How does one transition from a narcotic-based pain-management system to one that is non-narcotic-based? How do the two compare?

How does one transition from a narcotic-based pain-management system to one that is non-narcotic-based? How do the two compare?

The most important thrust of the question is: “I’d really like to come off the narcotics but I have no idea what else would successfully cover my pain.” THIS is what is facing most people in the midst of chronic pain: they don’t want to become addicted to pain medications, but they can’t function without them.  What effective alternatives are there?

This is a really great question, and it is one of the questions dominating focus, research, debate and policy in pain management today. Narcotics work very, very well: they “turn off” the pain signal, so that you don’t perceive it through your sensory nervous system. This is a delight for the pain patient who is constantly suffering. “A relief from that pain? Heck yeah, sign me up!”

The problem that pain management clinicians and researchers are struggling with is the “activation threshold” of pain. That is, when you dampen the pain signal over time, your system adjusts to that factor, and then the pain threshold lowers, UNLESS you have the medication intervening. Which means you need higher doses of your medication to achieve the same level of relief from pain.

Initially, this means that you can essentially do more with less pain. Yay, right? Not necessarily. What if, even while you feel less pain, you do more damage to the mechanical tissues of your body because you can’t feel the painful feedback your body sends to tell you you’re hurting it? If this happens, it usually results in further injury. For example, let’s say you have a torn muscle in your leg. You numb it with narcotics so that you can run on it. While you don’t feel the pain caused by running on the leg with the torn muscle, this exercise, in this state, almost guarantees extra damage to the torn muscle.

This brings up the crucial factor with which all researchers and clinicians struggle: What is actually causing the pain, both anatomically and physiologically? How did it start? What sustains it? How does one address both anatomy and physiology without making the patient increasingly dependent on medication for relief, or hopefully, recovery?

For this, you need a case director (usually MD/DO) who is well educated and experienced with a BROAD variety of treatment options. These options need to include “alternatives” such as chiropractic, acupuncture, biofeedback and advanced manual therapy. All of these techniques (tools in the therapeutic toolbox, if you will) do have limited studies done regarding their efficacy. The best “director” for your case will be an advanced MD/DO who has been apprised of those studies, and who also has had significant clinical experience with these “tools” and their benefits.

They will know how to best reduce your current medication (possibly in favor of one with lesser side-effects) and also how best to integrate effective “alternative” techniques into your treatment plan and its goals. These goals, often including comfortable and effective resumption of activities of daily living (ADLs) are superimposed with medication dosages in order to determine their therapeutic efficacy.

A good place to start finding a knowledgeable physician to guide your case is with the American Academy of Pain Management. The AAPM is the only institution to currently accredit those in multidisciplinary pain management, and they are committed to an interdisciplinary approach.

If you are merely exploring competent practitioners in alternative methods, PLEASE study their CVs, license, certifications and experience. I would recommend distrusting anyone who says, “Oh, I can cure you; the technique I use is the only one that works.” NO technique is a panacea – NONE. If they can’t discuss the strengths and limitations (almost more important) of their technique, then they are downright dangerous to you.

You need a good guide. That’s what a great pain management doctor does. Go find yourself one! Best of luck.

What can cause muscles to be sore for weeks to the point that they're painful when used?

What can cause muscles to be sore for weeks to the point that they’re painful when used?

Unfortunately, there are quite a few diagnoses that are relevant to muscle soreness and weakness beyond a week’s span. Be sure to have a physician examine you to at least rule out some of the more basic physiological diseases.

Once those are cleared satisfactorily, ask yourself the following questions:

  1. Was there a precipitating event? That is, did it happen all of a sudden? If so, how?

  2. Where in the body did the pain originate? What was the quality of the pain (sharp/burning/dull & aching/sore/tingling/numbness)?

  3. How long did the pain last?

If the pain began with a precipitating event (e.g. “I lifted something;” “I slept funny;” “I twisted in the shower;” “I leapt to catch a ball;” etc.), it usually indicates a sprain or strain to muscle, tendon, or ligament. If you hear a “pop” or “crack” in a joint, it is most likely a connective tissue rupture. If this is the case, you will need a good interview by a sports medicine physician (MD/DO) and probably a scan of some kind (x-ray or CAT scan for bony/cartilage tissues; MRI for muscle/tendon/ligament tissues). This will help to determine what damage, if any, has been done, and if the issue warrants surgery and/or therapeutic intervention. This needs to be your first port-of-call for pain lasting longer than 1-2 weeks.

Once you have determined that there is minimal damage, and therefore, that surgery is unwarranted, you can determine that the cause is one of the following:

  1. Not normal delayed onset muscle soreness (lasting 24-72 hours): See my answer to What causes delayed onset muscle soreness?

  2. A sprain or strain: See Sprains, Strains and Other Soft-Tissue Injuries

  3. If there are multiple areas around the initial location of pain and injury, you may have developed myofascial pain syndrome: “Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension. While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens.”

Myofascial pain syndrome (Mayo Clinic)

As a bit of an aside, sub-acute (1-6 months) and chronic (more than 6 months) of myofascial pain are treated thus:

“A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for a 1–3 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS), the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in myofascial trigger point therapy.” (Wiki: Trigger point)

(PS – I’m really proud of the Wiki on this. They nailed it, spot on.)

In a standard clinical interview, you have to go over all the aforementioned patient history, physicians’ reports, scans and anything else you can tell or show the practitioner about what may be the cause of the pain. Your practitioner can then figure out what muscles do the motion that produced the injury & other perpetuating factors, which allows the practitioner to decide what to treat first. This is the general clinical starting point for therapeutic focus.

Why does one not feel pain when having company?

Well first, I’d have to say that some people feel more tense and painful when having company, due to the stress factor. That being said, if you feel less pain while entertaining, it’s probably due to a lovely cocktail of adrenaline and distraction. Nociception (pain perception/sensation) is affected in contradictory ways by, on the one hand, focus, and on the other, distraction. Bradley Voytek and Paul King cover this quite well in their answers to the following question on Quora.com, Neuroscience: How does the level of conscious attention to sensation affect its intensity?

Now, stressful situations put us into the fight-or-flight response by shooting adrenaline into our system. Thus, the more stressed and nervous you are, the more likely you are to get a temporary break from existing painful sensation, otherwise known as “stress-induced analgesia:”

Stress-induced analgesia may be adaptive (i.e. increase survival) by reducing pain from injury and thereby allowing the animal to enact appropriate attack or escape behaviours. It may also be useful in injured animals using immobility or feigning death as strategies for eventual escape from a predator, by reducing pain sensation and associated motor responses, and this may also prevent further damage while the animal recovers from injury. (J4.191.w5)

Neurophysiology of Pain (Techniques Overview)

So, stress and distraction can temporarily relieve you of pain because your body is busy protecting you and making sure that you survive those wacky host-entertainment circumstances. But once you come down from that lovely cocktail of adrenaline and distraction, there tends to be a nasty price. Called a “rebound” effect, the pain once again resumes or even magnifies. This has been commonly observed, but the mechanisms are not well understood or documented scientifically yet.

 

How do I know whether or not a stretching exercise could actually hurt my body?

Very simply. The best way to ascertain if a stretching exercise is hurting you is … wait for it … if it hurts to do it.

Your body is actually quite adept at letting you know if it is being hurt. It is “wired” with sensors that send your brain pain signals if damage is occurring. If a stretch you are doing results in a sharp twinge or an “uh-oh” kind of sensation, it is best to STOP that stretch, and to also leave off similar stretches to that muscle and its myotatic group (associated muscles).

Rest is to follow, as well as ice applied to those muscles (to reduce swelling and inflammation). An anti-inflammatory medication such as ibuprofen (Tylenol) may also be called for. If symptoms are severe, naproxen (Alleve) can be especially helpful in the short-term. Please consult a physician if you are not sure what to take or are concerned about drug interactions or side effects, or if you have other significant health issues.