Opiate Pain Management
Our opioid chronic pain management program is a multi-disciplinary, integrative approach to managing chronic pain that includes the use of opioid analgesics when indicated by severe pain otherwise inadequately controlled by non-opioid medications and other alternative, conservative treatment modalities. Every effort is made to minimize reliance on opioids through the supplementary use of alternative modalities to reduce pain.
We engage a Bio-Pscyho-Social model of pain management, meaning that our approach to managing pain includes not only a biological approach with the use of medications and supplements, but also addresses the psychological side of pain in which a person is taught methods of using their mind to improve their experience of pain and enhance coping skill relative to living with chronic pain. We also engage the social side of pain by working with our patient and our patient’s family and significant others, when indicated, to facilitate improved engagement in activities and reduce functional impairment.
We recognize that severe chronic pain can be devastating to quality of life by impairing a person’s ability to enjoy many of the simple joys of life most people take for granted. Our primary goal of managing pain is to restore quality of life by reducing suffering and improving the ability to engage in work-related, domestic and social activities.
As the measure of successful pain management, our goals are to control pain adequately so that our patients are able meet the activity needs of their employment, maintaining their home and yard and getting a good night’s sleep. To meet these goals we integrate many approaches to prevent and reduce pain, to improve skills for coping with pain and to address the complications of chronic pain including anxiety and depression.
For the many people who have failed to obtain adequate control of their pain with other measures, opioid medications are the backbone of adequate pain management. The term “opioid” refers to both the “natural” medications derived from the opium poppy (the “opiates” – morphine and codeine) and synthetic opiate-derived medications including hydrocodone, oxycodone, methadone and many others. With few exceptions, all opioids share the same benefits, the potential for abuse and addiction and the same side effects but they may differ significantly in potency. That being said, not all people respond equally to any particular opioid. With genetic testing provided at Accurate Clinic, it may be possible to identify specific opioids best suited for an individual for improved effectiveness and less likelihood of side effects.
Another characteristic of opioids is the potential for developing tolerance, in which the opioid becomes less effective over time. This process often becomes problematic for patients taking opioids for a long time. Understanding this, we offer means of potentially minimizing this problem by careful selection of which opioid to use, the practice of appropriate opioid rotation, and the use of supplements.
Recognizing that opioids are often the backbone of adequate pain control, we strive to seek the safest, most appropriate opioid for the patient at the lowest dose needed to provide adequate pain control while also seeking to avoid the development of tolerance.
Short-acting and Long-acting Opioids
Opioids can be “short-acting,” with a duration of effectiveness generally lasting from 4-6 hours, or “long-acting,” with an effective duration of 12 hours or even as long as one week. Our physician will discuss the advantages and disadvantages of these different treatment options in order to devise the most appropriate approach to meet the patient’s needs.
In an effort to reduce reliance solely on opioids for pain control we often prescribe different classes of medications that reduce pain through mechanisms different from opioids, thus obtaining a synergistic effect for controlling pain. “Neuromodulator” medications are those that act directly or indirectly on nerves to reduce nerve pain such as sciatica, neuropathy or other nerve pain, generally perceived as burning, electric, tingling or sharp pain. Examples of neuromodulators include gabapentin (Neurontin), pregabalin (Lyrica), topiramate (Topamax), milnacaprin (Savella), duloxetine (Cymbalta), venlafaxine (Effexor) and others. These medications are usually tolerated well, especially when initially prescribed at low doses followed by slowly increasing the dose as tolerated. Because these medications reduce pain by different mechanisms than opioids, they can be very successful in reducing pain when used synergistically with opioids.
Topical medications, or those applied directly to the skin overlying the source of pain, include both commercial brand medications as well as unique blends formulated by our physician and provided by special “compounding” pharmacies. Topical medications offer the advantage of improved safety due to less systemic exposure and in many cases improved pain benefit due to enhanced access to the painful tissue. Topical medications can be very effective at safely reducing neck, back and joint pains with minimal likelihood of side effects and are frequently prescribed as a part of the pain control regimen when appropriate.
Complementary & Alternative Medicine
Complementary & Alternative Medicine (CAM) treatment options are extraordinarily helpful in preventing and reducing many painful conditions and no pain management regimen is complete without considering their use. In our pain management programs we place great emphasis on the use of nutriceuticals and natural supplements with evidence-based effectiveness in reducing the pain associated with such conditions as chronic headaches, fibromyalgia, arthritis, and chronic neck and back pain.
Evaluation by our physical therapist is included as part of our pain management programs. Patients are assessed by our licensed physical therapist with the goal of identifying how a person’s chronic pain conditions have affected their strength, range of motion and balance in order to develop an individualized home exercise program to improve whatever problems are identified. Included also is assistance in the proper and most beneficial use of canes, braces and other orthotic devices. Our therapist is also available to assist patients in determining effective sleeping positions, pillow placement and mattresses to optimize sleep.
Our certified personal trainer provides instruction in safe and effective aerobic and resistance exercise as part of a complete exercise program directed at reducing pain and preventing further injury. Our personal trainer is also an expert in teaching “muscle release” techniques that are very helpful in reducing muscle and joint pain. We also offer genetic testing to help identify an individualized exercise program genetically based to provide the most efficient exercise program for each patient.
The role of diet and nutrition is extremely important in the management of chronic pain. All patients enrolled in our pain programs are seen and evaluated by a registered dietitian including a body composition analysis of those patients who are overweight. Vitamin levels and other biomarkers are assessed routinely in an effort to optimize our patients nutritional status. Pain management patients are educated regarding the role of diet in pain and inflammation and are provided with the tools needed to navigate our modern food culture most effectively.
Of particular importance is the role of oxidative stress in obesity, metabolic syndrome and chronic pain. The majority of chronic pain patients are overweight and need help in successfully losing weight. Our pain management patients are strongly encouraged to enroll in our weight loss program and substantial discounts are provided to the patient and their family for enrollment.
Genetic testing is offered to all pain patients as a means of providing safer, more effective pain management. As identified in a study published by Dr. Ehlenberger in 2012, our pain patients have a substantial increased likelihood of having genetic variants in how they metabolize medications. Understanding these variants provides the advantage of safer prescribing by improving the ability to predict the effectiveness of certain medications, their potential for side effects and their potential for drug-drug interactions. As part of our coordinated care program, the impact of these genetic variants can be shared with the patient’s pharmacist and other prescribing clinicians to reduce the likelihood of potentially dangerous drug interactions, a signficant safety concern especially for those people taking multiple medications prescribed by multiple physicians.
Genetic testing also provides insights into a person’s sensitivity to pain and their response to opioids and other medications. Accurate Clinic is active in ongoing research investigating the role of genetics in predicting pain sensitivity, pain tolerance, and opioid tolerance. Dr. Ehlenberger’s strong interest and participation in active medical research reflects the importance Accurate Clinic places on a practice based on evidence-based medicine.
Meditation and Mindful Exercises
The mind is an incredibly powerful tool when harnessed to help control pain and reduce suffering. The truth is, when properly trained, patients can harness a great deal of benefit in living with chronic pain by using their mind to apply simply-taught behaviors, including meditation and other “mindful exercises,” simple mind-based activities that allow a person to focus their minds in ways that allow for improved coping with pain and reduced negative impact on quality of life.
Through the use of medical hypnosis, our patients can learn self-hypnosis techniques that give them the power to use their minds effectively to improve their sense of well-being, their degree of pain and suffering and their energy levels. The techniques can be learned quickly, by anyone, in only a few individual sessions and do not require susceptibility to being placed in a trance. Medical hypnosis is safe and contrary to common misconceptions, the participant does not ever lose control of their mind or their behavior and everyone can benefit from medical hypnosis.
CBT and Counseling
Treating pain is more than just providing medications and physical modalities of management. We believe that it is equally if not more important to address the psyche as a means of reducing pain and improving pain tolerance.
A particularly effective tool for managing pain is to incorporate Cognitive Behavior Therapy (CBT), a collection of techniques and education directed at improving a patient’s skills and ability to adapt to living with chronic pain and improving sleep. CBT also aids in improving communication skill for interacting with both the medical community and family. CBT training is provided in individual and group sessions for those interested or in need of help coping with a life of chronic pain. In addition, a free computer-based CBT education program is provided.
Anxiety and depression are significant and frequent complications of chronic pain and must be addressed for successful pain management. Our licensed counselor is experienced in the problems faced by chronic pain patients and is skilled at providing counseling to assist them. Individual counseling is provided for those patients who need help with anxiety or depression.
To download documents for initial Pain Assessment Visit at Accurate Clinic, click here.