The Facts on Addiction vs. Dependency, Part 1

Pain management is generally a subspecialty in medicine. There are some neurologists who take up this specialty, but most often, pain management doctors first studied anesthesiology. They are not, however, simple anesthetists. An anesthetist works in an operating room and administers anesthetic medication to sedate a patient during a surgical procedure. They focus on making decisions about how much anesthesia to administer during a surgical procedure that will suppress pain while not unnecessarily suppressing other functions like heart rate and breathing. They are like trade electricians who you would hire to connect the wiring in your home.

They are distinct from anesthesiologists, who may spend some time working as anesthetists, but are more like an electrical engineer who knows the theory behind electricity (and usually the closely-related theory behind magnetism, and the combined theory of electromagnetism) and could work as professors in a university. Anesthesiologists understand the neuropsychological mechanisms explaining how your nervous system works and not just how to use your height, weight, and general health to decide how much sedative to administer to keep you asleep during surgery. Anesthesiologists (and some neurologists) are among those who might decide to further specialize in pain management.

Although laws are changing, right now, even primary-care doctors can write prescriptions for pain-relieving medications, and they often will opt for opioids because, as I mentioned in my previous blog, they are generally the best. Whenever possible, primary-care doctors should refer these pain patients to pain management doctors. However, pain management doctors are few and far-between and really good, pain management doctors are ever rarer.

Let me apologize for not doing more research on this enough to provide you with actual numbers and statistics here, but I choose not to do so because I do not trust the organizations who publish these kinds of statistics (as evidenced by how the mainstream media chooses to use them), and because it detracts from the point I'm trying to make here. For now, it suffices to point out that those who are most knowledgeable about pain and pain medicine could work every minute of every day seeing patients and would only get through a small percentage of those who could benefit from their services. [See digression #1 below.]

A primary care doctor may prescribe an opioid hoping that it will only take one script to get a patient through the healing process. Unfortunately, patients will rarely fit perfectly into this scheme. Some patients will need more than one month because they are chronic pain victims and some will need much less because they heal more quickly. Those who need more time might "graduate" and be referred to a pain management specialist. Within that discipline, services vary extensively by state and by sponsoring medical organization. Although I was extremely fortunate that the main doctor I saw was one of the best in the world, I saw others along the way constrained by laws and regulations for how to best treat me and my condition despite lengthy and careful documentation that showed what worked best for me. That is why, even after having moved from Wisconsin in 2012, I continued to go back to Milwaukee travelling upwards of 18 hours to see my main doctor there.

Still, there were time over the years when I tried seeing other doctors who were much more local. They ultimately failed to fully take over my case because they worked within a state that would not allow them to write the prescription that works best for my condition. Others worked for a hospital or medical group that required such a heavy press of patients that they could not take the time
my unique condition requires. [See "digression #2 below.]

There is an important point to make here. Although my pain condition is extremely rare and unusual, as is my intense desire to fight it so that I can continue to teach full-time and provide for my family, every pain patient is uniquely tormented by their experience. For at least a short time, everyone in pain suffers. When the pain signals persist beyond the time when the original pain stimulus exists, it is nearly impossible to not experience a psychological state akin to being tortured. Only a well-staffed pain management center with both medical doctors and psychologists--all of whom have specialized in pain management--is equipped to deal with individuals like that, but many patients will never even get a referral to such a place. For reasons almost as numerous and diverse as the patients themselves, unqualified or underqualified doctors will continue their own feeble attempts to treat these pain problems.

This is where the problems so grossly distorted by the media come into play. This is already a relatively small percentage of people, and now an even smaller percentage in that category will heal quickly enough that when they continue to take their opioids they will become addicted. Still smaller is a group who have healed and now their system becomes depressed by the opioids and they die. One final category of individuals in this very small group are those who stop taking their opioids after they have healed, but do not properly dispose of them and the medications fall into the wrong hands... healthy individuals who are simply looking to get high.

Next blog: "The Facts on Addiction vs. Dependency, Part 2" (on or about Sunday, March 12)


Digression #1: Although the first indications of my pain condition began to manifest themselves in October 2003, I did not see a pain management specialist until July 2004. At that time, I had been enduring what most would consider severe pain for about five months. Within another six months, I would be internally transferred from seeing "a" doctor at the Pain Management Center within Froedtert Hospital to seeing "the" doctor. From late 2004 until February 2016, I was both blessed and privileged to be treated by Dr. Stephen Abram. He was among a small group of 12 doctors back in 1970 to be the first to officially receive certification in pain management by the governing board of the American Medical Association. Working into his early 70s, Dr. Abram was an incredible individual and humanitarian who always made me feel important and respected me both as a patient in pain as well as an educator that had studied neuropsychology, providing me with explanations for things using vocabulary he knew that I would understand given my background. I believe that being referred to him as early into the progression of my condition was providential as it was for me to find the doctor whom I am currently seeing where I now live in Georgia since Dr. Abram finally retired last year. Although the doctors at Froedtert are still good, and I would like to continue seeing them, Georgia law forbids me receiving prescriptions for opioids written by an out-of-state doctor (which is stupid considering the DEA issues the licenses to write those prescriptions). It is more than luck that I found a doctors here so quickly who was so willing to even take my case, let alone continue treating me using the methods proven by Dr. Abram.

Digression #2: One doctor, with whom I grew quite close during his fellowship and residency at the Medical College of Wisconsin (Froedtert Hospital), was put in charge of the pain management center at a hospital closer to my home, so I tried exclusively seeing him for a short time. As a resident working under my main pain doctor, he could spend an hour talking with me during my appointment and then additional hours researching cutting-edge methods and medications to try and help me. As the head of his clinic under his new employer (who I will not identify here), however, he was forced to limit our visits to 15 minutes and his research time was limited to what he had to voluntarily sacrifice away from his family. In fact, his employer told him outright that their statistics showed that nearly a third of the pain patients they had treated in previous years often canceled their appointments at the last minute. To avoid the prospect of paying his salary for just "sitting around," they required him to schedule six patients every hour banking that on average only four would show up, and of course, there were days when very few canceled. He referred me back to my previous doctor when he realized he could not dedicate himself to my case as he once did. Worse, he left pain management just a few years later and went back to exclusively working in anesthesiology because he felt so ineffectual under his employer's constraints. Last I had heard, his personal life had also suffered because of the long hours and immense stress he had to endure. Pain patients are not the only ones hurt by the flaws in the current system.

How to Relieve Pain, Part 2

Part 2: Actually Relieving the Pain

The most complete way to relieve pain comes ultimately from healing and of course, "time heals all wounds." The phrase has endured because when it comes to pain from damaged tissue, when the tissue heals, the pain impulse ceases to exist. For nerve pain, it typically takes more time.

Until enough time has passed to allow for healing, the cheapest and least risky way to relieve pain is with pain medication: anti-inflammatory meds, opioids, and analgesics.* Now, because of the way the media has portrayed the matter, they would have the general public believe that there is a better way... medications that don't have any side effects or at least not any that are so dangerous as the ones that lead to the "epidemic of overdose deaths" that have been occurring. However, at the present time, only medication can relieve pain by reducing or dulling the pain signal, and opioids do that "best." By best, I mean the combination of magnitude and duration.

Opioids work primarily on the brain and are also versatile, coming in both short-acting and long-duration formulations. Natural or synthetic, opioids have been further perfected beyond what the earth naturally provides. Unfortunately, two of the key side effects of opioid use is to depress/repress vital functions and nearly all stimulate the pleasure centers of the brain along with reducing the pain. Some medications--analgesics--will completely desensitize nerves, but need to be applied directly to the nerves either at the source of pain or between the source and the brain before perception occurs. Unfortunately, while fantastic for the magnitude of relief that they provide, analgesics are very short acting. Anti-inflammatory medication is the least versatile of the three types because it works mainly to limit the reaction of the swelling of soft tissue that has been damaged, and thereby minimize the pain signal at its source.

To repeat and emphasize the main point, let me say again, taking medication is the cheapest and least risky way to relieve pain. Other methods vary based on the area of the body in pain and what is causing it, but most are very invasive because they involve surgery--removing something from the body or implanting something into the body... or both. Some, like implanting a neurostimulator and connecting to the spinal cord can work like an analgesic creating what's called parasthesia and replacing the pain signal with a sort of tingly-numbing sensation. The advantage is that such procedures will reduce or eliminate the need for medication, but are obviously incredibly invasive and may have permanent consequences.

Personally, I was on the operating table for nearly four hours with only a local anesthetic while parts of my vertebrae were chipped away and a network of wires was laid down and sealed in. The risk for infection is high and even with the most advanced technology in play, the implants still need to be replaced periodically (every 3-9 years) and need recharging every one to two weeks. Thankfully, only the actual neurostimulator unit needs replacing; my wires are "permanent" and my implant replacement surgeries have only been hour-long procedures with just 2-3 days' recovery. I'm on my third implant in nearly 11 years now and should be good until 2025. Another disadvantage to neurostimulation is that it is not always perfectly precise; I feel extra jolts of electricity in my legs (particularly my left leg) which impacts my ability to walk or run normally, but an acceptable trade-off for the increased relief I get from the parasthesia.

Other than combinations of the above (implanting a drug pump that delivers analgesics and opioids directly to the spinal cord) or the radical surgeries involving amputation, organ removal, or nerve extraction, there is nothing more than this that can be done to relieve pain in any significant way. So doctors, and more importantly those enduring pain, are quite limited on ways to relieve pain. This situation is further complicated by cases where even after the damaged area has healed, there is a malfunction that keeps the pain impulse active. This is the disorder that qualifies a person for the designation of "chronic pain victim" and it is a lot more prevalent than is portrayed by the media. Its prevalence, so grossly understated, means that primary care doctors are overwhelmed with complaints of pain and a lack of genuinely-qualified, pain-management doctors to whom to refer these individuals.

Next blog: The Facts on Addiction vs. Dependency (on or around February 26, 2017)

*Note that I did not distinguish between non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, which are also considered anti-inflammatory, but use a slightly different mechanism within the body. I also did not include the pain relieving effects which can be had with muscle relaxers, antidepressants, anti-anxiety drugs, anticonvulsant drugs, and a few others--which have been known to help relieve pain, but are usually more individualized in that they do not consistently work as anti-inflammatory meds, opioids, and analgesics do.

How to Relieve Pain, Part 1

Part 1: Feeling Pain.

Pain relief is a fairly simple process--that is, it can only be generally done in one of two ways. You can either reduce (or eliminate) the nerve impulse that is "causing" the pain, or you can increase a competing nerve impulse. Unlike other senses like vision or hearing, touch is almost 100% singular in its channeling. In other words, even amidst a flurry of conversations, we can often hear our name when mentioned in a distant conversation without even being explicitly directed towards us. Peripheral vision is perhaps an even more obvious example of being able to sense things beyond our direct focus.

Pain, however, is a purely survival sense. The principle is that you are in pain because some part of your body is in imminent danger of destruction. Pain is supposed to be the signal that causes you to retreat from the source that is causing it.

Interestingly, the automated portion of our brain that deals with pain sense places priority on the area that it believes in the greatest amount of danger based on what we think "hurts most." More interesting, from a scientific perspective, is that beyond the thing that hurts most, our brain barely registers any other pain that might be occurring. It functions kind like that almost clinically-obsessive person who cannot leave his current task unfinished while moving onto another. Pain is not a great juggler. In most cases, this is a great asset.

In my case, for example, I have a tremendously heightened tolerance for "normal" aches and pains. Things that would probably bother me much more are hardly noticeable. OK, the trade-off is that I am in constant pain (aka "relentless agony"), but this actually works to my advantage to let me function somewhat normally. Because the pain from my disorder come from the same area in my body (my chest/upper-abdomen) and is always the worst pain I am feeling, it made it easier for doctors to treat it.

This brings me back to the original focus: how do you relieve pain?

Of course, the answer will depend on what is causing the pain and which part of the body is affected. Although nerves transmit the pain signals, it is rarely the nerves themselves that are the affected area. Damaged tissue is the most common cause... a laceration on the skin or a blunt trauma that breaks a bone or a tear of a ligament... which then triggers a pain signal to race to the brain along a peripheral nerve to the spinal cord and then up to the sensory cortex of the brain. It is rarer, but sometimes, a nerve cell can also be damaged and then trigger the impulse directly. It is commonly believed that nerve pain is the "worst" pain to experience. This phenomenon may be akin to the idea of you getting hurt and then telling a friend to relay your pain to you doctor versus telling the doctor yourself. It also may be that nerve pain tends to take longer to heal.

Next blog: "How to Relieve Pain, Part 2" (On or about Sunday, February 12th)

Neurocogntive Psychology 101

There are several different types of nerve cells in your body. Some cells are exclusively suited for communication, like telephone wires of olden days. Some specialize in sensation of specific things like reacting to light or sound, and within those specialties there is even more distinction, like retinal nerves that only activate with red light or taste buds that only activate with salty things.

The majority, of course, are actually in your brain and--truth be told--whenever you think you are sensing something like cold or bright or loud, those sensations are almost meaningless out of the context that your brain places them. As is typical in science, the greatest leaps in understanding occur when something goes wrong. The notion of contextual sensation is poignantly obvious with what we call "phantom limb syndrome." Even with an amputated limb, individuals report "feeling" things (often pain) in a limb that is no longer connected to the body. This is particularly difficult to treat since most often, it is the removal of the painful stimulus that results in the greatest relief.

So goes the saying that "it's all in your head." While that is certainly an oversimplification, it is true that the nerve cells in the brain are ultimately slightly more important than the nerves out "in the field" of the body's periphery. If you touch a hot stove, while it is the finger that gets damaged, another nerve delivers that carry that signal to the spinal cord and it's not until the signal reaches the brain that an impulse is generated that goes back to that hand to pull it back from the stove. Of course, all that happens in an instant, but you get the point. So all nerve impulse go through a sensation-perception-reaction process series. Depending on the individual and intensity of the stimulus, voluntary control can be seized before a reaction occurs, like a person who can hold their hand over a flame for a longer-than-normal interval of time.

So how do you help a person in pain, particularly when the source of the painful sensation is idiopathic and/or no longer physically present? The two conditions most baffling to pain management specialists are allodynia and hyperalgesia. The first is a malfunction "somewhere" in the sensation-perception process that causes a non-painful stimulus to be interpreted as pain. The second is a malfunction where a "mild" sensation of pain is perceived as "severe" to "excruciating" pain. Many individuals who need medical treatment for pain have one or both of these conditions.

Next Blog: How to Relieve Pain (to be posted on or about January 29, 2017)

The start of something new

I've been concerned lately about the terrible way that information is being misrepresented by the press and mainstream media concerning what has been derisively referred to as an "opioid epidemic." Between the deliberate attempts to mislead the public about those who are the cause of this epidemic and the deception about how to remedy the situation, I felt compelled to fight back, even if in this very small way.

In the coming days I will give you my opinion supported by facts for the truth concerning this so-called epidemic and present real solutions. Donations would be appreciated with money to be used to support efforts to reach out to elected officials and help them to better understand the who, what, how, and why of this matter. However, I would prefer that my readers take the opportunity to reach out to their elected representatives themselves wherever and whenever possible. Recognition of the real problem and plausible solutions will ultimately be easier to realize through a collective effort. Even if you are not personally impacted by this issue, I hope that you can empathize with me enough to help in whichever way least impacts your time and resources.