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Commonly asked questions about treating pain.

Q My 74-year-old father has chronic pain from an old war injury that significantly affects his quality of his life. Yet his doctor doesn't want to prescribe anything stronger than over-the-counter medications for fear that his system won't be able to handle it. What should he do?

A As people age, they tend to react to medications differently because their metabolisms change. For instance, we often prescribe the opiate Darvocet to people who need something stronger than an anti-inflammatory because it's a fairly weak narcotic. But as people get older, the half life of the drug (meaning the time it remains in their system) increases, so if you're not careful it can accumulate in the blood, leading to psychiatric and neurological problems.

Another problem we see in the elderly is that many are on several medications, sometimes up to 15 different drugs. So doctors are often reluctant to add more drugs for an older person because we don't know how they will affect the person, particularly for those conditions in which we know the medication isn't going to change the course of the disease, like osteoarthritis.

The important thing is to sit down with the patient and talk about the pain, when it occurs and how bad it is. Sometimes you find that something like acetaminophen (Tylenol) will work, but patients have to understand that they have to take it consistently, several times a day, or the pain returns.

Having said that, if your father feels that his doctor is ignoring his concerns, or the pain is getting worse, it might be time to seek a second opinion. And don't discount opiates altogether; several studies find they can be safe in older adults. (24)

Q When is it time to find a pain specialist?

A If you're not getting enough pain relief from your primary care doctor or the pain has affected your life to the extent you are not able to do the things you used to do, it's time to see a specialist.

Unfortunately, there aren't many. So far, the American Board of Pain Medicine has certified just 1,700 doctors as pain specialists--about one for every 23,500 people who need care. (25)

What kind of specialist you need depends on your pain. If it's related to osteoarthritis, lupus or rheumatoid arthritis, for instance, you should see a rheumatologist. If your pain is chronic and unrelated to any underlying disease, then you might want to seek out a pain clinic.

(See Resources on page 4 for information on pain centers and specialists.)

--John Meyerhoff, MD

Rheumatologist and Assistant Professor of Medicine

Johns Hopkins University School of Medicine Baltimore, MD

References

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4 Joranson DE, Gilson AM, Dahl JL, Haddox JD. Pain management, controlled substances, and state medical board policy: A Decade of Change. Journal of Pain and Symptom Management. 2002;23(2):138-147.

5 Green CR, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003 Sep;4(3):277-94.

6 Ploghaus A, Narain C, Beckmann CF, Clare S, Bantick S, Wise R, Matthews PM, Rawlins JN, Tracey I. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosci. 2001 Dec 15;21(24):9896-903.

7 Bantick SJ, Wise RG, Ploghaus A, et al. Imaging how attention modulates pain in humans using functional MRJ. Brain. 2002 Feb;125(Pt 2):310-9.

8 Villemure C, Slotnick BM, Bushnell MC. Effects of odors on pain perception: deciphering the roles of emotion and attention. Pain. 2003 Nov;106(1-2):101-8.

9 Ploghaus A, Tracey I, Gati JS, et al. Dissociating pain from its anticipation in the human brain. Science. 1999 Jun 18;284(5422):1979-81.

10 Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005 Apr 19;142(8):651-63. Review.

11 Vas J, Mendez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee; randomised controlled trial. BMJ. 2004 Nov 20;329(7476):1216.

12 Astin JA. Mind-body therapies for the management of pain. Clin J Pain. 2004 Jan-Feb; 20(1):27-32.

13 Kemper KJ, Danhauer SC. Music as therapy. South Med J. 2005 Mar;98(3):282-8.

14 Flor, H. Fydrich, T. Turk, D. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain, 49(1992) 221-230.

15 Pain Facts: An Overview of American Pain Surveys. American Pain Foundation. www.painfoundation.org.

16 Depression and pain comorbidity: a literature review. Arch Intern Med. 2003 Nov 10;163(20):2433-45.

17 Giesecke T. Gracely RH, Williams DA, et al. The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum. 2005 May;52(5):1577-84.

18 FDA Regulatory actions for the COX-2 Selective and Non-Selective Non-Steroidal Anti-inflammatory drugs. US Food and Drug Administration. www.fda.gov/cder/drug.

19 Brody JE. The Perils of Pain Relief Often Hide in Ting Type. The New York Times. May 3, 2005.

20 Johnson CJ. Headache in women. Prim Care. 2004 Jun;31(2):417-28, viii.

21 Diamond ML. The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine. Neurology. May 2002; 58(9 Suppl 6):S3-9

22 Allais G, Benedetto C. Update on menstrual migraine: from clinical aspects to therapeutical strategies. Neurol Sci. 2004 Oct; 25 Suppl 3:S229-31.

23 Loder E. Migraine diagnosis and treatment. Prim Care. June 2004; 31(2):277-92, vi.

24 Buntin-Mushock C, Phillip L, Moriyama K, Palmer PP. Age-dependent opioid escalation in chronic pain patients. Anesth Analg. 2005 Jun;100(6):1740-5.

25 Sternberg S. Chronic Pain: The Enemy Within. USA Today. May 9, 2005.

26 Tall JM. Raja SN. Dietary constituents as novel therapies for pain. Clin J Pain. 2004 Jan-Feb;20(1):19-26.

27 Nadler SF. Nonpharmacologic management of pain. J Am Osteopath Assoc. 2004 Nov;104(11 Suppl 8):56-12.

28 Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev. 2004 Apr; 8(2):119-32.

29 Onen SH, Alloui A, Gross A, et al. The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects. J Sleep Res. 2001 Mar;10(1):35-42.
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Title Annotation:ASK THE EXPERT
Publication:National Women's Health Report
Geographic Code:1USA
Date:Jun 1, 2005
Words:1125
Previous Article:Migraines & women.
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