one referred to in the article where the first thing they tell you to do is throw out all medication would in some cases be throwing out the baby with the bathwater since the painkillers many people take improve their quality of life and enable them to live more fully. That is the case in my situation and I imagine many other people would feel the same about the pain relief they get from their medication.

Only a sadist would want to rob me of the relief I get so that 'the signals telling me how to live' were not blocked. For me my painkillers only 'rob' me of my pain as far as I can tell and no pain clinic is going to convince me to experience unecessary and useless pain so I can 'receive the signals telling me how to live'!

dragon38757.7155787037I would have had no quality of life over the last year if I did not have pain meds. They enable me to live a somewhat normal life. If my doctor was not taking care of my pain, I would go to a pain clinic. Good luck - Paul

I have not been to a pain management clinic- but at my GP's office there is one doctor there who has had a number of patients needing chronic pain management...I have been seeing him for a month now- because I was taking 18 ibuprofen and 2 oxycodone and 4-6 valium a day and not even making a dent in the pain...So they switched me to Methadone and Tramydol for breakthru pain and Clonazapam for my neck and shoulder pain. I was hesitant at first as the methadone made me really sleepy and so of course I took it my way....half a pill instead of a whole one...Well at my 2week checkup he explained that I needed to be up to 30mg by the next visit- or we would be getting nowhere really fast...So I am now taking the meds as prescribed and have had a whole week of no pain..It is truly a blessing...To not be in constant ache ache land - I am still having a problem with the sleepies-but I guess for now I prefer that to the constant pain and have been told that will go away. It does not make me goofy or high- it just takes the pain away...I can still tell that it is there- way off in the distance...so if I listen to my body I will know when I am overdoing it.

Many people think that I am copping out by giving into and taking this pain medicine...which is why I was only taking 1/2 of a pill- My advise to anyone is you need to be knowledgeable about the medicines that are prescibed to you and you need to ask questions and research things...Don't just take someone elses word for it all.

You need to use common sense when you talk to a doctor about pain management and you need to design and implement a plan that will work for you and your situation.

I have come to the conclusion that people are well meaning- they just do not understand....

Hi! I am not sure what I am going to do yet. I saw my Dr. today and he wants me to try physical therpy to see if that will work. He said it was up to me if I wanted to see a pain manegement Dr. I have Vicadon but do not want to take any unless the pain gets so bad that I can not stand it. I do not like takeing addictive drugs. Right now I am Takeing Ibuprofen 800 mg. 3 times a day. It is only in my right hip that I am having all the pain. Take Care! Paul Paul, If you wait too long to take pain meds, they are not as effective. Just a thought.

sounds like a good plan Paul. i take pain medication when i can't stand the pain anymore as well. people tend to overdo it with the pills and tell everyone that they should just take a pain pill for everything. there comes a point when if you keep taking the pain pills when not needed they will not help you as much then you keep needing a stronger pill. we learn to grow tolerance to a certain amount of pain. let us know what you decide to do. best wishes.

Did you know that Dr's order PT for people who whine and they dont know what else to do for them? Just take the pain pills. Why suffer?Paul,

As of March I will have had this Dx for one year and It's been a hell of a year... I thought I would have to give up my job because I did not have use of my hands....

I have finally found relief with Humira....but I still have some pain. I take Aleve for it.

Please don't get sucked in to the "Pain Med" thing like alot of people do! You will become addicted to that stuff......like alot do.....

Then you will become tolerant to one and have to go to one stonger.....It's happening as we speak.

Stay strong...don't go the Pain Med route.......

Nancy

Paul, Pain meds are a very personal choice. It all depends if you have an addictive personality. Personally, I can keep several different strengths of pain meds in the house and take them only as needed. I never take more than the doctor prescribed and have many days that I do not take them at all. I am very grateful for my pain meds. I am an extremely active person and pain meds allow me to live the best quality of life I can with RA and be as active as possible. I just hope you have good communication with your doctor, you need to be honest with rd/gp and yourself. Some people have addictive personalities, some don't. I think some people just think that there is merit in suffering. I don't get it but we are all different. Wishing you pain free or less pain days to come.

I really disagree with this statement....I rarely say that when someone has an opinion; but this time I think I have to. My doctor has only suggested PT for me once, and that was for some continuous back problems.....but I do not feel like he recommended it because I was whinning and he didn't know what else to do for me.

And for the record; I am not against precription pain medication; I take plenty of it. I do however think that some people can benefit from PT.

Lovie38757.4184837963[QUOTE=1tko]

[QUOTE=Paul52] Hi! I am not sure what I am going to do yet. I saw my Dr. today and he wants me to try physical therpy to see if that will work. He said it was up to me if I wanted to see a pain manegement Dr. I have Vicadon but do not want to take any unless the pain gets so bad that I can not stand it. I do not like takeing addictive drugs. Right now I am Takeing Ibuprofen 800 mg. 3 times a day. It is only in my right hip that I am having all the pain. Take Care! Paul [/QUOTE]

[/QUOTE]

I agree with with 1tko. When my hip first started hurting me I first started using cruches. I didnt want to use pain meds because I have seen to many people addicted to pain meds. I started taking Darvocet before I had my first hip replacement and have been taking them ever since when ever I need them. My doctor says I should be taking them daily, I dont. I take them about once a week. I would rather deal with the pain than be a pain pill junkie.

Pain meds are sure a controversial topic. Maybe we should just stick with it is a personal choice.

As far as addiction goes I believe that most people desperate for pain relief aren't worried about addiction. Addiction is when you become preoccupied with getting the drug you are addicted to and take it to get high or feel good and not for any justifiable medical purpose. The Tramadol I take only takes the edge off my pain and does not make me high although there can be a slight sedating effect. If I suddenly stopped taking it I would suffer terrible withdrawal symptoms but if I came off it in gradually decreasing doses I could get off it completely in say 6 weeks without any problems apart from having to live in pain. I do not consider myself addicted to it because my body goes into withdrawal symptoms if I stop taking it. I am not addicted because the only reason I take it is the intended one-pain relief and I take only enough to reduce my pain to a level where I can live relatively normally. If the pain was not there I would immediately begin the process of getting off it completely.

An addicted person takes a drug compulsively for no justifiable medical reason and lives for the next �hit�. The addicted person�s life revolves around getting more of the drug he is addicted to and ensuring he can get his next 'hit'. I suppose it could be rightly argued that a person on pain medication was addicted if they routinely took far more of the pain medication than they needed, in order to get secondary �benefits� like feeling high but the sort of painkillers that might make you feel high don�t tend to be prescribed for pain relief long term by doctors. If the person saw different doctors to get more of the drug in order to get high then such a person would be addicted.

I take Tramadol because it has a long acting effect and my pain is in many of the joints in my body. I need a painkiller that lasts all day and dulls the pain all over my body. The fact that my body is used to it and goes into withdrawal if I stop taking it is of little importance to me since it allows me to live reasonably normally and I would not want to live in constant pain just to not be dependant on a drug. I may be able to learn how to increase my tolerance to pain by going to a pain clinic but I don�t want to spend several hours a day using relaxation techniques like meditation or cognitive behaviour therapy to be able to live with pain. I�m just thankful Tramadol was made available here in Australia not too many years back because I would hate to think what my mental state I would be if I lived every waking moment in pain.

I wish that there was a way of making every person that ran a pain clinic experience constant moderate to severe pain over an extended period of time so that they could appreciate what routinely telling people that go to the clinic to throw away their painkillers right from the start really meant. A relative of mine once casually told me that I ought to throw away my painkillers and learn to live in pain as there are many people that live in severe pain and get on with there lives all smiling and happy with their pain not bothering them because they�ve learnt to put it into the background. Only someone that had never lived in constant pain could make such an insensitive remark.

A doctor once told me I should increase my tolerance to pain and learn to live with greater and greater amounts of pain as I got older rather than take painkillers. The curious thing was that this doctor was relatively young and healthy and totally pain free. What sounds good in theory looks very different when you are the one that has to put it into practice. I no longer see the doctor that made that comment by the way. However if he gets a disease that involves moderate to severe constant pain and can show me he practices what he preaches I�d go back to him.