MIGRAINE REBOUND FOR SURE

Do I address the fact that I haven't blogged in four years or ignore it. Hmmm. I believe that information is power and that people need to be told the truth. I didn't die, no grievous injuries. I have been busy with other stuff. Ouch. But, I am now committed to making this blog the best in the field of pain. And so, a recent study in the field of headache demonstrated taht migraine frequently follows a period of decreased stress. Thus, the weekend "rebound" theory of headache is strongly supported. May not seem like a big deal to some, but no one had actually researched this until now. Cool. Good to be back. Say something - I can hear you breathing.

SAVELLA

Can't believe it's been ten months since my last blog! Got caught up in things clinical. A new drug just came onto the market, Savella. An SNRI, that is FDA approved for pain relief for Fibromyalgia. The generic medication is Milnacipran, in the same class as Effexor and Cymbalta. The manufacturer says it targets norepinephrine over serotonin in a 3-1 ratio, more than any other SNRI, which is what makes it such an effective pain reliever. Several of my patients have tried Savella and found it to be effective with minimal side effects. It is being prescribed off label for any type of neuropathic pain and will probably become the sexy, new antidepressant. If you've tried everything else, including the anti-convulsants, you might want to ask your doctor to prescribed Savella. Dosing begins at 12.5 mgs and titrates to 25, 50, and 100 mgs every 2-3 days on a twice daily schedule. It's good to be back.

The Disappearing Pain Doctor

Hope everyone is having a great holiday! It's my plan to resume blogging at least weekly after taking a 7 month hiatus that was partly caused by my real world schedule ratcheting up and partly because no one was reading or at least commenting about the blog. However, following the "build it and they will come" philosophy, I plan on resuming posting regularly. But, I have decided that the postings will not be restricted to only pain topics. People in pain (PIPs) have lives apart from pain that I can also address and I will as the mood and events strike me and seem important. It was always my intentionfor this blog to be integrated into PIPs lives, and nonpaintopcis are part of that. We'll see how this works out in 2009.

Dr. Tim

BACK PAIN, MEDS, AND NONCOMPLIANCE

I listened to a phone call between a patient and our secretary last week. The patient wanted to come in a week before she was due for a refill of her Methodone and Dilaudid as she would be on vacation the next week. She was informed that this was fine, but that she would need to bring in her two bottles of narcotic to confirm that she had a week's worth left. She was told that this was standard policy. We did not refill patients early if they ran out of their narcotics early. The patient was outraged. She stated that this had never been required before and demanded to know why she was being singled out. She railed against the possibility that we did not believe her. She yelled at our secretary that we were being unfair, unreasonable, and unprofessional. She demanded that she be able to speak to the office manager, and aggressed against her as well - for almost 20 minutes. Eventually, she refused to come in early if we could not trust her, and stated she would see us after her vacation. Clearly, she expected to remain a patient even after her tirade.

These interactions happen all the time in a typical pain clinic, but patients almost never see them. Everybody is special, everybody is trustworthy, everyone should get special treatment. Patients should be able to structure their treatments, refills, etc., any way they want. Everybody thinks we should break the rules just for them. This patient demanded that we refill the two strongest narcotics in the history of the world 7 days early out of 28 simply because she wanted us to. The common sense, minimally important request to bring in her bottles outraged her. Objectively, this was not a big deal - if she had the last week of her meds. We'll never know since she felt too outraged and betrayed to bring her meds in and so will fill her script after her vacation - the clear implication being, it will be our fault when she goes through withdrawal.

This patient's behavior was completely inappropriate, aggressive, and rude, and demonstrated grossly poor judgement. She yelled at the secretary and office manager for 30 minutes combined and expects to remain a patient of this clinic. She would probably threaten malpractice if we terminated her over this incident, which in fact we have every right to do.

Your doctor is not your mother, father, best friend, or priest. We don't have to care why you're being noncompliant, or inappropriate, or having a bd day - just that you are. The purpose of rules is to prevent us from having to figure out if you're telling the truth or not - that's for criminal courts and parents. We're neither. And we absolutely have the right to terminate your care if you act out. Always. The next time, you get angry because the doctor or staff won't bend the rules for you, remember this blog. And knock it off.

Dr. Tim

BACK PAIN AND PAIN MEDS

Every pain program I consult to, and there are dozens of them, is monitoring medications, especially narcotics, much more closely that ever before. You are expected to fill your meds on time, not early, and be responsible with them. Your doctor is neither the police, nor your parents. Having a good reason to be out of meds early is not the same as being on time. Whether you overconsumed, lost them, or they were stolen matters less than you think. Whether or not we believe your story matters less than you would think. Everybody gets one or two or even three free passes and then your doctor will probably confront you. No matter the reason, you are not a good candidate for strong pain meds if you cannot manage them. This morning a patient was outraged that she had to bring her meds with her to an appointment where she was filling her narcotics a week early so she could go on vacation. She was angry that we did not "trust her." The angrier she got, the more inappropriate. If she had the last week of her meds, why was it such a big deal to bring in her meds? Why does she think that the rules don't apply to her, that she is so special, she should be above everyone else? At best, she's being narcissistic, at worst she's using aggression to cover up being noncompliant with her narcotics. This happens all the time, the kind of interaction most patients never see but affects how pain doctors practice medicine. Be responsible with your meds, and if you run out, don't think your reason is important. It's not.

Dr. Tim

LIMBREL - A NEW ANTI - INFLAMMATORY

Limbrel is a relatively new prescription anti-inflammatory that is FDA approved for osteo-arthritis, but used off-label for a variety of inflammatory problems. Limbrel is not classified as a drug, but rather a medical food product. It inhibits the COX (cyclooxygenase) and LOX (lipoxygenase) enzyme systems. It is the first and only medical product that balances both COX-1 and COX-2 metabolism equally. It consists of flavocoxib, a blend of flavonoids from the two plants Scutellaria baicalensis and Acacia catechu, both well recognized for their aniti-inflammatory and anti-oxidant proerties. Anti-oxidants aborb free radicals in the joints that have been found to break down cartilage over time. Patients report effects within 4-10 days of taking the product. Side effects are minimal. Ask your doctor if he/she thinks Limrel might be effective for you.

BACK PAIN SURVEY OF TREATMENT SATISFACTION

A national, SpineUniverse survey of patient satisfaction with a range of back pain treatments yielded interesting results. Herbal remedies, over the counter pain medications, and acupuncture produced the greatest patient disatisfaction. Prescription pain medication, massage, exercise, and weight loss produced the greatest patient satisfaction. Less than half of the patients who underwent spine surgery were satisfied with the outcome of their surgery. If you are considering spine surgery, you may want to reread that last sentence. It is interesting to note that prescription pain medication and massage are treatments that are done to you. You have no real control over the outcome. Exercise and weight loss, both behavioral strategies are treatments that you do to and for you. You have complete control over them - but they are more work for you. You don't get to just passively lie there and be worked on. They are free, painless, and available to everybody. They also make every other treatment more effective. To read about the complete survey, go to:


http://www.spineuniverse.com/article/back-pain-3167.html