Medications Physician Training

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Doctors can call to schedule a 3 hour appointment for training in these medications. I do not train patients in prescribing. If you are a physician needing these treatments, please discuss with your treating physician and ask her/him to schedule a time.

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Patients with pain need to slowly taper off opioids and remain off for three weeks before starting. This is assuming good manual physical therapy and cognitive behavioral therapy is also prescribed.

 

Relevant medications can be started in one week for major depression or bipolar depression.

If for treatment resistant pain, these can be started in two or three weeks.

Medications may or may not include the following:

ketamine nasal spray – this may not be the most important medication. It takes a team.

naltrexone low dose  or  ultra low dose*****  one of the most valuable medications I have ever prescribed

dextromethorphan sustained release

oxytocin – a hormone. Your brain makes it, your heart makes it. It is NOT oxycontin.

memantine high dose – research in France has shown it may work for pain, exceeds the FDA approved 28 mg/day dose

lamotrigine an epilepsy drug

B complex – do not take more than 2 mg B6 as it is neurotoxic, creates burning pain and ataxia that may be irreversible

Vitamin D

Boswellia (migraine)

Others

They are not magic bullets, not cures. Experience comes in how and when to time the use of these medications to minimize risk of side effects and “clamp” pain and/or major depression. Thankfully, I do have patients whose “intractable” pain is in remission. Intractable means there has been no response to opioids or other medications or combinations tried so far.

Medications that I use are based on my focus on neuropharmacology, not on injections and spinal cord stimulators or ECT or rTMS which often have already been tried and failed to help.

Bear in mind, some physicians who do not use these medications may be unwilling to prescribe them. Some specialists limit their practice to procedures, others do not specialize in neuropharmacology. Most of my patients are complex and have usually been tried on a long list of medications and interventions that failed to help.

Use the search function on my website to read about some of the medications I prescribe or case studies, particularly note the articles posted May 26, 2009, for some of these medications and January 2011 to read some of the science of glia and inflammation that is present in chronic pain or in depression.

There is not a doctor on the planet who can predict what anyone’s response to treatment will be. If they do, you should avoid them for dishonest practices.

I cannot speculate what percentage of patients would be helped by my approach. To do that, you would need large numbers and placebo group to compare one person’s pain with another – no such standardized comparison exists. Research dollars are very limited and only one medication is tested at one time. However, if you get 10% result with 4 or 5 medications, you are noticing some change when one alone may do nothing noticeable.

Treatment and outcomes are individualized for every person with pain or Major Depression. Each person has a different pain threshold. Some lack a chromosome and/or have difficulty metabolizing medications.

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I do not recommend spinal cord stimulators because:

1. Most important, there are no long term studies showing lasting benefit;

2. they may cause complications, for example infection, paralysis, migration of the device or the leads, or new pain and scarring at the site of the external box, tethering to the cord itself;

3. for the rest of your life, you will never be able to have an MRI scan once the leads are in place, regardless of whether you have cancer or stroke;

4. there may be other ways to relieve intractable pain. Consider trying them first.

 

Patients who have had issues with substance abuse including alcoholism are not candidates for outpatient use of ketamine.

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Compounding Pharmacy

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LaVita Compounding Pharmacy 800-866-507-1990 open Monday – Friday until 5:00 P.M., has information and instructions on these medications if not used by your local compounder. LaVita ships to 11 or 12 states.

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Physical Therapy

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Bruce Inniss, P.T. at Inniss Physical Therapy, 1-619-287-4678, F 1-619-287-0350, 6475 Alvarado Rd, San Diego CA 92120. Bruce is an orthopedic physical therapist, a rare degree for therapists to achieve. Many of my treatment refractory patients who had no benefit from decades of physical therapy have found relief with Bruce and return two or three times a year even from London to see him. His office is 30 minutes from mine in good traffic. Besides the invaluable assessment and treatment, they are one of the first clinics west of Texas to introduce Unloaded Ambulation, partial Body Weight treadmill training and the first physical therapy clinic in San Diego to introduce isoinertial training and Norsk Sequence Training.

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Return to home page: Welcome to my Weblog on Pain Management!

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24 Responses to “Medications Physician Training”

  1. Suzy Doehler Says:

    Thanks for your honesty and information on your treatment protocol. I found your insite into the pain experience very insiteful as well. Interesting theories. MY PM group would not comply with the meds suggested. The seem intent on the SCS as a cure for most pain issues. If I knew I would get good follow up, I would love to work with you. Thanks for the input. Fondly,
    Suzy Doehler

  2. liz scribe Says:

    Dr Sajben
    I agree wholeheartedly on your thoughts about the SCS. Can you tell me how you feel about a short term epidural catheter (2-4wks) for RSD in the right arm? I am unsure as to whether this would cause any further spread or if the risk of infection is too great.
    Thank you

    • Nancy Sajben MD Says:

      Some individuals who have CRPS/RSD find that it began or became triggered by a flu shot or a therapeutic injection. One publication in 2009 said the most common trigger for this syndrome is phlebotomy, i.e. a needle stick to draw blood.
      It may be helpful, but no one can predict the risk. Infection is doubtful to be a major issue unless the person is immunosuppressed. Best of luck.

      • liz scribe Says:

        Thank you so much for your reply. I have printed up your website in the hopes her doctor in NY will be interested in consulting with you. RSD is a terrible disease and it is so wonderful to read about a potential medication combo to help relieve pain.

  3. Judy Antonakakis Says:

    Dear Dr. Sajben,
    We wish we never heard the words “you may have RSD”. My husband of 40+ years had a simple RT ankle sprain at work in April 2007. The sprain healed but the pain, swelling, inflammation, and cold foot never went away. Of course, now, we see everything very clearly as in a rear view mirror; but as you go through the weeks, months, and years wondering just what could be wrong it is anything but clear to the untrained observer. He was finally diagnosed by Dr. Kirkpatrick, Tampa FL in October of 2010 and by that time the disorder had spread through his whole body. Both lower legs were so completely impacted that they had blown up 2-3 times the normal size. They were full of red fire, blistering, running with fluid, and some open sores. It was impossible to get on even a sock or slipper. He began to lose grip in the right hand, the upper back from shoulder to shoulder felt to him as if Satan himself was dragging a razor blade rake slowly, ever so slowly, across his skin. A man who was very physically active was becoming barely able to walk. Were it not for a big black puppy I gave him for Christmas 2009, I think he would have stopped moving altogether. Yet each day he would get up 3-4 times and walk the pup the length of 5-6 houses down and back, or walk around the backyard while the pup romped. It was a minor lifesaver in terms of mobility.

    Except for the time when his 26 year old brother died suddenly, instantly in a motorcycle accident, I’ve never seen him break down uncontrollably. But this pain would spike, bring him to his knees, into a ball of tears. I would beg him to let me call 911, but he knew if he held on, eventually the spike would come down and he would be able to go on. For months, he “slept” sitting up at the edge of the bed or couch because the pain and swelling made him feel as if he were suffocating when he tried to lay down and the pain in the legs was more bearable in the sit position.

    In December of 2010, he underwent high dose Ketamine infusions – 3 days/4 hours per day. The transformation was happening before our very eyes as the swelling and edema began to subside. Within days, he was able to wear shoes and socks. It was a miraculous visual improvement. As the weeks went by he could breathe again. Weight gain that had been increasing exponentially by the day, began to decrease just as dramatically. Truly we can say he has had improvement.

    Why then, you must be thinking, am I writing to you. Even though he is improved, he is not out of the woods. His left leg was so impaired that the doctor told him a 4th day of infusion probably would have been beneficial. Also, although his appearance was dramatically improved, the pain in the left leg was relentless. So a couple of weeks ago he underwent another round of Ketamine infusions 4 hrs / 4 days. We cannot say that his pain has reduced – he suffers day in and day out.

    I have continued to search the web for information and came across articles on LDN, wound up on your site last week. I then recalled having seen your site many months ago, reading with great interest and saving it for later reference.

    I wanted to express to you how much I appreciate your informative articles, what seems to be your extremely personal and genuine approach to your patients, and then let you know how much I valued your article related to your RSD/CRPS patient treated with oral Ketamine, LDN, etc.
    It gives me hope that in the right hands, Nickolas may be able to overcome this beast.

    Although we live in FL and coming to CA is not possible at this time, I wondered if you would mind if I share your information with Dr Kirkpatrick. At the very least, we think Nickolas may benefit from LDN.

    In closing I would like to add that if the physicians who treated him for 3 years had even the slightest knowledge of RSD/CRPS or true interest in the total patient, instead of a body part, he may have been spared such a devastating blow. Nearly everything they did to “fix” him pushed this thing into overdrive. Yet even when it seems hopeless some days…I take courage in the good work I see outside of my immediate sphere, pray for his relief, and keep unwavering faith.

    Thank you most sincerely.
    Judy

  4. Judy Says:

    Each time we connect with an individual who understands the nature of this disorder from health providers, to sufferers, or those who are simply interested in learning more about CRPS, it is always such a positive experience. We always learn something new or are enriched by the encounter. Your thoughtful reply is much appreciated.

  5. Kathy Morrow Says:

    Dear. Dr. Sabjen,
    First, I’d like to thank you for your tireless devotion to the treatment, education & research of RSD/CRPS. The how & why of my journey to the prison sentence I currently serve is no longer important. The damage created by the long list of treatments is a factor however. 20 SGB’s, 1 effective for 5 days, 1 for 5 hours, the other 18-no improvements. Short term Ketamine Infusions, a long term K drip which ended up doing irreversable damage, an SCS that did improve swelling/apprearance on RT upper extremity: but created the worse CRPS area on my entire body (where the leads are tunneled through to meet the battery.) And every every modality in between, including a large pharmacy of medications.
    My long winded question is: Considering the 1 time (5 day) success of the SGB, would you recommend RF Lesioning for my case? (I do not have full body RSD but close to that. Every extremity aside from right leg. Also resides in tailbone, ribcage, & most severe at tunnelling area.) My anesthesiologist is recommending RFL.
    Oh how I wish to be one of your patients.
    Most sincerely,
    Kathy Morrow

  6. Sissy Alsabrook Says:

    Hello Dr. Sajben and any readers, I am so grateful that I live nearby and have access to your wonderful treatment medically and spiritually. Wonder where I would be with my CRPS if I had not been referred to you 5 years ago? I don’t think it would be pretty but luckily I function at 99.9%. Yeah! Sissy

  7. Yasmin Says:

    Good day Dr Sajben

    My sister has a needling and pinning problems since last July 2014 right after 10 sessions of solarium in Sweden. It was all started with skin rashes on her legs and arms but converted to needling and pinning afterwards. She has visited so many doctors in Sweden, overseas as well as Australia and done a lots of tests such as EMG, MRI and blood which are normal.

    Since neurologist gave her the gabapentin and other types anti-epileptic her pining and needling got worst and spread out to her face, mouth as well as entire body and including burning and tingling problems.
    I believe these medications are all having some much side effects which made her situation worst.

    Can you please let me know if you can provide online service to pain management to patients as well? She is not in the position to travel to US at the moment due to her body condition. She is now taking peapure tables from two weeks ago.
    I would appreciate if you can provide me with some guidance about that. I am happy to cover any costs and submitting all of her test results for review. Many thanks for your help. Yasmin

  8. Chris Jacoby Says:

    If you are a true chronic pain Patient like I am and have been for 16 years then why would you care if rooms available have movie theaters,zootrips, etc. I live bedridden like a wounded animal with no choice but convincing myself to stay alive. I certainly do wish I could enjoy amenities but that hasBenmadream for years now. I am in Florida where there has always been a lot of vacation activities so my brain is constantly working to keep strong about my loss of abilities. I absolutely cannot traveL alone too bad because you may have been able to help me. The doctors here have zero knowledge on my conditions or the pain involved because of them. Unbelievable the amount of understanding I have witnessed some of these doctors have concerning pain and or depression. It is as if they have never heard of it before let alone tried to treat.

  9. Jessica Rees Says:

    Hello, my son has suffered with Major depressive disorder for over 7 yrs. He has been on just about every antidepressant under the sun. He has also had Transcranial Magnetic Stimulation & two different sets of ElectroConvulsive Therapy. We live in the state of Ohio. My son is 23 years old. He attends college & only has Molina health insurance. We live in the state of Ohio. Are you aware of a doctor in Ohio that administers intranasal or sublingual Ketamine?
    Thank you,
    Jessica

    • Nancy Sajben MD Says:

      Check the Ketamine Advocacy Network, and best wishes to you.

    • Nancy Sajben MD Says:

      In my experience, teaching another physician via telephone very rapidly to squeeze in so much material, takes about 2-1/2 hours of my time.

      That can only increase the hope of more nearby psychiatrists willing to begin, or even refill medications I or others have started.

      Pharmaceutical companies are cutting back 70% on research budget for antidepressants – I read in a reputable source a couple weeks ago, 2 or 3 weeks. Not sure if NYT.com or Guardian.

      Ketamine is one of the safest medications I have prescribed in 40 years of medicine, but nothing even remotely compares to its efficacy —– in the right hands. I will post a short note on this perhaps now or when the time permits. Vast experience has taught me a lot – and cost effective home use because it is short acting.

  10. Jessica Rees Says:

    Thank you so much! My son and I have been looking on that site. That is where he found you actually. The closest treatment center to us is in Indiana. They only administer Ketamine by IV. Thank you, Jessica

    • Nancy Sajben MD Says:

      You are very welcome. The only problem is it is a short acting drug, which is why I feel it should be prescribed in a nasal spray. I have taught psychiatrists to use the protocol I use, if his psychiatrist wishes to call me.

  11. Jessica Rees Says:

    Thank you again, I truly appreciate your concern. Are all routes of administration (ROA) short acting? My son has been looking into sublingual. Are you aware of this ROA? Would you happen to know where we can order sublingual Ketamine? Thank you, Jessica

  12. Jessica Rees Says:

    My son is interested in intranasal but read that it can drip back out, or run down the throat. Does intranasal have to be administered in the office or can this be done at home?

    Thank you,
    Jessica

    • Nancy Sajben MD Says:

      Big subject. Will post on this – need time to edit down as it is a huge subject, never enough time.

      I am available to teach doctors and of course I teach my own patients.

  13. Jessica Says:

    You are very kind Dr. Sajben, thank you. My son is going to contact the doctor that performed his Electroconvulsive Therapy (ECT). Maybe that doctor will be open to consult with you. We are also going to check with the doctors at Ohio State University, where my son had Transcrainial Magnetic Stimulation (TMS), as well as, another set of ECT. I am very anxious to read your post. If you would like, you can message me privately through email. Is there any way my son could become a patient of yours without coming to your office? We live in the state of Ohio. Thank you SO very much!

    • Nancy Sajben MD Says:

      By law, I see patients only in California where I have a license. I see patients only in office and I prefer not to co-treat a patient long distance as I cannot supervise the small adjustments that could needed.

      Training is different than co-treatment.

  14. Jessica Says:

    It is wonderful this drug is available. Such a shame research is being cut that drastically. There are so many lives at stake.

  15. Donna Greiner Says:

    I have had RSD for 21 years. I began to discuss considering treatment with low dose naltrexone at a recent appointment with my physician. My physician would not discuss it, and told me not to listen to it and disregard it. I was very disheartened, hoping to reduce the severity of the daily pain. I could not find the listing you provided of various supplements and other substances. Perhaps my Primary doc will discuss with you. Thank you for your compassion and caring in people living in chronic pain. Thank you. Donna

    • Nancy Sajben MD Says:

      On November 6, 2016, I listed the many things I follow closely when I treat.

      No one is investing in comparing treatments unless it’s a new drug like neridronate that will bring billions in profit.

      I have seen extremely severe cases respond to the glial modulators I prescribe. It’s not one drug. It’s the whole system. Without major investment in research, no one can say how many are helped by any single therapy now in existence anywhere. But in those who have gone into complete remission on the medications I prescribe, they have been pain free for several years. Others may experience some degree of relief. There is no way to predict.

      But it’s easy to brush off science just because you don’t read the important breakthroughs in pain management. Too many of us are looking for one easy pill, like opioids, not combinations of modulators that work in an entourage effect.


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