Home Community Chat Transcripts-1/22/01

Pain Management with Dr. Susan Hoch

InsightHostKJ> Before we start lets go over the protocol for a guest speaker. Type a ? if you have a questions and DO NOT ask the question until I call on you

Melvin> JUst like back in Catholic school

InsightHostKJ> And I have a ruler melvin!

Melvin> LOL ouch

Melvin> Sister Mary KJ

InsightHostKJ> We're a little early but lets go ahead and start....Dr Susan is our guest tonight and will be discussing pain management BUT before we start with that I want her to address another issue

InsightHostKJ> Dr Susan, we've had several members that became very scared after hearing about the enbrel deaths, scared enough that they've stopped taking it....some without discussing it with their doctors

InsightHostKJ> is the fear justified?

DrSusan> It is frightening but so are the potential side effects from prednisone or gold or methotrexate or what the disease itself can do to you. There is no question that Enbrel suppresses the immune system. However, the risk of infection appears to be higher with methtorexate. Patients on steroids have more infections including life threatening infections than patients not on steroids.

DrSusan> Like everything else, you must weigh the risk and the benefit. Untreated rheumatoid arthritis is associated itself with significant morbidity and mortality.

InsightHostKJ> In your experience are the risks worth the benfits?

DrSusan> So far (and I am knocking on wood), I have not seen overwhelming infection from Enbrel.

DrSusan> I have seen some patients go off Prednisone after years on, I have seen others tell me they feel like their rA is gone and I have several others who have had no benefit whatsoever.

DrSusan> Rheumatoid arthritis itself is associated with an increased risk of joint infection.

DrSusan> Many patients are also on steroids which predisposes to infection.

Katie> So are there more deaths for mtx...that we just do not hear about?

DrSusan> In one study comparing Enbrel and methotrexate, the patients on methotrexate had more infections.

Katie> So are there more deaths for mtx...that we just do not hear about?

DrSusan> Actually there were no deaths in that series from either medication.

DrSusan> If you have mild RA and it can be controlled by hydroxychloroquine (Plaquenil) or asulfidine or minocycline, fine.

Tra> I'm on both; where does that leave me?

DrSusan> Tra, you are probably at some increased risk - are you also on Prednisone?

Tra> was, had to stop, stomach problems.

DrSusan> So at least that part of the immune system that Prednisone effects should be working.

DrSusan> I frankly prefer Enbrel to Remicade because it is shorter acting and is gone from the system in three days in the case a patient gets an infection.

Bettty> Is there a connection with heart disease and Enbrel that can be proved?

DrSusan> Enbrel is currently in clinical trial for the treatment of congestive heart failure.

DrSusan> It may turn out to be a good drug for the cardiologist as well.

Giggles> I cannot have enbrel due to having lupus and pericarditis ......why is that? Enbrel has just been released here so i dont know alot about it

DrSusan> Elevated TNF is not a feature of lupus, and we have no evidence that either Enbrel or Remicade have any positive effect on lupus.

Melanie> If you have infection and stop mtx, how long till system is recovered?

DrSusan> Methotrexate's immunosuppressive effect lasts for a number of weeks - it probably takes 6 weeks or so until it is out of the system.

DrSusan> In contrast, Enbrel is basically gone in three days.

Lucy> I have a pituitary tumor and have been on the prednisone for 2 years, could it have been the cause? or

Lucy> can the pituitary tumor be a cause of the ra

DrSusan> Certainly the majority of patients with RA do not have pituitary tumors. I tend to think you have two relatively unrelated problems.

I<i>nsightHostKJ> Thank you Dr Susan for helping to set us straight on that issue

InsightHostKJ> We ready to talk pain now?

DrSusan> Pain is certainly a hot topic these days what with the new JCAHO regulations. Are you familiar with this?

InsightHostKJ> Yup! We have a right to have our pain treated...right?

Melanie> Yes, thanks to KJ.

InsightHostKJ> Actually Ron wrote that one Melanie...thanks Ron

DrSusan> Yup. Since January 1, the Feds now require that hospitals, nursing homes etc monitor pain like it is a vital sign.

InsightHostKJ> and treat it accordingly?

DrSusan> That means asking patients to rate their pain on a scale and documenting whether the patients pain is relieved.

DrSusan> Presumably it also means notifying the physician and letting him/her know the patient's status.

DrSusan> It is not currently required to be done in outpatient offices as JCAHO has no jurisdiction there.

DrSusan> However, in my opinion, this increased attention to the patient's pain is good and should improve patient care.

DrSusan> And hopefully it will rub off on outpatient practitioners as well.

InsightHostKJ> Wouldnt that be great!

DrSusan> One of the things I find is that patients often assume that they must have pain and don't always tell me about their pain.

Melanie> Maybe it will help Social Security recognize pain as a debilitating factor too.

InsightHostKJ> It becomes a part of life for some of us and we don't think it is worth mentioning

DrSusan> Or, as happened today, with an inpatient, the patient refuses pain medication because "my sister told me I would become addicted if I took it."

InsightHostKJ> Can we become addicted?

DrSusan> KJ, we are realizing that there are many properties of addictive behavior including drug seeking behavior.

DrSusan> In general, someone who has never had a problem with addiction to nicotine, alcohol or other drugs, is not going to be easily addicted to medications given for pain control.

DrSusan> There is a difference between tolerance and addiction.

InsightHostKJ> Can you explain that difference?

DrSusan> Addiction requires ever increasing amounts of medication. It involves behaviors in which compulsive seeking of the drug becomes the paramount force.

DrSusan> In general, most people without an addiction history do not develop this personality just because they develop RA at the age of 40 or breast cancer at 45 or whatever.

DrSusan> What is difficult is when someone who already has had problems with addiction then develops an illness which requires pain medication.

InsightHostKJ> How would you deal with that?

DrSusan> Honestly, openly, maybe get a Pain specialist as well as a expert in addiction medicine involved.

panda> in australia if we want anything stronger than codeine we have to go on a government drug register

DrSusan> That is not true in the U.S.

InsightHostKJ> Addiction runs in my family..am I at risk?

DrSusan> Possibly more so than if it didn't.

DrSusan> But then, you were not addicted to anything before you developed rheumatoid arthritis.

InsightHostKJ> nicotine

DrSusan> I hope you stopped.

Lucy> what do you suggest the best non narcotic painkiller is to use?

DrSusan> One issue in Pain is that there are many kinds of pain - joint pain in RA or OA,

DrSusan> fibromyalgia pain, neuropathic pain.

DrSusan> So, in some ways, the answer is what kind of pain do you have.

Lucy> RA pain joints

DrSusan> In the U.S., your choices for nonnarcotic painkillers include Tylenol, Darvon, Darvocet, and Ultram as well as various nonsteroidals.

InsightHostKJ> are any of those addicting?

DrSusan> Many rheumatologists will give a patient an NSAID but will also add a pain medication.

DrSusan> There are individuals who can develop addiction problems with Darvon, Darvocet or Ultram.

rush> What about pain meds make me sick

DrSusan> Well, I suppose NSAIDs could bother your stomach; codeine and other narcotics can be associated with nausea and constipation.

DrSusan> And of course, people are allergic or intolerant to a number of medications.

DrSusan> I also find it helpful to distinguish between generalized pain and local pain.

CeeJay> Can diet, exercise etc. play a part in pain management...

DrSusan> You bet, pain medication is only one part of effective pain management.

I<i>nsightHostKJ> Can you explain how they can help?

DrSusan> Breathing exercises - ladies remember Lamaze, relaxation techniques, biofeedback, physical therapy, massage, heat, ultrasound, hot packs, cold packs, TENS, acupuncture - all these can be used to help with pain.

DrSusan> Diet may be helpful in that inflammatory substances tend to be generated in the usual beef/saturated fat diet and a diet rich in polyunsaturated oils tends to be less inflammatory.

DrSusan> Remember pain is a complex phenomenon involving nerve signalling from the peripheral into the spinal cord and up to the brain which then interprets pain.

DrSusan> Cold slows down some types of neural fibers. TENS blocks neural pain transmission by competing for transmission.

DrSusan> I don;t think I really understand how relaxation or biofeedback precisely work but it is clear that theyare effective for some people.

panda> i have trouble with codeine keeping me awake is there an answer to this?

DrSusan> First take it earlier in the day or second take it with a potentiating med that helps induce sleep - such as amitryptilene, neurontin for example.

panda> are they prescription?

DrSusan> Yes.

swimmer> How do you know if you need a pain medication. I have never taken one, and feel like I am getting by ok without it. Am I missing something?

DrSusan> If you don;t have pain, you don't need medication for pain. I assume on a scale of 1o 10, you are a O.

swimmer> well no

swimmer> but, I feel like I can tolerate it ok

DrSusan> But you can function adequately without extra meds for pain.

swimmer> yes I would say I can

DrSusan> That's great and I am happy for you. But not everyone can tolerate it. And people have vastly different thresholds for pain tolerance.

Giggles> I have only slept a couple hours a night for the past 4 years and the Dr gave me sleeping tabs to take..but I cannot walk for a couple days after using them due to severe flare up's....is there anything I can take to just increase my sleep by a couple of hours

Giggles> hot baths etc dont work to well

DrSusan> There are a number of approaches to this - true sleeping medications such as Ambien or Sonata or Restoril.

DrSusan> Or medications such as muscle relaxants like Flexeril that have a side effect of inducing sleep.

DrSusan> Or antidepressants such as amitryptilene or Remeron that tend to put people to sleep.

DrSusan> Or one of my favorite meds, Neurontin, which when taken at night tends to make people sleepy.

InsightHostKJ> Why is that a favorite?

Giggles> I'm on antidepressants..but they make me sleep to long and I have more pain the next day

DrSusan> Benadryl, an antihistamine, which is in Tylenol PM often makes people sleepy.

DrSusan> Then there are herbal teas such as SleepyTime tea.

DrSusan> There is also sleep hygiene - avoiding caffeine, mood music, soft silk or flannel sheets, etc.

DrSusan> KJ, why do I like Neurontin? Well, it is safe, generally quite well tolerated, has a wide dosage range, is wonderful for neuropathic pain such as diabetic neuropathy. I like it for fibromyalgia as well.

DrSusan> The most amazing thing about Neurontin is that so far, there is no lethal dose. A patient who took 47 grams as a suicide just became sleepy and drowsy. There is apparently no lethal dose for animals as well.

Melanie> Is there any benefit to hanging tough - putting up with the pain versus getting a pain med? Or negatives in that situation?

DrSusan> I don't personally ascribe to the hanging tough and bite the bullet school of pain control.

DrSusan> You must recognize that there is a difference between acute and chronic pain.

DrSusan> Acute pain is a warning to the system. Chronic pain results in chronic changes in neurons as well as changes in other organ systems - pulse rates and blood pressures rise with pain. I can't believe that chronic untreated pain is biologically good for the organism.

InsightHostKJ> So it is healthier to treat the pain?

DrSusan> In my opinion yes. You know it is interesting - we never used to treat pain in neonates and then there were some studies that showed that their pulse rates and blood pressures improved if their pain was treated.

DrSusan> But many of us are stoical individuals and don't want to be seen as whining. So we tolerate pain.

InsightHostKJ> So we aren't being wimps when ask for help with the pain?

DrSusan> I don't think so. And I believe the medical profession is now coming around to recognizing that we have an obligation to do better with pain control.

oops> Is there any scientific explanation for arthritics feeling more pain during weather changes? Why do I feel more pain when it is going to snow within a few days?

DrSusan> Actually this is interesting. The pain is BEFORE the rain not during it.

oops> right. is there any trick I could learn to help deal with the weather change?

DrSusan> Studies have been done in sheep putting pressure sensors in their joints. When the barometric pressure changes rapidly as it does before it rains, it takes a while before the pressure in the joint equilibrates.

DrSusan> Try that hot bath or hot rice sock or capsaicin cream or patch or take a pain pill.

oops> That is fascinating. ok. thank you. I just learned something!

Lucy> I know we are off the subject but I forgot to ask if the Enbrel is safe to take while on the Dostinex for tumor.

DrSusan> I am not familiar with Dostinex. I would call Immunex.

InsightHostKJ> WHat happens when you become tolerate to a pain med?

InsightHostKJ> intolerant

DrSusan> Do you mean physiologically?

InsightHostKJ> yes

DrSusan> With NSAIDs there is often a phenomenon called tachyphylaxis which means you are not getting the same relief you got before.

DrSusan> Often it can be helpful to switch agents as there may be some subtle differences in inflammation.

InsightHostKJ> does that happen with other drugs like darvocet?

DrSusan> Generally, if the pain level is about the same, many people find they can continue to use one pain medication on a routine basis and save a stronger pain med for rescue pain.

DrSusan> It can happen with Darvocet which is a short acting pain med.

DrSusan> There is also a major difference between the long acting pain meds and short rescue pain meds.

DrSusan> Long acting meds such as Durgesic, Oxycontin and MSContin are supposed to provide a continuous level of pain relief - with shorter acting drugs like Percocet, OxyFast, Darvocet etc causing a burst of increased pain relief.

DrSusan> For acute pain, such as having a tooth pulled, you don't need a long acting drug to try to maintain a continuous level of pain relief. But for chronic pain, patients do better when they are not continuously playing catchup with their pain.

Melanie> I have an addictive history of narcotics but find now that these drugs put me out to a major degree. I avoid them and the lesser, non-narcotic stuff works like Ultram. Do you run into that much?

DrSusan> Yup. It is much harder to control pain in patients with an addiction history.

swimmer> I am still not sure I understand how and when you would take a pain medication for RA pain. (call me a stoic scandinavian)

swimmer> wouldn't you be taking them continually or just on really bad days?

DrSusan> Can anyone else give an opinion who is not a stoic Scandinavian.

DrSusan> I think it is useful to have a pain medication that works for very bad days. Obviously with RA, the goal is to get the disease under control.

swimmer> for example, I have ankle pain all the time when I walk. Should I treat that constantly?

InsightHostKJ> LOL...I take a darvocet twice a day.....takes the edge off so I function better

DrSusan> Ankle pain is a rather localized, not generalized form of pain.

swimmer> for my overall well being?

Melanie> I take the NSAID continuously but use Ultram for rescue pain (once in a great while). Daily when I was working.

DrSusan> I would approach ankle pain with local measures - orthotics and appropriate shoes, ankle injections, local heat, capsaicin cream or patch.

swimmer> having surgery in May. :)

DrSusan> Are you having a fusion?

swimmer> yes

DrSusan> Good luck. And you may need stronger pain meds acutely post operatively.

Guest117> thank you, i got a common question i guess. im 23 years old and have had RA for 6 years, my right knee needs full replacement, is it adviceable at my age?

DrSusan> Not quite a pain management question but.... if the cartilege is gone and the knee is keeping you from functioning in your life the way you would like to, I would certainly consider a knee replacement.

DrSusan> Twnety years ago we did not do knee replacements in young adults but in more recent years, we have realized particularly in rheumatoids, that patients can improve their quality of life and go for a long time with a replacement.

InsightHostKJ> Dr Susan...any closing thoughts for us?

DrSusan> KJ, do you have any specific pain management areas that we did not cover?

InsightHostKJ> I think we touched base on everything....is there anything else you want to cover?

Melanie> What type of credentials does a Pain Management Specialist have or require?

DrSusan> I want to reemphasize that pain medication is only part of pain management and to encourage people to use physical modalities as well.

DrSusan> Melanie, many pain specialists come from an anesthesia background so that they can do nerve blocks, epidurals, facet blocks etc. Others begin in neurology. Your rheumatologist should be familiar with the meds and the physical measures.

DrSusan> For example, I don't do epidurals, nerve blocks or facet injections but I do prescribe narcotics as needed and refer patients for appropriate injections when needed.

InsightHostKJ> Dr Susan..thanks for another great chat!

DonnaM> Thank you again for your time and information Dr Susan

Tra> Thanks, DrSusan, as always, a very informative chat.

Carolanne> Thank you Dr. Susan

Melanie> Yes, thanks Dr. Susan

InsightHostRon> Yes, thank you very much for your time.....Good chat as always

DonnaM> and Swimmer,lets not change LOL

InsightHostKJ> If you didn't get to ask your question you can ask dr susan by sending it to experts@arthritisinsight.com 

DrSusan> So long, I have to get my beauty sleep.