Check out my new article about Osteoporosis and Chronic Pain here:
I’m happy to announce that I am a monthly columnist for ALIVE health and wellness magazine starting November 2015.
ALIVE magazine is an East Bay healthy lifestyle publication celebrating 10 years this year.
It focuses on being a leading source of information for natural health and wellness and has topics and engaging articles related to family, fitness, beauty, health and food.
Please comment on any specific topics you might like to hear about in future publications related to pain management for my column.
The “Secret” Key to a Healthy, Long Life ALIVE #1
The importance of the appropriate management of chronic pain is finally getting some attention. Unfortunately, it’s also seems to be the next “new” illness for money mongers and pharmaceutical companies to make billions more in revenue. This article from the New England Journal of Medicine gives insight to and hints at the perpetrators of this problem. http://www.nejm.org/doi/full/10.1056/NEJMp1404181
My opinion is that slow release formulations of narcotic pain medications are best for chronic pain, in most circumstances. Some of the caveats include older patients, those with liver or kidney failure and people who use pain medication infrequently and sparingly. One of the goals of pain management is to reduce the pain level and improve function on a regular and long term basis. This means using medications that last longer and prevent changing levels of pain severity throughout the day. Long acting pain medications also fix the “pill popping” phenomenon during which every 3-4 hours another dose of medication is needed to prevent severe pain from returning. Fast acting or regular formulas of pain medications typically only last 3-4 hours whereas slow release formulas work for 8 to 24 hours per dose. Less pills, better pain relief and increased activity is my mantra for pain management.
There has been considerable debate regarding the new slow release medication, Zohydro. It’s a long acting Vicodin (Hydrocodone). Vicodin is the most prescribed narcotic in the country for acute and chronic pain. It’s also most likely the “gateway” prescription that leads to addiction if not used and monitored appropriately. Zohydro could be a very useful medication in specific groups of people such as those having severe post- operative pain expected to last more than 2 weeks and older patients who don’t tolerate stronger narcotic medications but have chronic pain 24/7.
On the other hand, Zohydro will be lethal for specific groups of people. Unlike the current slow acting narcotic pain medications, Zohydro has no safe guards against tampering. That means it can be crushed and snorted or injected for an immediate “high” for drug addicts. That in turn means that it will ultimately be the next hottest drug available on the street. The end result of all of this is more accidental overdose deaths that could have been prevented.
Apparently, the FDA commissioner, Margaret Hamburg, isn’t so concerned about this. As a matter of fact, she also supports and approved a new drug, Evizio, an injectable naloxone, which is the antidote for narcotic overdose, ahead of schedule. Hamburg and other supporters believe that if doctors take extra steps and jump through even more hoops, then patients won’t abuse medications like Zohydro. This is the wrong idea. Patients who want to abuse medications will find a way. Enough burden is already on us doctors without the fear of having our medical license taken away because we didn’t follow another “prevention” algorithm before prescribing controlled substance medications when we deem it appropriate. The FDA has approved Zohydro even though doctors are telling them that risk of Zohydro is too great to put it on the market, as is. How does it make sense to ignore the recommendations of doctors who may be ultimately blamed in the event of adversity regarding the medication? Why does that make sense to Hamburg? My guess is that the almighty dollar is involved, as usual, despite the harm it may cause many people. How convenient that now we also have the antidote for overdose in Evizio that was fast tracked through the FDA. This is not a coincidence; Zohydro and Evizio will not be affordable and these medications will be very profitable.
I personally do my best to try to identify the high risk patients and not prescribe narcotic medications to them, but the nature of the addict is to be deceptive in order feed the habit and they are quite good. Just look at a few of my bad YELP reviews for some examples of this. Addiction is an illness. It is reckless for the FDA to approve a new narcotic pain medication that doesn’t have basic safeguards against abuse and misuse when accidental overdose of prescription pain medication is the leading cause of death in this country today. Shame on the FDA. Shame on people who value money over lives.
My first experience taking a pain medication was when I was 26. I asked a friend if he had any Tylenol for my headache.
I was working in my first year of the residency program in Anesthesiology at Johns Hopkins Hospital and enjoying a night off watching television with a couple of friends. I was suffering with a bad headache all day and was just trying to ignore it, but to no avail. That evening, I finally decided to find something to relieve it. Matt went to get some Tylenol but came back with Tylenol with Codeine, saying that it was all he could find in his mother’s bathroom cabinet. Mary Lou immediately told me not to take it, but I eschewed her comments and took one. Thirty minutes later, I still had the headache and thought it was a good idea to take another. It was after all, only codeine, 1/10th as strong as Vicodin. It’s not really used to treat severe pain anymore, I told myself. Ever faithful, Mary Lou again said “don’t”. Despite taking more, I still had no pain relief and I ultimately went to bed.
The story doesn’t end here, but let me give you some interesting background.
Johns Hopkins Hospital is even more impressive in person than it is in reputation. It’s a beautiful place filled with pictures of medical messiahs and heros. It has the unmistakeable air of compassion and competence and historical greatness. Everyday I was reminded of how fortunate I was to have the opportunity to work and learn amongst the most intelligent and capable of doctors. The first day of my residency training was unforgettable, but in a totally unexpected way.
It was 6:00 in the morning and all the residents, fellows and attending physicians were in the Grand Rounds auditorium which was a huge amphitheatre with stadium seating and a stage at the base. This is where in the 1800’s, the famous doctors Halsted, Cushing, Blalock and others would perform procedures in the “operating theater” on patients in front of an audience of students and doctors who learned their techniques. Out onto the stage walked a string of distinguished looking physicians with their white coats on and one by one they told their stories. “My name is Dr. Jones and I’m a drug addict, my name is Dr. Andrews and I’m a drug addict, etc.” Chills ran through my body and my heart broke for those doctors whose lives and promising careers were ruined by drug addiction. Ruined by the wrong decision at the wrong time that set off a chain of regrettable and irreversible consequences. The common theme behind their downfalls was that they were tired and stressed out and wanted to sleep and feel better. They tried some of the medications that they had to give their patients and that was the beginning of the end.
As anesthesiologists, we have very easy access to any and all controlled substances (narcotics, propofol, sedatives, etc.) because we use them in our anesthetic treatment plans for patients undergoing surgery every day. We have access and perhaps more importantly and dangerously, we have more knowledge and a higher comfort level than anyone on how to use them and avoid potentially lethal side effects. The disease of addiction; however, is such that the irrational use along with physical tolerance and dependence causes even the most knowlegable of us to keep chasing the “high” that inevitably leads to overdose and death. A woman in the residency class behind me was found dead in the ladies restroom with an I.V. in her ankle one night while she was on call. Certainly she hadn’t anticipated that outcome when she was heading for work that day.
So, back to my story abou taking Tylenol with Codeine for a headache…
Even though the medication hadn’t helped my headache, I awoke the next morning feeling like I was in Nirvana. I had this amazing feeling of calmness and well-being and of feeling loved. There was a breeze coming through the window and it felt like a wave of happiness caressing my skin. I couldn’t grasp anything to worry about! As a type A person, there’s always something to be concerned about, real or imagined. I had never experienced a feeling quite like that before and it was beautiful– at least for about an hour. Shortly after waking up, I got into the car to get breakfast. I became so nauseated after driving only a mile that I had to pull the car to the side of the road to throw up and up and up…That was the perfect example of both the high and the low of a narcotic pain medicine. I also realized with great clarity how anyone can become enamored with and addicted to the euphoric effect that these medications have. It became obvious how a medication can quickly become a drug if used in the wrong way for the wrong reason. I recalled those doctors from my first day of residency and was reminded of the lament, “But for the grace of God, there go I”.
Today, prescription medication overdose is the leading cause of any accidental death. Unfortunately, the very same medication that is used to improve function and quality of life for someone in chronic pain, is a loaded gun in the wrong hands. Statistics (and anectodal reports) show that teenagers are stealing pain medications from parents and grandparents and then passing them around at parties like Skittles. It’s not uncommon for an elderly patient to tell me that they took a friend’s pain medication “to try” but they have no idea of the name of the medication or dose that they took. There is a general feeling of indifference and a cavalier attitude regarding the danger of narcotic pain medications and this is alarming. Patients become upset that they can’t have their usual alcoholic cocktail and use pain medications. They fail to tell their doctors that they also take other controlled medications like Xanax or Valium that are prescribed by other physicians. Some patients say they’re taking certain pain medications when they’re not and say they’re not when they are. It seems that the general public, as savvy as they are with their internet medical knowledge, has no idea that these medications can make you stop breathing. They don’t realize that the higher the dose, the more potent the medication, and that mixing it with alcohol or other drugs makes the possibility of overdose and death exponentially more likely.
Unfortunately, chronic pain and addiction oftentimes exist side by side. As human beings we’re wired in a way that makes us prone to addiction to pain medications. It’s no one’s fault. It happens and there is treatment, but a person must be willing to accept that the problem exists in order to get help. It is important for physicians to treat each person as an individual and develop a treatment plan based on a specific cause of pain. As physicians we have a responsibility to our patients to prescribe the safest medications for the greatest benefit and lowest risk at all times. Some patients are not good candidates for narcotic treatment if they have specific risk factors for addiction and/or their behavior is consistent with addiction. Everyone deserves relief from pain, but no one deserves a Percocet prescription upon demand. Patients who say, “I know what’s best for me” usually don’t.
Everyday I do my best to take care of people and relieve pain. The medical training and the M.D. license that I have is my most valuable and important achievement. It is also the most difficult goal I’ve ever accomplished. I will not be that doctor who would even remotely consider the notion of selling her prescription pad or her ethics. I have the highest respect for what it means to be a physician. It is my obligation to uphold the ideals of my profession and to help and never harm a person who comes to me for treatment.
Offering hope and encouragement to the many adults who have somehow neglected to exercise for the past few decades, a new study suggests that becoming physically active in middle age, even if someone has been sedentary for years, substantially reduces the likelihood that he or she will become seriously ill or physically disabled in retirement.
The new study joins a growing body of research examining successful aging, a topic of considerable scientific interest, as the populations of the United States and Europe grow older, and so do many scientists. When the term is used in research, successful aging means more than simply remaining alive, although that, obviously, is the baseline requirement. Successful aging involves minimal debility past the age of 65 or so, with little or no serious chronic disease diagnoses, depression, cognitive decline or physical infirmities that would prevent someone from living independently.
Previous epidemiological studies have found that several, unsurprising factors contribute to successful aging. Not smoking is one, as is moderate alcohol consumption, and so, unfairly or not, is having money. People with greater economic resources tend to develop fewer health problems later in life than people who are not well-off.
But being physically active during adulthood is particularly important. In one large-scale study published last fall that looked at more than 12,000 Australian men aged between 65 and 83, those who engaged in about 30 minutes of exercise five or so times per week were much healthier and less likely to be dead 11 years after the start of the study than those who were sedentary, even when the researchers adjusted for smoking habits, education, body mass index and other variables.
Whether exercise habits need to have been established and maintained throughout adulthood, however, in order to affect aging has been less clear. If someone has slacked off on his or her exercise resolutions during young adulthood and early middle-age, in other words, is it too late to start exercising and still have a meaningful impact on health and longevity in later life?
To address that issue, researchers with the Physical Activity Research Group at University College London and other institutions turned recently to the large trove of data contained in the ongoing English Longitudinal Study of Aging, which has tracked the health habits of tens of thousands of British citizens for decades, checking in with participants multiple times and asking them how they currently eat, exercise, feel and generally live.
For the study, appearing in the February issue of the British Journal of Sports Medicine, scientists isolated responses from 3,454 healthy, disease-free British men and women aged between 55 and 73 who, upon joining the original study of aging, had provided clear details about their exercise habits, as well as their health, and who then had repeated that information after an additional eight years.
The researchers stratified the chosen respondents into those who were physically active or not at the study’s start, using the extremely generous definition of one hour per week of moderate or vigorous activity to qualify someone as active. Formal exercise was not required. An hour per week of “gardening, cleaning the car, walking at a moderate pace, or dancing” counted, said Mark Hamer, a researcher at University College London who led the study.
The scientists then re-sorted the respondents after the eight-year follow-up, marking them as having remained active, become active, remained inactive or become inactive as they moved into and through middle-age. They also quantified each respondent’s health throughout those years, based on diagnosed diabetes, heart disease, dementia or other serious conditions. And the scientists directly contacted their respondents, asking each to complete objective tests of memory and thinking, and a few to wear an activity monitor for a week, to determine whether self-reported levels of physical activity matched actual levels of physical activity. (They did.)
In the eight years between the study’s start and end, the data showed, those respondents who had been and remained physically active aged most successfully, with the lowest incidence of major chronic diseases, memory loss and physical disability. But those people who became active in middle-age after having been sedentary in prior years, about 9 percent of the total, aged almost as successfully. These late-in-life exercisers had about a seven-fold reduction in their risk of becoming ill or infirm after eight years compared with those who became or remained sedentary, even when the researchers took into account smoking, wealth and other factors.
Those results reaffirm both other science and common sense. A noteworthy 2009 study of more than 2,000 middle-aged men, for instance, found that those who started to exercise after the age of 50 were far less likely to die during the next 35 years than those who were and remained sedentary. “The reduction in mortality associated with increased physical activity was similar to that associated with smoking cessation,” the researchers concluded.
But in this study, the volunteers did not merely live longer; they lived better than those who were not active, making the message inarguable for those of us in mid-life. “Build activity into your daily life,” Dr. Hamer said. Or, in concrete terms, if you don’t already, dance, wash your car and, if your talents allow (mine don’t), combine the two.
Everyone should be aware of the unequivocal facts that smoking tobacco cigarettes is a leading cause of several serious medical diseases; that nicotine is a powerfully addictive substance; and despite the availability of several therapies that are approved by the US Food and Drug Administration (FDA), the vast majority of smokers who try to quit have incredible difficulty maintaining abstinence. Although alternate forms of nicotine delivery, such as nicotine patches and nicotine nasal spray, have been around for many years, electronic cigarettes (e-cigarettes) have achieved impressive popularity in a very short period.
The Rise of E-Cigarette Use
Many individuals — young and old, smokers and nonsmokers — are using e-cigarettes with little knowledge of the potential harmful health effects. Available data from the past few years show dramatic increases in awareness and use of e-cigarettes, especially among adolescents. The majority believe that e-cigarettes not only are safer than conventional cigarettes, but also are effective tools to aid in smoking cessation.
Many clinicians stand ready to advocate for any means to reduce cigarette smoking, yet too is little known about e-cigarettes to endorse these products as a cessation tool at this time. E-cigarette ingredients are not standard across the industry, and the levels of those substances remain variable from product to product. Recent research shows quite clearly that the fluid and aerosol in e-cigarettes contains known toxins, including propylene glycol, heavy metals, volatile organic compounds, and tobacco-specific nitrosamines. 
The good news is that these toxic agents are found in far lower concentrations than in regular cigarettes. However, the long-term effects of exposure to some of these compounds are unknown and require additional research. Other studies have shown that e-cigarette “vaping” adversely affects lung physiology similar to that observed with conventional cigarettes.
The medical community must acknowledge the fact that nicotine itself (referred to as “juice” in e-cigarette cartridges) is a powerfully addictive substance and is a toxin when ingested in large quantities. Nicotine poisoning is most likely to occur in small children who tamper with e-cigarette cartridges; this is a potential, yet unknown, risk that is nearly impossible with cigarettes and nicotine replacement products. Moreover, repeated exposure to nicotine will predictably increase physiologic variables (heart rate) and stress system reactivity (cortisol). On this basis, it seems clear that e-cigarettes containing nicotine should not be promoted as harmless alternatives to regular cigarettes.
Other concerns about e-cigarettes should also be considered. First, the use of these products could prolong actual smoking cessation using FDA-approved therapies. Specifically, people wanting to stop smoking may try e-cigarettes first in lieu of using one of several effective over-the-counter forms of nicotine replacement (ie, patch, gum, or lozenge) or talking to their doctor about using an FDA-approved medication for smoking cessation (ie, bupropion or varenicline).
Second, data are emerging to show that some users are not stopping cigarette use, but concurrently using e-cigarettes (“dual use”) in all the places where they would have otherwise have been unable to smoke (eg, restaurants, airports, and the workplace). This presents an interesting public health question because many smokers, as a consequence of smoking bans in public places, have become more motivated to quit smoking.
Finally, and perhaps most problematic, is the very real possibility that e-cigarettes may serve as an initiation device for young people, who may eventually transition to regular cigarettes when they reach the legal age to purchase those products. 
This procedure provides immediate pain relief for back pain due to a fractured spine.
People who have osteoporosis, osteopenia, or cancer such as Multiple Myeloma are at risk of fractures of the spine which are called Vertebral Compression Fractures. Oftentimes no major injury is involved other than a slip and fall, but because the bones are weak, they break and cause severe back pain. Most commonly people are prescribed pain pills by their doctors or the emergency room, but usually this is not enough to block the pain and allow people to function normally. Also, the strong pain pills usually cause side effects such as sleepiness, confusion and nausea.
The Percutaneous Balloon Kyphoplasty (PBK) is a simple procedure than is performed in my office under light sedation in under an hour. Patients are immediately able to move about with little or no pain and no longer require the strong pain pills.
Check out this YouTube video for a brief description.
Another benefit of treating a spinal fracture with PBK is preventing long term deformity of the spine. If the fracture is allowed to heal on its own, it can cause stenosis of the spinal canal which can lead to other chronic low back pain symptoms. This is due to the fracture that causes loss of height of the vertebrae.
Call Balanced Pain Management for a Consultation and more information at 925-988-9333.
This is a really good article that describes chronic pain from a layman’s perspective. This woman is living with Trigeminal Neuralgia and very aptly comments on how her chronic pain is a disease just like any other medical problem and deserves to be appropriately treated.
Online chat rooms provide a welcome venue for chronic pain sufferers to talk about their pain and receive encouragement from others who understand what they’re going through, according to a new study published in the journal Cyberpsychology, Behavior, and Social Networking. Click here to read the full article»
Balanced Pain Management has been mentioned in a Diablo magazine article. Come check it out here »