Ketamine Survey for MD’s from RSDSA – Please Help

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Jim Broatch, Executive Director of RSDSA requests help from doctors giving IV Ketamine to treat CRPS. Please ask your doctor to do the survey. 

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 https://www.surveymonkey.com/r/ZPP9BXY

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And remember, if you shop Amazon, you can direct Amazon to contribute a portion to RSDS.org —- many thanks! 

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This site is educational, not for email.

Relevant comments are welcome.

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Advertising on this free website, below, is not endorsed or sanctioned by me.

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Complex Regional Pain Syndrome in Remission 6 years

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 Complex Regional Pain Syndrome

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Celebrating six years of complete remission

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Why ketamine should never be used alone

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I first posted her case here. 

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For years, pain below both knees was 8 to 9 on scale of 10, “like I had swallowed a fire burning.”

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She was unable to stand or walk for more than 4 years before seeing me. This week, I again saw this very healthy athletic RN who at almost 70 of age is very youthful, very energetic. She failed IV ketamine given first by Dr. Schwartzman daily for one week, then boosters for 8 months.

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After 8 months of ketamine, then no response at all. None. 

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That’s when I prescribed other glial modulators and rational polypharmacy that brought CRPS into remission. Then very very slowly tapered off all but one, leaving only low dose naltrexone (LDN) for the last 8 years. Zero pain. None. Hiking, working, fully active.

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When used in conditions with known neuro-inflammation, rats or human, LDN is a one of the most powerful, most effective glial modulators I have ever seen clinically in my patients in the last 15 years.

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Until proven otherwise clinically, LDN should be taken lifelong in those cases.

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This website is not for email.

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The advertising is not approved by me and

unrelated to anything on these pages.

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The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Ketamine Prescribed Since 1994 – My Experience

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Ketamine offers an opportunity for normal life unmatched by any medication I know of when given off-label for chronic treatment of intractable pain, treatment resistant depression, bipolar depression, juvenile bipolar disorder. It is one of the safest medications I have prescribed in 41 years of medicine. I have never seen anything more effective – it is not a cure, but remission is highly possible. Please refer to peer reviewed references since 2009 on this website on ketamine and depression or pain. Read elsewhere about street drugs, junkies, addicts and media headlines.

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Never Ketamine Alone

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Ketamine is short acting no matter how it is given.

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I never prescribe ketamine by itself – a fools errand; the religion of ketamine is like the religion of opioids. Decades of intractable conditions and chronic neuroinflammation require more than one short acting drug and usually require a multi-disciplinary approach. I work with psychologists or psychiatrists and other specialists when indicated.

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Entourage effect 

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DRUGS ARE LIKE POLITICIANS. A FAMOUS POLITICIAN MAY WALK UNRECOGNIZED, BUT WHEN YOU SURROUND HIM OR HER
WITH MANY PEOPLE, EVEN OF LESSER STATUS, THE POLITICIAN HAS A FAR MORE POWERFUL EFFECT.

Mechoulam

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1994 – I first prescribed IV when teaching cancer pain at MD Anderson Cancer Center.

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2001 – prescribed for outpatient care of chronic intractable pain

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2011 – prescribed for treatment resistant depression, bipolar depressed, juvenile bipolar/fear of harm phenotype often diagnosed as oppositional defiant disorder.

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2009 – writing about ketamine, neuro-inflammation and glial modulators on this site, with classic references to publications from the foremost peer reviewed journals, including low dose naltrexone, oxytocin.

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Dosing

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Depression, Bipolar Disorder, Juvenile Bipolar/FOH, treatment resistant – may need a dose only twice daily or every 3 days. The dose and frequency of use cannot be predicted – it is idiosyncratic – look up that word.

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Intractable pain – dosing and frequency of medications is very different than for depression.

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My work with these medications, these glial modulators, is too extensive to annotate on these pages. This website since April 2009 has references for context and guidance with active links to peer reviewed publications. Example:

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Clinical experience using intranasal ketamine in the treatment of pediatric bipolar disorder/fear of harm phenotype. D Papolos et al, J Affect Disord. 2013 May;147(1-3):431-6.

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RESULTS:

Ketamine administration was associated with a substantial reduction in measures of mania, fear of harm and aggression. Significant improvement was observed in mood, anxiety and behavioral symptoms, attention/executive functions, insomnia, parasomnias and sleep inertia. Treatment was generally well-tolerated.

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CONCLUSIONS:

Intranasal ketamine administration in treatment-resistant youth with BD-FOH produced marked improvement in all symptomatic dimensions. A rapid, substantial therapeutic response, with only minimal side effects was observed. Formal clinical trials to assess safety and efficacy are warranted.

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mTOR-Dependent Synapse Formation Underlies the Rapid Antidepressant Effects of NMDA Antagonists. R Duman et al, August 2010, Science, Science 2010 Aug: Vol. 329, Issue 5994, pp. 959- 964. [this article free with registration]
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ABSTRACT:

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We observed that ketamine rapidly activated the mammalian target of rapamycin (mTOR) pathway, leading to increased synaptic signaling proteins and increased number and function of new spine synapses in the prefrontal cortex of rats. Moreover, blockade of mTOR signaling completely blocked ketamine induction of synaptogenesis and behavioral responses in models of depression. Our results demonstrate that these effects of ketamine are opposite to the synaptic deficits that result from exposure to stress and could contribute to the fast antidepressant actions of ketamine.

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“The resulting protein synthesis and neuronal alterations in the medial prefrontal cortex are the opposite of those produced by chronic stress….”

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Read elsewhere about street drugs, junkies, addicts and media headlines.

If that is you, see an addictionologist, not me.

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Some medications can be drugs of abuse but every patient and every medication that I dispense is followed meticulously. If any sign of misuse or abuse, that unfortunate person is immediately discharged and referred elsewhere.

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For my Home Page, click here: 

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Welcome to my Weblog on Pain Management!

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This site is not for email or medical advice.

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It is not legal for me to give medical advice

unless you are my patient which means I have done a medical history and examination.

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I generally accept only those who have failed most or all known treatments, and only those who I feel I can help.

 

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I interview each patient before accepting.

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Any advertising below is not recommended or condoned by me.

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Medicine Costly, Where’s the Gain?

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It’s been seven years since starting this blog April 2009.

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To find information:

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  1. SEARCH – small rectangle, top left above my photo

  2. TAGS – size indicates frequency the topic was posted, bottom left narrow column

     

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Sorry there’s no time to make the site easier for you to find your way around.

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I hope you all have a good summer. Get some much needed rest.

 

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It has been a blessing to have this resource as a way to structure and teach myself the many research publications and ideas I come across in Pain Management, Neurology, Integrative Medicine, Neuroimmunology and, yes, maybe politics of medicine. I only wish I had had this tool decades ago so that I didn’t have to recreate the ones I’ve already reviewed and forgotten in the last 41 years, long before MRI scans and decades before computers in daily medicine. Now we all risk carpal tunnel from repetitive injury, which is why I need to stop posting for awhile.

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This great experience and months of effort has rewarded me, bringing me in touch with the RSD Organization, device manufacturers, editors, publishers, academics, CEO’s, scientists, physicians and patients from around the world. Thank you all!

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The politics of the world is spinning fast, harsh winds are blowing, prices of drugs are beyond belief, beyond beyond — $50,000 to $100,000 a year for new drugs. My own colleagues cannot afford $5,000 insurance deductible for visits and medication. If you are diagnosed with cancer, pray it is January before your $5,000 or $10,000 deductible comes up again at end of year. Medical care in this country is in a down spiral, affordable to the few.

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Until I see something exciting to write about, I’m over and out. What more is there to say?

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Give us some hope in research for pain and major depression. Something more we can use now, something covered by healthcare insurers who seem not to cover much of anything anymore.

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Many insurance companies have not updated reimbursement rates for some specialties for 10 or 20 years. The specialties that had the highest percentage of doctors who accept insurance are cardiology, oncology and orthopedic surgery.

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Only 55% of psychiatrists accept insurance. How sad is that? When people need Mental Health Care more than ever, what do they do but in desperation, some turn to drugs, self treating, while the $3 trillion dollar war on drugs has created and perpetuates the spiral of addiction and endless funding that only serves to enrich the military prison industrial complex.

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War does not work. Medical care works. Instead of war on drugs, war on addiction, we need medical care not war. Medical care for addiction, medical care to prevent pain, to prevent and support mental illness, to prevent addiction.

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While setting writing aside, I shall enjoy turning more of my attention to my patients. It is a privilege to work with so many fine people, striving to put disabling conditions into remission.

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If you find exciting news, please post news below.

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I wish you all a wonderful summer – get some time out!

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For those with CRPS RSD, note a new comment on this site, this past week, on Neridronic Acid.

It was posted in an unrelated section at bottom on my home page.

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 For my Home Page, click here: 

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Welcome to my Weblog on Pain Management!

 

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This site is not for email or medical advice.

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It is not legal for me to give medical advice

unless you are my patient

which means I have done a medical history and examination.

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I generally accept only those

who have failed most or all known treatments,

and only those who I feel I can help.

 

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I interview each patient before accepting.

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Any advertising below is not recommended or condoned by me.

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CRPS – Appendicitis treated with antibiotics can avoid surgery

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For someone who has CRPS/RSD, any trauma including surgery can severely flare CRPS and/or cause it to spread.

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A young man in his mid 20’s was headed for surgery for acute appendicitis last night. He is resolving now, 24 hours later, with IV antibiotics as I suggested. He’s the first in his hospital, a major hospital in Los Angeles.

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Dad called me last night. Mom texted me reports of CT abdomen showing thickened wall of appendix, and all labs consistent with acute bacterial appendicitis: WBC’s elevated 15.1, elevated neutrophils consistent with bacteria rather than virus. Overnight, his generalized abdominal pain is now focal and much reduced, WBC’s are ~8, well within normal range including neutrophils, and he took a good walk in hospital. By day two, WBC count was 5, normal, no elevation in neutrophils indicating brisk response to antibiotics knocking out bacteria. He’ll go home on oral antibiotics probably tomorrow. I asked and was told he has chronic constipation which begs the question if it can trigger infection because of sluggish gut.

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Treatment & References

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1. If you have CRPS, then before any procedure small, large or dental, begin minocycline, a glial modulator. It was found in animal research many years ago to prevent flare or spread of CRPS.

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2. Antibiotics IV for the bowel.

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Below is a list of articles, most from the outstanding library of the Reflex Sympathetic Dystrophy Association. Their vast collection of publications is organized by subject. I strongly recommend donating to them.

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Minocycline inhibits microglia activation and alters spinal Endocannabinoids

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Minocycline Neuroprotective- Johns Hopkins 2010 Archives of Neurology

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CRPS prolonged remission obtained by treatment of intestinal bacterial overgrowth. A multicenter study from Washington University in St. Louis, Stanford, Brown University.

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Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. One year prospective study from Nationwide Children’s Hospital, Columbus, Ohio, JAMA December 2016. IV Antibiotics for at least one day followed by 10 days of oral antibiotics.

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“Conclusions and Relevance  When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.”

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Antibiotics alone can be a safe, effective treatment for children with appendicitis. An article from Science Daily about the Nationwide Children’s Hospital study.

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“Families who choose to treat their child’s appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn’t work, have expressed that for them it was worth it to try antibiotics to avoid surgery,” said Peter C. Minneci, MD, one of the authors.

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The appendix may be an important reservoir of bacteria to populate the gut with good bugs, our healthy microbiome.

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Why don’t we see appendicitis more often in adults?

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Surgery has very real potential dangers that may include infection, abscess, pulmonary emboli, cardiac arrythmias, brain damage from loss of oxygen, death. Years later, there may be chronic abdominal pain from scarring, adhesions of bowel, leading to more surgery to lyse the adhesions. Or acute pain from infarcted bowel when needed oxygen gets choked by adhesions that cause necrosis of segments of bowel, intense pain or perforation, possible death.

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Specific to laparoscopic surgery, I have seen two patients who developed years of intractable abdominal pain from the scope itself and in 2015 there was a recall of scopes across the country that caused death and/or antibiotic resistant infections carried on segments of the scope that could not be sterilized. Another concern, during laparoscopic surgery, they blow up the abdomen under very high pressures to float the organs away from the scope. Very high pressure.

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 Constipation

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Let’s see a study to determine how often chronic constipation is present for years potentially causing the appendix to become inflamed. This young man will be taking a stool softener such as DSS or Colace (same thing), and if that doesn’t work then a prescription for Amitiza is something to consider.

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There are 70,000 surgeries for appendicitis each year in children, usually teens, more often in males. In many cases the appendage is normal and surgery unnecessary.

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Antibiotics for uncomplicated appendicitis could save lives, prevent acute and long term complications, and lower healthcare costs.

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Immune cells make appendix ‘silent hero’ of digestive health

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November 30, 2015. . .Innate lymphoid cells (ILCs) are crucial for protecting against bacterial infection in people with compromised immune systems, report investigators. Their work shows that a network of immune cells helps the appendix to play a pivotal role in maintaining health of the digestive system, supporting the theory that the appendix isn’t redundant.
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The research team, a collaborative partnership between the groups of Professor Gabrielle Belz of Melbourne’s Walter and Eliza Hall Institute, and Professor Eric Vivier at the Centre d’Immunologie de Marseille-Luminy, France, found that innate lymphoid cells (ILCs) are crucial for protecting against bacterial infection in people with compromised immune systems.

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By preventing significant damage and inflammation of the appendix during a bacterial attack, ILCs safeguard the organ and help it to perform an important function in the body, as a natural reservoir for ‘good’ bacteria. The research is published in today’s issue of Nature Immunology.

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Professor Gabrielle Belz, a laboratory head in the institute’s Molecular Immunology division, said the study’s findings show that the appendix deserves more credit than it has historically been given.

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“Popular belief tells us the appendix is a liability,” she said. “Its removal is one of the most common surgical procedures in Australia, with more than 70,000 operations each year. However, we may wish to rethink whether the appendix is so irrelevant for our health.

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“We’ve found that ILCs may help the appendix to potentially reseed ‘good’ bacteria within the microbiome — or community of bacteria — in the body. A balanced microbiome is essential for recovery from bacterial threats to gut health, such as food poisoning.”

Professor Belz said having a healthy appendix might even save people from having to stomach more extreme options for repopulating — or ‘balancing out’ — their microbiomes.

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“In certain cases, people require reseeding of their intestines with healthy bacteria by faecal transplant — a process where intestinal bacteria is transplanted to a sick person from a healthy individual,” Professor Belz said. “Our research suggests ILCs may be able to play this important part in maintaining the integrity of the appendix.

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“We found ILCs are part of a multi-layered protective armoury of immune cells that exist in healthy individuals. So even when one layer is depleted, the body has ‘back ups’ that can fight the infection.

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“In people who have compromised immune systems — such as people undergoing cancer treatment — these cells are vital for fighting bacterial infections in the gastrointestinal system. This is particularly important because ILCs are able to survive in the gut even during these treatments, which typically wipe out other immune cells.”

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Professor Belz has previously shown that diet, such as the proteins in leafy green vegetables, could help produce ILCs. “ILCs are also known to play a role in allergic diseases, such as asthma; inflammatory bowel disease; and psoriasis,” she said. “So it is vital that we better understand their role in the intestine and how we might manipulate this population to treat disease, or promote better health.”

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This site is not for email.

If any questions, please schedule an appointment with my office.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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For My Home Page, click here: 

Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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Off opioids, pain better. Life is back!

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We have all seen pain go down when patients taper off opioids. Look down many paragraphs to see a case report near the end.

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I prescribe opioids for intractable pain, but I have never seen opioids take pain to zero on a sustained basis, year after year – I have seen glial modulators with the specific off-label combinations of medications do that. Chosen because of mechanism: neuro-inflammation that we know is present in chronic pain or chronic depression and recently reported in teens with early psychosis. Inflammation. Brain on fire – imaginary fire, skin is burning, shooting, pulsing, changing from ice to hot, unable to tolerate light touch, sunlight.

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You don’t have to be a rocket scientist to read the brilliant science that’s come out since 1991 that has changed neuroscience more profoundly than anything I’ve ever seen – many prizes given from many countries. Ignored by docs – don’t blame them. Not everyone is able to take the risk to be different in medicine. It is NOT rewarded. Doctors can just ignore patients now after 30 years of living with pain 10 on scale of 10, pain now zero. Like one of my patients best care for 8 years, told to live with pain that was 8 on scale of 10 constant, unvarying, burning.

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You never will see that with opioids, procedures, pumps, stims, blocks, biofeedback. Most of my patients with intractable pain from hell, been there, done that at the top places: Boston, Philly, Cleveland, Mayo, years of grueling P.T. Kids get the worst. No drugs for pain until after age 18 – pediatricians need to be studied what they do, and oncologists need to be studied again. I know a top hospital in the country where for decades not one oncologist ever called for a pain consults – decade after decade. I know too many stories from too many top places about how cancer pain is not treated as well as it could be because of opiophobia perhaps, but there are so many other things done for cancer pain – oncologists refuse.

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The oncologist at a famous hospital in Beverly Hills that will go unnamed, threatened the grandmother of my UCLA Pain Clinic colleague, an MD Pain Specialist, who had come with her grandmother. Oncologist threatened the 90 year old woman: “If you want pain medicine, find another oncologist.”

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Any hospital would sooner get rid of pain specialists – they don’t bring money to the hospital like cardiologists who get streams of patients from around the country. In Houston, Netherlands would load a jumbo jet full of patients who needed heart surgery, fly them Sunday to Baylor and fly them back home end of week after heart surgery. Every single week, a plane full. These are GODS!

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Your pain is a low priority on the scale of gods. Excuse my tone. It breaks my heart to see every pediatric nurse threaten to walk off the entire floor if the MD did not call a pain consult. And I read in nurses notes, line after line after line the same thing for 3 months: “Patient screaming in pain.”

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I diagnosed the problem that they overlooked – every spinal nerve root coming off every level of spine was lighted up like a tiny 1″ band of pearls each side. This 17 year old athletic muscular tall male had lost 45 lbs of muscle, unable to move, screaming, 2 nurses required to bravely try to roll him onto his side to change sheets and toilet in bed, him screaming, perhaps rigid – I was never there then. Ignored by one of the world’s foremost oncologist for three months. The humanity of it.

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I’ve seen worse.

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GODS. These men are GODS. As a junior faculty, you do not look them in the eye, ask a question, or even speak to them. He was one of the best in the world, perhaps the very best, #1 – God of Leukemia, not god of pain so intense the lightest touch of skin elicits severe pain.

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That’s called allodynia. Slight touch, just a breath of air, very very slight touch = SEVERE PAIN.

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Nerve pain when severe does that. It can be focal or widespread, every where, like his. He had the mentality of an 8 year old, but loved playing basketball. Leukemia brought him in, and you cannot see leukemia on scans or xrays. Are you going to tell a GOD that pain exists in people with leukemia? – malignant blood cells and pain. No, no, no.  No one of the leukemia service was ever allowed to call a pain consult at a world famous cancer hospital. You would be fired. Career over. Mom was trying to raise the money to treat this leukemia. $30,000 she did not have.

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So many case reports I could write. But it never changes. Patient calls after decades of intractable pain. I have had them taper off opioids slowly before I see them. I assess whether I want to take them as patients. They’ve been to Europe and across the US, the best places, nothing has helped. Even ketamine coma in Germany, it did not last but boy it caused PTSD. You cannot give those doses of a psychoactive drug to brain. Ketamine is a short acting drug. No matter how you give it. The dose is different for everyone. They burned through her threshold and PTSD could not even be discussed, it was so bad.

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I never use ketamine alone – only with certain combinations, and later, my patients may not need ketamine again. Pain free. Not everyone becomes pain free, but it occurs so regularly that it’s almost hard to fall off my chair so many times with the results. It used to be a surprise many years ago and I would always fall off my chair. It has become regular. No surprises. This is getting old and sad no one knows how to do it. Pradigm shifts do not just occur, and not without publications, studies, one slow drug after another. That’s not the way you are ever going to get results – study only one single drug for 10/10 pain present for years to decades. When disabled 30 years, the standard for research is to study one drug. That’s fine for mild conditions.

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It’s incomprehensible to think one drug alone is going to budge intractable intractable pain or depression. And difficult for me to understand patients who think one drug alone will do everything though they have failed so many classes of medications for years or for decades. One drug is not adequate to restore balance in the complex system of transmitters, receptors and DNA changes.

Wrong thin

Mechanical pain complicates things and must not be overlooked even though it may be “minor” compared to the bear in other parts of the body. Wrong thinking. All pain ends up upstairs in the big lake at top (brain). Not minor. Never has anyone found a pill that can do better than mechanics of the spine or limbs.

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My new patients have already been through every known form of interdisciplinary treatment at the worlds best pain clinics. You all know that entails a number of specialists as a team – you do the work, mind and body. Done by most of my patients before they see me. Past History.

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Once off opioids:

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My focus is on neuroimmunopharmacology. Read January 2011, the innate immune system. There must be a balance between anti-inflammatory cytokines and pro-inflammatory cytokines. The pro-inflammatory cytokines are too high, out of balance. Let’s modulate them, restore balance.

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Lovely to see people better. It makes me want to go to work. I suspect CRPS may respond best to these medications  but I have seen many other syndromes respond well – but remember, no treatment is 100%. I see impossible cases. It would be a miracle if anyone saw 100% remission or cure in their medical practice. But the combinations of medication I am using are certainly life saving for many of the toughest.

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Mechanics – so many patients have groaned when I said I felt they had to see the physical therapist I refer to. Groans. 30 years of P.T. never helped, they say. After seeing Bruce, they come back smiling. Bruce says these are basic things he does. Well, didn’t help my patients. Not one of the best university centers in the country where my patients have been for 3 to 6 months, never helped one bit. Bruce says it’s basic. Bruce is unique, certified orthopedic physical therapist – most never get that high degree. Decades after training at the famous rehab center Rancho Los Amigos from whence books were published, basics of orthopedics and rehab. After seeing Bruce, patients come back smiling, awed. I am shocked there is still so much crap P.T. out there. I thought all this changed after the new manual P.T. was brought to the US before 1980. Yikes.

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Opioids. How many use them for anxiety instead of pain, misreading and confusing what you are treating yourself with. They work great for anxiety, but America – you must learn better ways to cope and opioids are not to be used for anxiety. I hear the groans and downright refusals. A few years later, one of my older guys has nowhere to go, nothing helps but the opioids and his body will not tolerate more. Not one coping skill was going to get near him years ago. If his wife couldn’t do everything for him, then his caregiver would. He wasn’t going to have it. Granddad is a very proud businessman who cuts himself off from family, they should not see he has a walker.

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Opioids ain’t the answer. But sometimes we have no better – in limits. Only after other things, glial modulators should be tried first. How many of you have seen results with gabapentin? Maybe I just only see the ones who’ve failed everything.

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I frequently see people who are better off opioids than on, but then, then what do MD’s do about that pain that may be still 6 out of 10 or worse? They don’t have an answer. And are not curious to figure out what to do with the new science. They have been trained the old way. Nothing new but hope for a new drug from pharma some day.

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I am writing so far off track. I hope you understand a little of this rapidly changing antediluvian field and that some places are still in the Middle Ages where we don’t treat pain at all. How do they get away with that? It’s not a priority anywhere. NIH gave one half of 1% to pain research in 2008. Really? !?!!

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CASE REPORT

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Many paragraphs ago, I was planning to write to tell you about a case, 2nd visit so much better! and a lot of that is simply due to being off opioids 6 weeks after 6 years on them. Falling asleep from opioids for how many years—  imagine an MD taking on a patient who said they need a new pain doctor because their old doctor cut them back and will not give them a dose that helps. Makes you wonder if they were falling asleep and getting any oxygen to the brain. I find myself in that position when people call for new appointment. I hate to be the one to tell you I am not going to increase your opioid but many other pain doctors will. Soon this nice person sitting by my desk would have been one of those opioid deaths the headlines tell us about. This person today sitting next to me, happy she is off, and better!

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She is not drugged, pain is down and it changed character/quality, still rated 6 on a 10 scale, but she is doing more, actually waking up alive instead of zombie until 5 pm, walking. Walking – that’s the biggest.

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She has CRPS for 6 years as well as pain of the entire spinal axis. Failed gabapentin, Lyrica, Spinal cord stimulator – implanted 2013.

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At the first visit Jan 25, one month ago, she had tapered opioids in 3 weeks [far too fast], and was off for 6 days, lost 15 lbs – opioid  fluid retention. I ask people to be off 2 weeks before seeing me but she was in crisis. Most of the time she was lying down elevating BLE’s [both lower extremities] as it reduces pain in feet and RLE. She used to play two soccer games back to back without a sweat 6 years ago.

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“And I feel better. I always felt like my insides were swollen,” brain fog – unable to read, blurred vision – improving, “and the character of the pain seems different. The nerve pain used to feel like I had a huge halo and if you just touched the halo, not the skin, it was unbearable. I feel like the halo sensation was severely diminished. My sister also said I am walking better than I ever had – I was just weaning off then.“

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Before seeing me, she had been on MSContin 30 mg x 3/day with MSIR 15 twice daily or on methadone 80 mg in past. Pain then was rated 6. Today, 2nd visit, off opioids for 6 weeks, pain 6/10. But walking.

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2nd visit, 4 weeks later

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Her prior “biofeedback therapist told me I should write a book.” Helped in some ways, just to teach me better body mechanics to minimize pain. Did both temp and pulse and wore EKG-type patches on her back for muscle feedback.

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Now using desensitization – on dorsum hands able to use loufa, and can use a special rough soap on palms she could not tolerate before. Dorsum left hand is nearly normal.

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Pain on opioids was “6 to 7 but different character, I’m much improved now,” ranging 4 to 7, average 5. “I could live with this.” It’s lower. I used to always say I want to cut off my leg, and I haven’t said that in at least a month.

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Foot felt so swollen like it was gonna pop, and be so cold, made it very difficult with pins and needles to put a sock or shoes on. The occurrence is much less and when it happens it feels less severe.

Still has mild swelling “more what I perceive than what I see.” Her friends say she is not a zombie anymore. She wakes up and is out of bed.

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“If I concentrate very hard, I think I can walk without a limp, but I think I need some retraining.”

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We have barely begun much treatment. She is on her way back to life. 

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I have seen patients become even better simply off opioids.

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You must treat the whole person: the mind, body and spirit.

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Physical Therapy, Cognitive Behavioral Therapy, Biofeedback, Medication, Procedures.

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Compounded medications are the key. Thank the insurance industry for not supporting anything but opioids. I can’t even prescribe Namenda off-label for a patient with dementia because her dementia is not Alzheimers or Vascular, mild or moderate only. She has traumatic brain injury with CRPS and I prescribe Namenda (memantine) in double dose – good science behind that, published around 2001 when I starting prescribing for pain. Now I see the best migraine docs doing it in the last year. I don’t know when they began using it.

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Namenda (memantine) not covered. Unless … two things are possible.

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But compounded medications are essential for these combinations of medication. What is this country doing to its injured veterans? Opioids do not work. But their mechanical spine joints needs are serious and I know it is not being addressed because manual physical therapists are hard for me to find in this age, only 40 years since it was brought to the US from British Commonwealth and Scandinavian countries. Impossible to find, to trust you have a good one, and far beyond that, Bruce is awesome. How difficult is it to train better physical therapists? Or upgrade teaching from the theoretical that all these shiny new PhD’s in physical therapy. But get me the clinical experience, Orthopedic Physical Therapist because Bruce is awesome. No other word for what he has done to unwind the cause of CRPS in the ribs after thoracic surgery. Drugs can only get you so far. The mechanics become everything and they can take your body to more pain than you will ever dream of unless mechanics are properly addressed. My local patients may live 2 hours away from Bruce. That is not feaseable.

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Obesity.

Then, the elephant in the room. Guardian just now reports Penguins on a Treadmill, Study shows fat ones fall over more often than slim ones. How can we help those of us who will not be helped? Sanity does not prevail in politics and thou shalt not forbid 80 teaspoons of sugar in each can of “energy” drinks. America waddling onward into disablity. Sanity in politics. Behavior. As a great sage said: “You cannot uncurl the curly tail of a pig.” 

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Behavior is the hardest for me to change myself. I know. I don’t care how old you are, let’s wake up! and get you back to life. Off opioids. So many of us give up too little food on our plate or treats. You do not have to exercise to do that.

 

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The problem remains:

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You have to be rich enough to get decent care for intractable pain in this country. Rich enough to afford the compounded medications that used to be covered by insurance – do these guys cover anything anymore? The business reeks like the rest of the 1%. Same people. The big three: energy, pharma, insurance. Waves of anger across the country. The Middle Class is disappearing and they cannot afford an extra $300 a month for medication without family struggle. Stagnation.

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Donald Trump and Bernie Sanders are riding on that anger, and Democrats are shifting to Trump who, as Jeb Lund writes, with his “gallimaufry of disconnected thoughts” has the money to put his bombast into action. He destroyed his running mates. Lund goes on:

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“a billionaire beholden to no one and able to abuse every disingenuous and pettifogging remora latched headfirst on the nation and sucking upward.”

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“If the system is already so broken that it abandoned you, its preservation is not your concern. Hell, burning it down might be what you want most.”

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“Anger has a clarity all its own. It renders most detail extraneous….It is not to be underestimated….”

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His “disgusting behavior gets paired with the sight of Trump humiliating establishment empty suits like ….X….stuffed shirts like…Y…. party pets like…Z….. and habitual liars like…W…..” Trump is “lying in service of exposing another government predator.” 

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He will destroy Clinton. The politician who panders to money will be blown away by Trump. People respect that.  No one cares what his policies are.

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This site is not for email.

If any questions, please schedule an appointment with my office.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me..

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Norway Prioritizes Healthcare for Pain – A Note on Cosmetic Breast Surgery

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Hello Norway! I need an emoji to smile welcome!

Population 5 million – therefore data on pain can be obtained

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534 readers on these pages from Norway in the four years since 2012 got me curious.

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Norway Institute of Public Health is charged to prioritize healthcare for pain.

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Impressive! Very smart.

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“Chronic pain affects about 30 per cent of the adult Norwegian population.”

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In Denmark, “chronic pain patients had four to five times 

more in-patient days in hospital than the general population.”

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Cosmetic breast implants one in five have nerve pain for life.

Implants must be replaced every 10 to 15 years.

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Surprise note from Irish physician on Norway- see below.

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Pain is the most common reason people see a physician. Pain is the most common cause of long term sick leave and disability in Norway, and likely in every first world country. Without doubt every investment in returning people to productive health relieves the burden on the entire country.

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The most common method of treatment is analgesic drugs, and, I would add, the most cost effective.

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Pain is more common in females than males. Cosmetic breast surgery is the most common gift to girls for high school graduation in America. It was of interest to find Norway’s statistics on that:

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In a Norwegian study of young, healthy women who had cosmetic breast surgery, 13 per cent reported spontaneous pain and 20 per cent reported pain when touched one year after surgery (23).” Ahhhh, but implants are a lifetime commitment and depending on style, must be replaced every 10 to 15 years.  Is pain compounded with each overlapping surgery? Scarring? Use of arms? What further issues arise once these women require breast cancer treatment? We know that after breast cancer treatment, chronic neuropathic pain affects between 20% and 50% of women. Obesity has been linked to chronic neuropathic pain developing after breast cancer surgery.


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. 13 per cent had pain after surgery

20 per cent one year later

7 per cent more than they did immediately following surgery –

Is risk compounded when replaced every 10 to 15 years for the next 70 years?

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One in five, 20 per cent with chronic lifelong nerve pain!

Insanity

How can they know? Show them prior to surgery.

 Informed consent: view a video interview of girls who developed nerve pain.

Can it be prevented? Or treat early?

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This is neuropathic pain, the hardest to treat. Miserable.

Light touch elicits intense pain.

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We all routinely underestimate risk of surgery. For true informed consent, it would be essential to show a video interview of girls with postoperative neuropathic pain, explaining the financial cost of chronic neuropathic pain the rest of their lives, how it affects use of the arms and ability to work, how many times they must see an MD every year for pills, how it may get worse over time, what type of pills are required – this educates the surgeons too on how to diagnose and treat nerve pain with sequellae of depression, anxiety, insomnia, and how it affects everyone in their family. Everyone suffers. Many are disabled and agitated by this intense nerve pain.

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How does stress and fear affect risk of cancer and other serious medical diseases?

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We know with rodents, from John Liebeskind’s research with an Israeli team at UCLA in the mid 70’s, pain profoundly increases spread of cancer resulting in quicker death from metastases. Pain kills. He lectured nationwide on this. I posted on his message just weeks ago, December 27. “Pain kills. A malefic force.”  “…pain can accelerate the growth of tumors and increase mortality after tumor challenge.”

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John C. Liebeskind, 1935 – 1997, distinguished scholar and researcher, past president of the American Pain Society, had the radical idea that pain can affect your health.

 

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Twenty percent! Girls don’t know. How could they?

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Does cosmetic breast enlargement at such young age

increase

potential risk of  tumorigenesis, invasiveness, metastasis?

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Trauma (surgery) activates microglia lifelong. Glia never return to baseline.

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Microglia produce inflammatory cytokines –  inflammation.

Inflammation underlies almost all known disease.

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Does breast surgery, any surgery, increase risk of other known disease?

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What does inflammation do to endometriosis and autoimmune risks in this population?

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These are purely speculative thoughts. We cannot know until it is studied longitudinally and prospectively – if ever. Large breasts are very trendy. Obesity is very common; alas it is also pro-inflammatory.

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Postsurgical sequaellae can be extremely challenging. I will try to post two case reports in the near future. They are complex, enlightening, tangled, difficult to diagnose, post-surgical cases. The senior chief of surgery at Mayo Clinic had only seen two prior cases like it in this man who had laparoscopic prostate surgery many years before. Surgical sequaellae cannot be predicted. Large scale surgery in girls for cosmetic reasons have unexpected consequences. What is their cost decades from now?

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Norway Institute of Public Health has very nice data on drugs used, graphed vs time for men and women.  

 

Chronic pain in children and adolescents

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The incidence of chronic pain in children and adolescents is poorly mapped in Norway, but the consumption of analgesics and figures from other countries suggest that chronic pain is also common in adolescence (8). In the Health Interview Survey of 2005, parents reported that 6 per cent of children aged 6-10 years and 12 per cent of adolescents aged 11-15 years had chronic pain symptoms.

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A study of 12-15 year olds in South and North Trøndelag shows that 17 per cent suffered regularly from headaches, abdominal pain, back pain or pain in arms / legs (9). Consumption of analgesic drugs among Norwegian 15-16 year olds is high and has risen considerably since 2001 (10).

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Treatment

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Pain is probably the most common reason for patients to seek health care (26). A Swedish study found that 28 per cent of patients in general practice had one or more medically-defined pain conditions (27) – (my patients have at least 3 or 4). Corresponding figures are found in Denmark (28), where it has also been shown that chronic pain patients had four to five times more in-patient days in hospital than the general population (29). Corresponding figures for Norwegian conditions are unavailable.

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Irish physician comments on Norway

just minutes before writing about Norway! sweet coincidence. He posted on a case report I wrote in 2010 on Complex Regional Pain Syndrome (CRPS) and low dose naltrexone, (LDN).

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Dr Edmond O`Flaherty

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I am a primary care physician in Ireland. I have been prescribing LDN for 9 years and it has utterly changed the lives of hundreds of people. The main conditions I see are fibromyalgia, chronic pain, MS, various cancers, Crohns/UC, chronic fatigue/ME, several other auto-immune diseases and one case of Interstitial Cystitis where a 30-year woman had “a fire in her bladder 24 hours a day” and who was due to have a cystectomy (bladder replaced by a plastic bag!) a month later than when she came to me by chance and soon became well.

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TV2 in Norway made a film about LDN in 2013 which was seen by 10 % of the population. The number using it there went from 300 to 15,000 in a few months. It is now on the website of http://www.lowdosenaltrexone.org in America and I was the only doctor outside Norway who was involved. I agreed to partake if they subtitled it in English which they did.

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Yes. Opioids cause pain. Naltexone relieves, and often resolves pain.

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My comment:

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Based on the work posted on these pages, RSDS.org sent scientists and specialists to my office in 2010. Over two days I introduced them to eight of my patients with years of intractable chronic pain, all of whom responded to low dose naltrexone, four of whom required treatment only one month with sustained pain relief   for years! RSDS is now funding a study on LDN for CRPS at Stanford.

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Norway has well known large cities, UNESCO heritage sites and this absolutely gorgeous small seaport village Reine on an island in the Lofoten archipelago, above the Arctic Circle. It was “selected as the most beautiful village in Norway by the largest weekly magazine in Norway (Allers) in the late 1970’s” and is visited by many thousands annually. “Lofoten is known for a distinctive scenery with dramatic mountains and peaks, open sea and sheltered bays, beaches and untouched lands. Though lying within the Arctic Circle, the archipelago experiences one of the world’s largest elevated temperature anomalies relative to its high latitude. Lowest temperature ranges from 28.4 to 35.6 degrees F.  The warmest recording in Svolvær is 30.4 °C (87 °F).

 

 

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Sequoia wildflower

 

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The material on this site is for informational purposes only.

It is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

Relevant comments are welcome.

If any questions, please call the office to schedule an appointment.

This site is not email for personal questions.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free website is

NOT advocated by me and NOT approved by me.

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