Pills and skills: you need a tool set to deal with chronic pain. (Caution: longer than average.)

This post is far from laconic

On a subject that’s close to demonic

I don’t think it’s wrong

To write twice as long

On pain, not acute, that is chronic.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A lot of people deal with a lot of pain in this world.  I’m one of them.

Acute pain, short term in duration and a useful signal to avoid destructive situations, distinguishes itself from chronic not only in terms of duration but in neurophysiology.

My back started to hurt at age 13; my pediatrician initially attributed the problem to growing pains.  Worsening symptoms brought me to the orthopedist at age 17; he proposed surgery and I declined.  By the time I came up for my draft physical during the height of the Viet Nam war, I had a solid 7 year history of back problems well documented.  But the x-ray of my low back gets more credit for keeping me out of a stupid war and saving my life than the pain.

Normal people have five vertebrae between the last rib and the top of the pelvis.  I have four; what should be the bottommost one, the fifth, is fixed to the pelvis on one side but not the other, giving me a mechanically unsound low back. 

So I survived when 50,000 of my generation did not, and my back hasn’t stop hurting.

By the time I hit age 30 I had seen seven different doctors; in their aggregate they convinced me that the pain was in my head.  In so doing, they taught me the most important part of learning to live with the pain.  In a shared triumph of therapeutic decision making, they hadn’t started me on narcotics.

In fact I owe my life to a disease called ankylosing spondylitis, which hits the spine in much the same way that its cousin, rheumatoid arthritis, hits the joints of the arms, hands, legs, and feet.

In the intervening years I had a disc go bad.  One of my low back vertebrae has slid forward on the one below up (spondylosis and spondylolisthesis), and I have developed a worrisome curvature (scoliosis) in the same region.  All in all, I have five bad diagnoses between my ribs and my pelvis.  I’ve only met three people who have worse backs than mine.

When I finally got the right diagnosis of my main back problem, I got a prescription for indomethacin, a very powerful anti-inflammatory drug.  I took it for a decade and I paid for pain relief with loss of kidney function.

I have learned a great deal about chronic pain management on a personal basis.  As with most other problems in medicine, successful management includes both pharmacologic and non-pharmacologic approaches (pills and skills).

We currently measure pain on a ten-point scale; zero being no pain at all and 10 being the worst pain of a person’s life.  When thinking about my pain, I think about the hours after abdominal surgery when I refused narcotic pain relief; it hurt about as bad as when my disc broke open and pushed against the nerve that goes to my shin muscles. 

Life, just the ordinary course of living, includes pain, on the ten-point scale, up to level 4.  At level 6, I start to withdraw socially, and at level 8 I cannot acquire new information or learn. 

As the years went by, I put together a skill set, much like a set of tools, to deal with the pain.  None of the tools would take away all the pain, but each could take away at least a half point.  I recommend my chronic pain patients put together their own tool kit to learn to live with pain.

Indomethacin helped me by at least 3 points; its close relative, naproxen (the active ingredient in Alleve) helped by 2 points but also hurt my kidneys, and now I’m permanently off the entire class of drugs.

Acetaminophen (Tylenol) takes two points off my pain and deserves a Personal Favorite Drug designation.

A 6 level of pain turns into a 4 with a good night’s sleep and into an 8 after a night with poor sleep, and everyone knows it; much of the time and energy I put into pain management goes into sleep management. 

Skelaxin, a muscle relaxant, takes two points off pain caused by spasm.

Enbrel, a drug that costs $1500 a month, takes 4 or 5 points off my pain because it quells the root cause of my ankylosing spondylitis pain, inflammation.

Acupuncture can take two points off.

Massage or a long hot shower is each good for a point.

I can lose between a half point and a point of my pain by socializing, just getting out and talking with other people.

A good, long aerobic work-out can drop a point or two.

A person becomes completely insensitive to pain during orgasm; and relatively insensitive to pain during foreplay and afterglow; how much the activity reduces pain and how long the reduction lasts varies from person to person. 

Good footwear, including shoes, orthotics, and socks, can take off a half point each if I have been ignoring their importance.

Capsaicin cream helps me more in the winter months than in the summer months.  The active ingredient in jalapenos interferes with the dorsal root ganglion’s ability to transmit the signals of chronic pain.  I have no problem slathering it on whenever I need it.  However, most people need to start with a small area, the size of a quarter or half-dollar, apply it three times a day, and not enlarge the area for three days.  And everyone needs to wash their hands with soap and water twice after applying it.

Fish oil capsules, from 2 to 6 grams a day, can reduce inflammatory pain by up to a point (I get about half a point) if used conscientiously for six weeks, but fish oil that sat too long on the shelf (more than six months) can make things worse.

Transcutaneous electrical nerve stimulator (TENS) units bring me about a point of pain relief, but only during certain parts of the flare cycle; they are much more effective for the pain that follows shingles.

I haven’t mentioned the anti-depressants like Cymbalta, trazodone, or nortryptylline.  Good agents all, a doctor in a call rotation can’t take them regularly because of sleepiness.

Study after study has shown oral narcotics capable of reducing chronic pain by 2.7 points, placebo by 2.1 points, and lowly Tylenol by 2.4.


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9 Responses to “Pills and skills: you need a tool set to deal with chronic pain. (Caution: longer than average.)”

  1. Pills and skills: you need a tool set to deal with chronic pain … | Neuro Physiology Blog Says:

    […] Read the article: Pills and skills: you need a tool set to deal with chronic pain … […]

  2. MLB Says:

    Steve: I was googling for ATLS information, since I have to take it soon. I ran across your blog, and recognized your life and wife’s name, and then your picture. How are you? Sounds like life is interesting! I am sort of doing a similar path. Please email me! Would love to see you!

  3. Jerrell Langshaw Says:

    acute pain is of course annoying, i always take some OTC pain medications to relieve it.*

    My web-site

  4. Michelle Hampton Says:

    I feel like HELL… I have barely made it to the computer just now, yet somehow I am already grateful beyond simple words because I BELIEVE that it’s going to get better, that I WILL get through this (and that your compassion first and expertise second will make SURE that I do…) and that I am going to be happy again.

  5. David Says:

    Thanks for the info, didn’t realize norco was so modestly effective

  6. Helen Stopa Says:

    The blog was very helpful. I have found myself withdrawing socially and usually being a voracious reader have almost completely stopped. I have had no feeling in my toes for about 2 years now. Because of the healthcare changes I can now see specialists. I went recently to the Nevada Spine Clinic because of sciatic nerve pain. The x-rays they took of my spine for a loss of better words, “freaked me out”. It is a perfect “S” the PA diagnosed it as scoliosis. Exactly 2 yrs. ago I had a normal x-ray, so now I am confused as to the reason for the rapid deterioration. They prescribed physical therapy and 800mg of ibuprofen, 2mg hydromorphone and 15mg amrix. On top of all of this, I have a stress test scheduled because of a lifetime of palpitations, irregular heartbeats and an abnormal EKG. So I am thankful for the insurance coverage that started in May. So far this month I have had 5 doctors visits and 1 to the ER. Better late, than dead.

  7. magsdaggs Says:

    Very informative.
    As I have formulated my own Capsaicin ointment within my brand.
    I trialled on on myself and used it to help with the pain in a finger joint.
    I have a person with the same condition as you,although at this stage not as servere.He wants to trial it.

  8. Pooja Amy Shah, MD Says:

    Thank you so much for sharing – a very interesting, helpful piece. (You gave me your info long ago after a talk I did on low back pain for AAFP FMX.) All the best, Pooja Amy Shah, MD

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