Commonly Missed Problems in Chronic Pain

Back in 2006, Janice Montbriand  and I wrote a poster about “Often Missed Treatable Co-Morbidities in Patients with Treatment Resistant Chronic Pain”. They included Bipolar disease, B12 and Vitamin D deficiencies, and sleep disorders.  Each one of these is still an important issue today.

Often Missed Treatable Co-Morbidities in Patients with Treatment Resistant Chronic Pain: Case Studies
Janice Montbriand MA and Michael Montbriand MD CCFP
Canadian Pain Society Edmonton 2006 Meeting Poster      powerpoint here

1) Bipolar illness – often submerged by chronic pain so hypomanic symptoms are reduced to insomnia, irritability and inability to concentrate – more a mixed state presentation. Poverty submerges any overspending. It is suspected they form part of the more resistant dysfunctional angry segment in pain rehabilitation groups.

  • Italian study found bipolar history prevalence of 29.7%
    The high frequency of manic symptoms in fibromyalgia does influence the choice of treatment?
    Mauro Giovanni Carta et al. Clinical Practice and Epidemiology in Mental Health 2006, 2:36   free article here
  • Small US study in Refractory FM – 5/19 = 26%
    Ropinirole, Open Preliminary Observations of a Dopamine Agonist for Refractory Fibromyalgia
    Andrew J. Holman
    Journal of CLINICAL RHEUMATOLOGY Volume 9, Number 4 August 2003; p277-278 no abstract
  • Larger US study – 25.2%
    Fibromyalgia and bipolar disorder: a potential problem?
    William S Wilke et al.
    Bipolar Disorders Volume 12, Issue 5, pages 514–520, August 2010.  abstract here

Implications are very important because brain degeneration is possible in both diseases.

Lithium can grow gray matter and atypical anti-psychotics prevent deterioration. Antidepressants  encourage brain growth especially in hippocampus.

Vitamin D – discussed in a recent blog and becoming more evident in extremely deficient.

Vitamin B12 – the secret disease missed here because folic acid supplementaion in Canadian flour prevents pernicious anemia . There is no tick box for it in out lab work so it’s often not checked. There are more and more people avoiding meat and at risk.

Sleep disorders – though frank sleep apnea can be more uncommon, dumbed down versions of upper airway obstruction are common. Unfortunately, they can be missed by standard sleep lab (trouble breathing wakes them up without an oxygen desaturation).

Obviously , the writers were ahead of their time…

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