Would opioid guidelines always work on cancer patients?The answer is NO. – 13.7% do not respond to usual doses and only half of those will get any benefit from increasing the dose. If one were to extrapolate, this would mean 7% of opioid users would need higher than usual doses of opioids to respond. I guess this is why the new rules are only suggestions and not hard and fast regulations. Now, if only College regulators could handle these implications… Opioid induced hyperalgesia might be helped by switching opioid.
I see often older men wearing belts who solemnly come in with nerve-like pain level at low back and flank level. I tell them I can treat this – but they are going to laugh – because what is a good portion of the pain is cluneal nerves crushed by the waistband as it crosses the wing of the hip ilium. Muscles become tight, facets and sacroiliac pulled out of alignment, iliac crest starts to rub on ribs, and the pains go down hill from there. Lack of sleep and low resultant testosterone make it worse. Treating the pain is now a mess because you have to work ribs out of pelvis and deal with Quadratus lumborum spasms. These tissues also get tenderized by chronic back pains and need treatment in their own right.
Injecting skin nerves where constricted in the skin can significantly relieve pain in Complex Regional Pain Syndrome – a secret as is only published as a letter
Below is a study poster presented to the Canadian Pain Society showing benefits of frequent B12 Injections. Unfortunately, a study found men with smoking history have a 3 times lung cancer rate so I have now restricted B12 injection use to women.
Post-thoracotomy pains are the worst post-operative pains, occurring in high frequency and can be severe. Surprisingly, asthma beta-adrenergic stimulants greatly reduce any neuropathic pain, though not muscular pains, postsurgery. It suggest beta-adrenergic circuits, thought to be involved in descending inhibition, might be important.
I wrote about how beta-adrenergic agents might be involved in downward inhibition:
Antidepressants Just Don’t Work on Descending Inhibition
The fact beta-adrenergic agents prevent post thoracic neuropathic pains here:
Eur J Pain. 2015 Nov;19(10):1428-36. doi: 10.1002/ejp.673.
Effects of β2 agonists on post-thoracotomy pain incidence.
Salvat E et al
“The chronic use of β2 -agonists was an independent predictor of thoracic neuropathic pain (but not of non-neuropathic pain) and was associated with a five-fold decrease in the relative incidence of neuropathic pain [OR = 0.19 (0.06-0.45)].”
beta adrenergic agents were found to work as well as antidepressant in animal model of diabetic neuropathy:
Choucair-Jaafar, Nada, et al.
The antiallodynic action of nortriptyline and terbutaline is mediated by β2 adrenoceptors and δ opioid receptors in the ob/ob model of diabetic polyneuropathy.
Brain research 1546 (2014): 18-26.
Pain and spasm on the inside of the knee in adductors is not uncommon – – especially in the heavy set with stairs. A brutal stretch massage can relieve but takes effort and willingness of subject to deal with the pain.
POT’s is a syndrome where one is unable to maintain blood pressure standing and so often faint – and is often associated with attacks of tachycardia.
Finding this situation in a chronic pain patient, greatly complicates the situation, and makes pain recovery less likely. I find myself scratching my head about where to go.
- Association of POTS with autonomic neuropathy brings up issue that certain Fibromyalgia cases have small fiber neuropathy. Autoimmune mechanisms are involved and question lies, which ones would respond to IV gamma globulins or Plasmaphoresis – certainly the ones with frank Chronic Demyelinating Inflammatory Polyneuropathy (CIDP) but what about milder forms? Prednisone steroid pulses work in early CRPS and could help some autonomic neuropathy (certainly in CIDP) – but when to try? Measuring certain antibodies might help but in some situations testing is rare or unavailable.
- Association of a case of POTS with chairi malformation brings up association of certain FM cases with treatable chairi syndrome cases. Our MRI testing is either unavailable or untrustworthy.
- Large association of POTS with Ehlers-Danlos hypermobility syndrome makes pain issues much more likely. Saw one case of CRPS caused by superficial radial nerve injury from unstable distal radius. Does one dare try prolotherapy to an already painful site?
- Body- wide serotonin in POTS is low and POTS is associated with high suicide risk, adding a deeply troubling challenge to pain in POTS cases.
- Treatment of associated sleep apnea with CPAP may be complicated. Ordinary CPAP might not work and BIPAP might need to be tried. The anxiety that is associated might limit mask use and in one case, clonazepam 1 mg hs had to be used to reduce nightmares and ensure CPAP use.
- Cases are found of CRPS and POTS helped by treatment of bacterial overgrowth. Is this why Cefadroxil antibiotic cured one CRPS case?
- Using Naltreoxone dual opioid blocker /mild stimulator could help CRPS and POTS but how does one get subjects off opioids first?
- Rare POTS cases found deficient in thiamine, B12 and Vitamin D offer rare cures. These deficiencies also flare Fibromylagia. Treatment of the POTS with local measures and Flourinef and or Midodrine can help.
Antidepressants are poorly tolerated in elderly and DHEA, found to be low in elderly, has been found to help with depression. I suspect part of its effect is through androgen stimulation as some is converted to such. I have patients order DHEA from USA and have it sent C/O my office as I thought it would legitimize its import. Had a visit today from 2 men from Canada Customs who made it clear that wasn’t so.
Cost-utility Analysis suggests not. I am not a big fan of attributing chronic pain to anxiety-depression – (sorry Dr. Sarno)… Recent analysis suggests in osteoarthritis it is not cost -effective to spend special time on anxiety depression
Study did meta-analysis of multiple article and found at 1 or 2 months will drop pain by 1.1/10 with no difference between 100 or 200 units. Often there is significant inflammation around the knee – anserine bursa being an obvious one. Botulinum, not being directly injected into it would have zero benefits there. Steroid is very forgiving and would effect inflamed areas close by. I contend they should be both injected at same time.
I’ve always liked the anterior knee injection using a 2 inch needle but have had to accept the recent statistics put forth by Durolane injectable lubricant that lateral injection mid patellar is better
Refractory Migraine Eliminated by Pulse Radiofrequency to Superior Cervical Ganglion -Good for Chronic Neck Pain as well
Awe inspiring case of chronic migraine headaches eliminated by pulsed radiofrequency (low burn) to a neck sympathetic ganglion.
Local steroid/local injections can greatly attenuate shingles and post shingles pain yet has received very little notice.
I wrote about it in a couple blog notes:
Alternate Approaches to Post-Herpetic Neuralgia (PHN)
Early Fix For Herpetic Zoster/Shingles – Inject the Spots With Local and Steroid
Now a controlled trial found pains in 12.8% of injection treated group versus 47.8% in the standard treatment group (P<0.001)
The most successful treatment for CRPS especially early is Prednisone. It is even used in wrist fracture situation. Yet this fact seems not all that well known as is the fact one should continue the course for 8 weeks. Needless suffering though ignorance.
Steroid injection of SI joints can be very helpful. It is more common than one would think as is seen in post-traumatic cases, in celiac disease, in various colitis, and in certain Fibromyalgia misdiagnosed subgroups. I highlight this study so patients can see its benefits.
Recent Article diagrammatically demonstrates where opioid deaths have been coming from
So spend less time looking at medical opioid prescriptions and more at illicit fentanyl trade. All doctors are now under tremendous pressure to cut their dose of opioids for chronic pain sufferers from organizations that feel they have to do something even when it is not the issue. Just don’t do something – stand there! (instead)
Not a new study but the benefits mandated that I include it. Study presented were 2 cases in their 80’s with severe Post Herpetic Neuralgia – one on face, other T8-10 that tried everything including spinal stimulator without effect. Pain level was 10/10. Relief was gradually obtained by increasing doses of Nabilone, starting with 0.5 mg hs and working up over 1 year to 4 mg hs – got pain down to 4/10 without opioids. Having gone generic, cost is not prohibitive .
Capsaicin 8% patch was compared to pregabalin (lyrica) for effects on non-diabetic peripheral neuropathy. A treatment with Capsaicin can cut skin sensitivity (dynamic mechanical allodynia) in half and render 29% free of sensitivity. Was embarrassed to publish this once I found out how much the patch costs ($800/patch in 2012)
When I first started Botulinum injections I just just injecting intradermally the areas where they felt the pain. Then it became clear the trigger zone needed special treatment and subcut was more done. I used to have a researcher repeatedly email me for any updates on TN injections. Now there are some – Injecting the roots (origins) of the affected trigeminal nerve (II and III anyway), and injecting the muscle in the trigger zone.
Pisiform instability can cause nondescript pain over lateral hand eminence, and in some cases present with ulnar nerve damage. It is little recognized.
Growing evidence that some gluten sensitivity is actually sensitivity to the carbohydrates in Gluten Foods rather than to gluten. None the less, avoiding gluten foods during colitis flareups, helps suggesting a temporary sensitivity.
Back in the 1984, I listened to Dr. John Bonica admonishing Doctors over the poor treatment of cancer pain. I felt ashamed. Now, with the war of Chinese based Fentanyl washing over all use of opioids, cancer patients are again being targeted and living in undo pain. I had one patient with arrested metastatic cancer having to deal with severe issues over her opioid use. My college actually wrote me about complaints and I sent her cancer clinic report and bone scan and told them that is all they needed to know. Now a human rights group has picked up on fact cancer pain patients are forced to reduce their opioid doses. This is inappropriate in cancer cases and again I feel ashamed for the medical profession.
You can read about the problem here:
Human Rights Watch Investigating U.S. Pain Treatment
March 15, 2018
Pain News Network
I have to admit Doctors can be very stupid. It took them years to realize you needed to use sterile technique with deliveries, that a germ caused ulcers, and now it extends to opioid use as well – go for the fad – forget the patient.
About eye, forehead, and temple pains from headache source, or surgery can be disabling yet responsive to blocks of the back of nose. The description is laid out in an online article at:
Post-Craniotomy Headaches are annoyingly common – “Headaches following craniotomies are reported in up to 91% of neurosurgical cases”. Injecting craniotomy edge defect triggers, scar neuromas, and botulinum to temporalis muscle are local treatment options.