Dafny writes:  I often struggle with the question of balance in coping with my chronic pain condition, Complex Regional Pain Syndrome (CRPS).  For 1 ½ years I was in remission, when I didn’t work at a steady job – I slept, ate, did physical therapy, made jewelry, and was off most medications.  I often wonder, was this a type of resetting of my system, like the idea of a ketamine coma, but in a natural way?

I have CRPS in my leg from knee surgery, when a nerve block was not used (even though this was my request – another separate topic).  I originally tore the ligament skiing.  After PT, I was still experiencing giving way of the knee, so I decided to have the knee surgically repaired.  The dangerous thought of falling at a subway station was enough to motivate me to seek surgery.  The knee was more stable, but the pain was problematic, so I decided to have surgery to repair the knee again.  Little did I know that this surgery would change my life forever, causing full-blown CRPS.

Despite this occurring in my second year of graduate school, I persevered head-strong through experiences of discrimination, taking some partial time off for a pain program, being angry, depressed, somewhat accepting, being patient, determined, trying to balance, and jumping through each ring that was thrown at me.  I made it through, but constantly continue to struggle with the issue of balance.

To be able to work,  I had to get on more medication, it took me more time to accomplish things, more strain on my relationships, and less time for housework, relaxation, and sleep.

“This time it’ll be different,” I say to myself.  I’m on fewer medications, I’ll start off working slowly, building my way up to full-time, and not even full-time, if I find that’s what keeps my health stable.

A month into my new job, I experience a flair.  I know what to do.  I’ve been through this before and I take time off to get the medical treatment I need, and work the other day that I usually have off.  “I’m lucky this way,” I say to myself, “I have some flexibility within my job for this.”  I continue along, but add physical therapy a couple times a week to work on a new area of muscle tightness that I’ve not experienced before.

My mind questions, “Why now is this spreading?  Is it because I’m working again?  What’s the right balance?”  I seek treatment for nerve blocks which have been helpful for me.  “Lucky to have something that I respond to,” I say to myself. “Many people don’t respond to nerve blocks.”  I have a great response to the nerve block targeting the calf area—the new area of spread.  With physical therapy, it lasts for about 1 ½ weeks.  I work hard in physical therapy, but mechanical knee pain sets in, limiting my physical therapy.  Again, my mind questions, “What’s the right balance?  How much physical therapy do I do to keep the muscles from wasting, but yet keep the mechanical knee pain in check.”  I seek advice from an orthopedist who tries an injection to try to calm the mechanical nerve pain.

Overall, I try to keep myself positive and tell myself about the nerve block, “that’s okay, I know the effects of nerve blocks can be cumulative.”  I schedule another one.  This time, the block for the upper leg works great (when I didn’t even realize how much pain it was causing until it was relieved).  However, the calf nerve block only half works.  The disappointment sets in, but I try to remain calm and positive, telling myself, “I will just try it again.”

Now another balance question sets in, “how many nerve blocks to try?  Is there a point when it’ll be too much.”  I work on stretching, some exercise, muscle relaxing gels and creams, and I buy another moist heating pad.  I’m determined to try to get back to remission, to keep my job, so that I can give back to others in the field that I’ve worked hard in.

My significant other tells me, “reduce your workload and get your health better.”  “I’m trying to keep that balance,” I think.  He says, “it’s not fair to me if we can’t do things on the weekends.”  I know he’s been picking up the slack, cooking and doing laundry.  I know I still have to keep up with my side of the relationship and come home earlier to cook more, and tidy my belongings (not my strong point).  Again, it’s a continual balance.

Another balance issue I struggle with is the relaxation issue.  When I stop, when I’m sitting in a chair, when I’m sitting in a car, when I’m trying to relax, I feel more pain.  I’ve tried so many techniques to cope with this.  I’ve tried to go inside the pain, to experience it, to say to myself “it’s okay to feel this,” to relax my spine and imagine blood flowing freely to the area, healing and calming.  I’ve tried stretching.  Sometimes stretching helps, sometimes stretching seems to tighten the muscles more, like a reflexive tightening arc.  I’ve tried muscle rubs, creams, lidocaine patches, and heat.

I’m learning that this new area of spread is not the same as the old area that I’ve learned to cope with.  I’m still trying to figure out how to best manage it, and that some things that worked for the old area don’t always work for this new area of spread.

I feel myself having to re-experience the stages of grief, and I’m still fighting to get back to the remission that I had.  I continue to try to find the right balance of working, managing finances, managing relationships…  continuing to ask what’s the right level of PT?  how much sleep do I really need to maintain my health?   how much is work stressing my health, versus the weather change or other issues?

How do we work with these struggles?

For many of us, being aware of and working on balance is a significant issue.  It takes time.  It takes energy.  Often, more time, energy and effort that for those without pain.  Thanks to Dafny for sharing her thoughts and challenges.

Readers, do you have similar questions as Dafny?  How do you work on balance?

Grand Rounds, a medical blog carnival, is published this week at Crzegrl, Flight Nurse.

Today we’ll look at the medication category of Antipsychotics.  The original use of antipsychotics is for psychiatric disorders like Schizophrenia or Bipolar Disorder, where a person’s thinking becomes disorganized.

Like many medication classes, antipsychotics aren’t FDA-approved for any pain disorders.  As well, instead of even a few good studies supporting their use, there are only a handful of “case reports,” each with only 1 patient in it.  So not only are antipsychotics not primary medications for pain, they are only rarely tried, to be used when other medications aren’t effective.

Effect of Antipsychotics:

The only antipsychotic for which I could find any report of its use in pain is Zyprexa.  Antipsychotics such as Zyprexa have an effect on many neurotransmitter systems, including dopamine and serotonin, so it’s not clear where its pain-relieving effect comes from.  As well, antipsychotics typically cause sedation, so some wonder if they help mainly through improving a patient’s sleep.

Side Effects:

• sedation (which can be helpful at night)
• dry mouth
• dizziness
• weight gain
• “metabolic syndrome” in some patients, which includes weight gain around the abdomen, increased blood pressure, and elevated lipids such as cholesterol and triglycerides

Specific Pain Disorders
In these case studies, Zyprexa had a positive effect when used for both neuropathic pain disorders and Rheumatoid Arthritis (RA), an inflammatory pain disorder.  This is quite interesting, as these are 2 different types of pain disorders.  Medication more commonly works in 1 type of pain, but not both.  For example, anti-inflammatory medication works in RA, but not neuropathic pain disorders, such as the pain which occurs in diabetes.

While these medications may be worthwhile to study for their effect on pain, currently they should only be used when other more traditional medication has not worked.

In this series:

1. Medication for Pain Series 2009
2. Aspirin, Motrin and NSAIDS
3. Anticonvulsants
4. Antidepressants
5. Anesthetics
6. NMDA receptor antagonists (e.g. Ketamine)
7. Muscle relaxants
8. Blood Pressure Medication
9. Narcotics (Opiates)

Today’s video is from Esceha 57.  This has some amazing photography of Fall rain droplets.

For those of us with pain, these type of questions can be puzzling and cause distress.  A new book, The Wisdom to Know the Difference, looks at how we figure out what’s right for us to do.

In this book, Flanagan explores the Serenity Prayer:

God grant me the serenity to accept the things I cannot change
Courage to change the things I can change,
And the wisdom to know the difference.

From a spiritual perspective, she looks at what clues we can use to figure out what we should change in our lives and where we should instead focus on acceptance.  There is much wisdom in the book.  It’s full of examples of real people working to discern how they are meant to lead their lives.

While not specifically about pain or medical illness, the book is helpful to think about where you are in your life and if that’s where you’re meant to be.  It offers guidance to help get you on the track you’re called to follow.  I think it would be most helpful for patients with chronic pain in several ways:

• in what ways is acceptance called for in my situation?
• how can my experience of pain fit into my life, rather than define my life?
• what are the life lessons I’m learning from my situation?
• how can I grow because of this pain?  despite this pain?

Chronic pain is often a life-changing situation, and this book offers wisdom to learn how to cope with such a difficult circumstance.  The Wisdom to Know the Difference can be useful to integrate your experience of pain into your life, and move forward with living.

Other articles you may enjoy:

• A journey from being lost to acceptance (book review of Lost Souls)
• Take this test to see how you’re doing with acceptance

Grand Rounds, a medical-blog carnival, is posted this week at Non-Clinical Jobs.

Today we’ll look at the medication category of Opiate Medication, sometimes called “narcotics”.  These are medications designed to treat both acute and chronic pain.

 Of all medications for pain, narcotics probably get the most press and cause the most controversy.  If you judged how important or effective narcotics were based on how much is written about them, you’d assume they were the primary treatment for pain:

Blue = Narcotics,  Red = Everything else

Instead, your pain medication regimen for chronic pain should look something like this:

If used for chronic pain, narcotics should be 1 medication in an array of helpful treatments.

Narcotics:
Narcotics include opium derivatives (Morphine and Codeine) and synthetic opiates (Methadone, Demerol, Oxycodone).

Effect of Narcotics:
Narcotics work at opioid receptors, where they interfere and stop the transmission of pain messages to the brain.  They also alter your psychological reaction to pain.  Patients sometimes report still being aware of pain, but not having such an aversion to the feeling.

Side Effects:

• sedation
• nausea or vomiting
• constipation
• breathing difficulty at higher dosages

Issues with Narcotics…

1. Effectiveness
Unfortunately, while narcotics are great for acute pain, they often don’t work so well for chronic pain, especially nerve pain.  Sometimes the problematic side effects outway the good effects when they’re used for chronic pain.

2. Tolerance
When narcotics are used, over time your body gets used to their effect.  So to get the same effect, often a higher and higher dose is needed.  Often as the dosage is increased to continue to get a benefit, the side effects continue to increase.  However, don’t mistake tolerance, which is simply a physical process, with addiction.

3. Addiction
True addiction is a disease in which people continue to use a substance (alcohol, street drugs or prescription drugs), despite bad consequences such as physical illness, relationship problems or inability to function at work.  Just because your body is tolerant to a medication, it doesn’t mean you’re addicted.  Addiction is a behavior; tolerance is a physical process.

However, a small percentage of patients who use narcotics will develop true addiction, with symptoms such as lying about how much medication they’re using, doctor shopping to get more prescriptions, obtaining narcotics illegally, and using the medication to get high rather than to control pain.  About 5% of patients who are prescribed narcotics for chronic pain develop addiction.  The risk is higher in people who’ve been addicted to drugs or alcohol in the past, and for those who have few other coping skills to deal with pain.

4. Side Effects
Side effects of narcotics can be significant.  The 2 most bothersome ones are usually sedation and slowness in thinking, and constipation, which can be severe.

5. Do Narcotics Increase Pain?
An under-recognized problem is that for some people, narcotics can set up a process where pain will increase over time, even if the medication initially decreases pain.  Narcotics can cause what’s call hyperalgesia, which is an increase in pain sensations.  When this occurs, sometimes doctors think the medication isn’t working and increase the narcotic, when in fact the narcotic itself is increasing pain.  A vicious cycle can develop.  As with all drugs, for narcotics to continue to be prescribed, it should be clear that they’re decreasing pain.

Conclusion…  Pain is bad, and sometimes narcotics are helpful and should be used.  Doctors and patients need to be sure that the benefits are worth the risks.  When narcotics are used, it’s important to see if a person’s functioning is also improved, in addition to a decrease in pain.

I’ll be interested in reading your thoughts about narcotics in the comments…

In this series:

1. Medication for Pain Series 2009
2. Aspirin, Motrin and NSAIDS
3. Anticonvulsants
4. Antidepressants
5. Anesthetics
6. NMDA receptor antagonists (e.g. Ketamine)
7. Muscle relaxants
8. Blood Pressure Medication
9. Narcotics (Opiates)

Thanks to Not Walton at Flickr for the first photo.

A new blog to join us, Life with Chronic Pain, has some good writing about his life coping with pain.

Migraine Chick uses humor to cope with pain.  Creativity anyone?

One Big Health Nut reminds us about eating healthy.  Good advice for the upcoming cold and flu season, and important for our bodies which cope with the stress of pain.

The Migraine Girl shares her experiences with mindfulness-based stress reduction.

CRPS/RSD A Better Life informs us about a study of CRPS being done by RSDSA.

Pain Relief Blog of Rebecca Rengo posts about accepting your feelings towards your illness.

4 Angels Momma writes an interesting article about what she feels are the spiritual reasons for her chronic illness.

Going Down Swinging, A RSD Blog asks what nourishes you and makes you happy?  She has some suggestions to be sure to include in each day.

Free My Brain from Migraine Pain explores ending relationships with doctors – when?  why?  what to tell them?  Great post about taking responsibility for your own care and being sure your doctor works with you well.

Rhymes with Migraine shares 30 things about her invisible illness (migraines).  I think hearing about someone else’s illness and struggles helps us feel less alone.

I hope you enjoy the selections.  Next month I’ll be hosting Grand Rounds, a medical-blog carnival, on November 24.  The theme will be any posts related to pain.  Send your submissions here by Sunday, November 22.

Today we’ll look at the medication category of Anti-Hypertensive Medication.  This class of medication includes drugs originally used to control high blood pressure.  A common medication from this class that’s used for pain is Clonidine.

Like muscle relaxants, anti-hypertensives indirectly decrease pain.  They would be considered supplemental medications for pain, rather than primary ones.

Effect of Anti-Hypertensives:
These medications work by decreasing the activity of your sympathetic nervous system.  This is the “fight or flight” system in your body, the one that’s responsible for getting your body going – raising your blood pressure and getting your heart beating faster.

Uses of Anti-Hypertensives:
In some pain disorders, it’s thought that an overactive sympathetic system may be partly responsible.  CRPS (RSD) and other neuropathic pain disorders are some examples.  Using anti-hypertensives in pain isn’t “FDA-approved,” but there are some studies supporting the use of these medications for pain.

Side Effects:

• a decrease in blood pressure, while a direct effect of the medication, is considered a side effect when it’s used for pain control, as that’s not the effect that’s necessarily desired.
• sedation
• dizziness or lightheadedness

In this series:

1. Medication for Pain Series 2009
2. Aspirin, Motrin and NSAIDS
3. Anticonvulsants
4. Antidepressants
5. Anesthetics
6. NMDA receptor antagonists (e.g. Ketamine)
7. Muscle relaxants
8. Blood Pressure Medication
9. Narcotics (Opiates)

Today’s video is from Ferrari Boeing.  For those of you in the southerm hemisphere where it’s Spring instead of Fall, perhaps you can imagine this in reverse! 

The first study is ”Ketamine produces effective and long-term pain relief in patients with Complex Regional Pain Syndrome Type 1” which appears in Pain, October 2009.  This study of 60 subjects with severe pain used an average of 4.2 days of IV Ketamine infusion.  Results showed significant decreases in pain at the end of the infusions, but no sustained decrease by 12 weeks after treatment.

This study confirms previous studies which also showed that Ketamine effectively reduces pain, but most patients need “booster” sessions to maintain pain reduction.  Unfortunately, the title of this paper is a bit misleading, as long term pain relief did not occur.

The second study is “Effects of low-dose intransal (S)-ketamine in patients with neuropathic pain” which appears in the European Journal of Pain, in press, 2009.  This study looked at the use of Ketamine administered by nose in a small sample of 16 subjects.  Pain was reduced for about 2–3 hours, with the best pain relief (30 – 40% decrease in pain) achieved at 1 hour.

These 2 studies are part of a growing body of literature supporting the use of Ketamine.  It’s a treatment that I’m warming to, but still would recommend only after more conservative measures have been tried.

Sharp Brains hosts Grand Rounds this week, a medical-blog carnival.

Today we’ll look at the medication category of Muscle Relaxants.  Muscle relaxants are drugs which help muscles relax and prevent muscle spasms.  Common medications include Zanaflex and Baclofen.

Previous medications we’ve looked at, like anticonvulsants and antidepressants, can directly reduce pain.  Starting today and over the next few weeks, most of the medications I’ll review work instead indirectly on pain, by affecting some other system and indirectly decreasing pain.

There are many categories of muscle relaxants, all working on different neurotransmitter systems in the body.  While most muscle relaxants work indirectly on pain, Baclofen may also have direct pain-reducing effects.  You might think of muscle relaxants as supplemental medications for pain, rather than primary ones.

Uses of Muscle Relaxants:
Muscle relaxants are used in conditions where these symptoms are a problem:

• muscle tension
• muscle spasm
• dystonia (severe, long-lasting spasm)

These symptoms can occur in pain disorders such as chronic back pain and CRPS.

Side Effects:
Side effects include sedation and weakness.

You might also be interested in the article Dystonia Makes Movement Hard.

In this series:

1. Medication for Pain Series 2009
2. Aspirin, Motrin and NSAIDS
3. Anticonvulsants
4. Antidepressants
5. Anesthetics
6. NMDA receptor antagonists (e.g. Ketamine)
7. Muscle relaxants
8. Blood Pressure Medication
9. Narcotics (Opiates)