Chronic Pain Treatments for Mind and Body

Low Back Pain Relief

Chronic Pain Treatments for Mind and Body

WebMD Live Events Transcript

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MEMBER QUESTION:
My cousin said she took the strongest prescription pain medicine she could for her knee pain. When it no longer worked, she then knew it was time for a knee replacement. Is that true?

ARGOFF:
Not necessarily. There's a lot that has to be kept in mind when thinking about joint replacement. The first thing that needs to be clarified is did some medical person tell your relative what was the cause? Did she go for physical therapy? Did she have any injections into her knee? What do you define as the strongest prescription medicine, because I have had numerous experiences when people use that terminology and they're not talking about very strong medication? So I don't have enough details to answer your question as it is.

On the other hand, in the right setting, joint replacement can help alleviate significant joint pain, but I don't have enough information to tell you whether it's right for the person you're talking about.

MEMBER QUESTION:
I have skin pain. I guess it is nerve related. I cannot get an answer for this. However, I am looking for a way to relieve it. My body feels bruised all over when I rub up against things or when someone touches me too hard. I also have a burning sensation on my face and arms (like a sunburn or chemical burn). I have not received any answers for this condition. I know you cannot diagnose, but what you would recommend for this?

ARGOFF:
I would recommend strongly that you see a physician, perhaps a neurologist who specializes in pain management, or a neurologist in general, to first establish what your diagnosis might be. I think it may be necessary for you to see somebody with pain management expertise, and that person might be able to make suggestions that may be helpful to alleviate your pain, but you truly need to have a diagnosis first.

MEMBER QUESTION:
I have seen two neurologists and two rheumatologists. The only thing that has been mentioned is fibromyalgia or STRESS. ... Can STRESS really cause nerve pain like this?

ARGOFF:
No. Where do you live?

MEMBER QUESTION:
Houston, Texas.

ARGOFF:
You should consider traveling up to San Antonio to see John Russell, MD, who is one of the world's experts on fibromyalgia. He's at the University of Texas in San Antonio. Head to their web site and you'll find him there. You can also go to any bookstore and get his handbook on fibromyalgia. That should be helpful also. He will take you quite seriously. He may want to do all kinds of testing on you, but he will do his very best to understand why your skin burns as much as it does. He is also a rheumatologist who truly understands pain.

"If a drug works, even at a lower-than-usual dose, and even if you experience side effects that are tolerable, then it probably makes sense to stay on it."


MEMBER QUESTION:
How damaging to your body can long-term pain medication be? Ultram, to be specific.

ARGOFF:
We don't have enough experience to know if there are any toxic side effects. However, it is not the greatest medicine in the world, and is likely to cause what we call physical dependence. What this means is as time goes on your body cannot live without it, making it not necessarily harmful to you, but making it very difficult to get off of it when you want to. This may be relevant if it sometimes no longer helps you, but if it's helping you and you're not experiencing that particular problem, then there's nothing to worry about.

It would be wise, however, since we don't know everything, for you to have routine blood work done annually, if you're still on this medication, just to be sure everything is OK.

MEMBER QUESTION:
Blood work checking for what?

ARGOFF:
Liver function, kidney, or other abnormalities.

MEMBER QUESTION:
I was diagnosed with hypermobility syndrome, and my doctor says this is causing my osteoarthritis. I have had terrible pain in my hips knees and ankles since I was 10. I am now 31. I have been on many medications and nothing helps. Do you have any suggestions?

ARGOFF:
What sort of treatments have you been given in 21 years, and what, if anything has been successful?

MEMBER:
I was just diagnosed five years ago. I was on Vioxx, Celebrex, and Mobic.

ARGOFF:
Like many other chronic pain syndromes, hypermobility syndrome doesn't have a specific treatment for the pain itself. What this means is that you have to consider medications or other approaches that have been successful in managing pain in general, but, which may not have been tested specifically in people who have your problem. So that's perfectly fine, but you need to understand that.

Having said that, if various anti-inflammatory drugs have not been successful, you might want to consider the following types of medications. I'm going to concentrate on medications, because I don't know or think physical therapy, per se, can give you longstanding benefit in this area. It might be in your best interest to see a pain management specialist who has specific expertise in utilizing medications for your condition or conditions like yours. Types of medications that might be helpful for you:

  • The opiate-type pain medications. These are medicines like oxycodone, morphine, and fentanyl, which can be administered in various ways, and which many people use on a daily basis successfully to control their pain without any significant side effects.
  • Meds that can be applied topically, that is directly to the site of your worst pain. There are certain patches and certain creams, prescription and/or over-the-counter, that can be considered.
  • Curiously, both antidepressants and medicines that are used to control seizures, because of their chemical properties, have been used for pain control and can be considered, as well.
  • You may be a candidate for certain pain procedures, possibly acupuncture and other treatments, but I don't have enough information to state that for sure.
MEMBER QUESTION:
I have osteoarthritis in my knee and would like to go on Vioxx, but my doctor doesn't speak highly of it. What do you think of Vioxx to control knee pain?

ARGOFF:
Vioxx is one of the newer anti-inflammatory drugs, which, when compared with traditional anti-inflammatory drugs, is less likely to have any GI irritability, such as ulcer and heartburn and so on. It's extremely effective for many patients with osteoarthritis, so on that basis, I am not sure why your doctor would not be in favor of it.

As with all medications, not everybody responds to a particular medication and there are adverse effects to certain medications. Perhaps your doctor can clarify if he or she is concerned about the particular side effects, since there is no doubt that this medication works.

MEMBER QUESTION:
I have had stabbing pain in the left thoracic area at the bottom rib. I am taking oxycodone and Neurontin three times a day plus Medtronic spinal cord stimulator. Prior to this, I took morphine for six years! Since the stimulator effectively targets the area, why can't they surgically fix my problem with the disk/nerve? What about that SNX frog venom? Is that working yet?

ARGOFF:
Wow! So I gather from your question that your problem is believed to be related to a thoracic disk herniation. I cannot answer why your surgeon chose not to operate on the disk itself, as opposed to managing the pain the way you're managing it, but I can only guess that your surgeon did not feel that he or she would be successful by operating directly on the disk or the problem in the spine itself.

Just so you know, that's not infrequent. In other words, it's often that there's something in your spine causing you pain, but we don't have good surgical experience treating it directly, that is, removing it. And experiences have in fact shown that very frequently, or too frequently, operating directly on the spine can actually lead to more pain.

So it looks like what you've been offered, in terms of treatment, are approaches that can be reversed, as opposed to surgery, which is irreversible. The stimulator helps to decrease the amount of pain that your experience by providing literally electrical distraction of the pain itself. That is something if for some reason it no longer worked, it's totally reversible and you should be no worse off for it.

In addition, you could change your medication if they stop working for you, again without any significant adverse consequences, if done properly. So these approaches are helping your pain without destroying your body, which is what further surgery could do.

The second part of your question relates to a not yet FDA-approved medication, and that is SNX 111. That drug is a brand name called Prialt, and this medication is only available intraspinally, that is injected directly into the spine. It's not yet FDA approved, so you would have to find a center that is doing the research, and you would also have to be willing to have a device installed into you, a Medtronic pump, that would provide a reservoir for the medicine to go into you. Where do you live?

MEMBER:
Seattle, Wash.

ARGOFF:
Call the Swedish Hospital and see if Gordon Irving is involved. He's a great doctor and might be able to help you. You might also want to contact Elan Pharmaceuticals in San Diego, because they are doing the studies and they might be able to tell you if there's a study center near you.

"The Rolls Royce of the long-acting drugs are either a fentanyl patch, which can last up to 72 hours, or a once-a-day morphine pill, which truly lasts 24 hours."

MEMBER QUESTION:
I am on Topamax 75 milligrams a day for migraine. It keeps the migraines away, but has very long list of side effects, which I get most of. When should I consider going off Topamax because of the side effects? I have been on it for five years now.

ARGOFF:
Seventy-five milligrams is a relatively small dose. This drug was just FDA approved for migraine with usual doses being approximately 200 milligrams a day. If a drug works, even at a lower-than-usual dose, and even if you experience side effects that are tolerable, then it probably makes sense to stay on it, as there is no guarantee that something else will work better.

If you are not pleased with the comfort you are receiving, again, please note that you are taking a relatively small dose of this drug. Ideally, you should increase the drug dose unless the side effects that you are currently experiencing prevent you from doing so. If you are not happy with your headache control, and you do not feel that raising your Topamax dose can be done because of side effects, then it's time to consider other treatments.

MEMBER QUESTION:
Can you suggest a time-release pain med (probably narcotic) to make it through the night without having to get up to take more AND wait up due to GERD/Barrett's esophagus?

ARGOFF:
It depends how you define controlled-release or long-acting medication. Let's start from the beginning, then. Short-acting medicines, and I know you didn't ask about these, are designed to last three or four hours. Generic medications in this category include hydrocodone, either combined with acetaminophen or ibuprofen, oxycodone, morphine immediate release, or fentanyl lollipops.

The next step up is medications that last between eight to 12 hours. These include time-release morphine, time-release oxycodone, methadone, and Levo-Dromoran.

Finally, the Rolls Royce of the long-acting drugs are either a fentanyl patch, which can last up to 72 hours, or a once-a-day morphine pill, which truly lasts 24 hours. Either of those two, at the right dose, should allow you to sleep much more comfortably.



MEMBER QUESTION:
May I ask a question about spinal stenosis? Are there any injections to the region of the back that would help that?

ARGOFF:
Sure. Epidural steroid injections can be very, very helpful, and are commonly done.

MEMBER QUESTION:
My husband has had right shoulder/back pain mid-scapular for approximately a year now. Initially he was unable to move his arm. With physical therapy and pain medication it has gotten a little better, but whenever he does lifting or moves the wrong way it gets more severe. He's had MRIs, CTs, and X-rays. His doctor can't find anything wrong, but suggested nerve block. My husband is afraid that if he has the block and he hurts it again he would not know and it would get worse. Is this true? Can you suggest any other therapy?

ARGOFF:
What is his diagnosis?

MEMBER:
They were never able to tell him what was wrong.

ARGOFF:
It's very hard to give you advice without seeing your husband, but I do disagree with his concern that if he has pain relief he will mask the pain sufficiently and that he would hurt himself. That's not likely to happen, and should not be used as a reason for not getting the relief.

MEMBER:
I know, but he's getting worse and I'm not sure what to do.

ARGOFF:
Get him to a competent pain management physician and tell your husband to be open-minded.

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"Don't underestimate the benefit and safety of painkillers, especially when properly prescribed, because in general they are safer than the more common anti-inflammatory drugs."

MEMBER QUESTION:
I have back pain caused from two protruding disks and also some degeneration. My doctor says he can correct the disk problems, but I still will have pain from arthritis and some spinal stenosis. I've already tried physical therapy with not much change in my pain level. What would your next move be?

ARGOFF:
Have you had any injection therapy?

MEMBER:
No.

ARGOFF:
Consider that.

MEMBER QUESTION:
I am female, widowed, live alone, am 65, and have been dealing with SLE, systemic scleroderma for almost 10 years. I take Lorcet and have for years. Would the pain patch I have read about be effective? It seems like just having to apply one a week or every few days for constant absorption would be much easier for me to manage.

ARGOFF:
Possibly, but you really need to discuss this with your physician partner to know if this is the right thing for you. In my experience many rheumatologists, if that is who you're seeing, are rather phobic about using narcotic pain medications on a long-term basis, so you may need to see a pain management physician or other who is more comfortable, since your rheumatologist is not.

MEMBER:
I had a four level fusion L to S1 in February and now am in severe pain again. I take Vicodin ES and it doesn't work. Is there any alternative for me except pain meds?

ARGOFF:
I don't know enough about your condition to answer your question properly. Vicodin ES is one of the horrible medications because it provides short-duration pain relief, almost teasing you and placing you into a roller coaster of pain return, meaning ups and downs.

Don't underestimate the benefit and safety of painkillers, especially when properly prescribed, because in general they are safer than the more common anti-inflammatory drugs, which result in more injury and mortality to people in the U.S. on an annual basis than appropriately prescribed pain medications. I hope that helps.

MODERATOR:
Dr. Argoff, before we wrap things up for today, do you have any final words for us?

ARGOFF:
This has been a lot of fun. Thanks for the great questions. I'm happy to come back anytime, because I know we couldn't get to all your questions.

MODERATOR:
Our thanks to Charles Argoff, MD, for joining us today. And thanks to you, members, for your great questions.

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Reviewed on 11/8/2004 4:09:37 PM

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