Q+A: From Back Pain to Arthritis

May 11, 2005 -- How do you find a reputable pain clinic? Are you a good candidate for a pain specialist? Here is a selection of your questions about pain management with answers from Dr. Carol A. Warfield, chair of the department of anesthesia, critical care and pain medicine at Beth Israel Deaconess Medical Center in Boston and a professor at Harvard Medical School.

Paula in New Orleans asks: How do you feel about patients with chronic pain going to the emergency room for narcotics? Do you feel that a patient with chronic pain should only be given narcotics by a physician who knows the patient and is a pain specialist? Thank you.

Answer: Any patient should feel comfortable going to an emergency room for what they feel is a medical emergency. However, patients with chronic pain often find that bouts of severe pain are better handled by making a plan in advance with your primary care doctor. This person knows you and your pain problem much better and can thereby better tailor your treatment to you. Many primary care doctors prescribe narcotics to patients with chronic pain on an ongoing basis but many feel more comfortable doing this after the patient has had a second opinion from a pain specialist who can best discuss all the options available for treating pain before resorting to narcotics.

Diane in Texas asks: There have been several news reports recently regarding pain management clinics being shut down for the blatant misuse of prescription pain medication. How would you recommend evaluating a pain specialist or pain clinic to make sure that they are qualified and reputable? And how do you know if the clinic is appropriate for your ailment?

Answer: There are many fine pain clinics across the country in many settings. Unfortunately there is no good and widely accepted standard used to accredit these clinics. If you have concerns, my advice would be to call the teaching hospital affiliated with a medical school in your area. They generally have clinics which treat all types of pain and may be able to recommend local private pain clinics in your area which might be most appropriate for your type of pain.

Mary in Kentucky asks: I take Dilaudid for chronic pain. I was hospitalized a year ago for shoulder surgery and the hospital staff seemed very judgmental about my medication, it was as if I was some drug abuser. I will never go to that hospital again. I never dreamed I would end up with debilitating pain and my experience with doctors and nurses tells me they need more education and sensitivity, are medical and nursing schools getting any better at addressing this issue?

Answer: Medical and nursing schools are putting much more emphasis on education in pain management than they did in the past. In fact, the Joint Commission on the Accreditation of Healthcare Organizations which is the major group which accredits hospitals has made it mandatory that nurses document pain scores in hospitalized patients just as they document blood pressure, temperature, rate of breathing and pulse. Unfortunately there are still many medical personnel who do not understand that strong painkillers like Dilaudid are sometimes necessary to treat chronic pain.

Jan in Idaho asks: Where do I find the names of pain clinics and in particular people that specialize in TMJ problems?

Answer: My advice would be to call the local dental school in your state or region and ask them for some recommendations of doctors who specialize in TMJ in your area. Many dental schools have pain clinics which focus on issues such as TMJ.

JoAnn asks: I lost my daughter on 9/11, since than I have been experiencing pain in my joints, pain in my chest, some swelling of hands and ankles. I have been to many doctors and the answer is always the same -- Post Traumatic Stress. But what can I do to feel better? No one has an answer for me. Do I really have a problem that is being overlooked because of 9/11? Everyone just assumes it is stress?

Answer: Since most of what you describe could be joint pain (yes, there are joints in your chest) I suggest you get a consultation with a rheumatologist. These physicians are specialists in joint disease and may be able to help diagnose and treat your condition.

Zim in Cincinnati asks: Diabetes often brings on peripheral neuropathy. What can you suggest/offer/inform this sufferer?. And as you know this request can not be fully conveyed! Ouch!!! Ow!!! Argh!!!

Answer: Diabetic neuropathy is a condition that commonly affects the nerves in the hands and feet, causing burning pain. The most common treatments for this condition are antidepressant medicines and anti-seizure medicines. The antidepressants are used because the same chemicals in the brain which are low in depression are also low in pain states. The anti-seizure drugs are used because damaged nerves in the hands and feet can act similar to damaged nerves in the brain which cause seizures. There are a variety of new antidepressants and anti-seizure drugs which can be very helpful for this condition.

Mara asks: I'm a 15-year-old girl, and am a basketball player, dancer, and I am an honor student. I had a transverse stress fracture in my sacrum. One day last May my back started hurting, I do not remember falling, or injuring it in any way. The MRI shows the fracture is healed however I am still having extreme lower back (butt) pain. I have missed over 50 days of school because of the residual pain.

I have tried everything from steroid injections, acupuncture, nerve blocks, physical therapy, and I even went to a chiropractor. Nothing has seemed to give me any relief. I just want to be able to play basketball and dance again. Do you have any suggestions about what may help relieve my pain?

Answer: It sounds like you may be the type of patient who may benefit from an evaluation at a comprehensive pain center. Contact the hospital associated with your local medical school to find one near you. Usually a single type of therapy does not completely relieve chronic pain. Rather a combination of treatment options may be needed.

Glenda asks: My mom has constant back pain -- her doctor told her it is the worst case of arthritis he has ever seen. Vicadin doesn't stop the pain. She is 82 years old and I hate that she is in constant pain. What can be done to help alleviate her pain?

Answer: The treatment very much depends on the cause of her pain. She should have a complete evaluation. However, if she has had one it may be that she needs a painkiller stronger than Vicodin. She may be a good candidate for a comprehensive pain center.

Deborah in Raleigh, N.C., asks: What do you do when your doctor tells you there's nothing that he can do for you? All of my tests came back negative: MRI, X-Ray, CT Scan, nerve study test and I have taken those test about 3-4 times each -- and I feel pain in my lower back and down my legs? The doctor has no diagnosis for me at all, what should I do next?

Answer: Many patients with severe pain have normal tests. Not all causes of pain show up on X-Rays and blood tests. When this happens often we will elect to treat the symptoms rather than the cause once we have satisfied ourselves that no serious treatable problem exists. I would recommend you get evaluated at a comprehensive pain center where they can custom tailor a pain management program for you.

Shirley in Pennsylvania writes: I have a Medtronic Stimulation System and I take 50 mg fenaul and also pain pills. I get some relief but I still have a lot pain. I had back surgery and it has left me with a lot of scar tissue. Pain doctor said I should live with it. Are there cases like mine where truly nothing can be done? Or could a pain specialist be of help?

Answer: A pain specialist definitely may help. You should have a comprehensive evaluation to determine which treatment options might be best for you.

Carol in Missouri asks: I have chronic back pain and have had several back surgeries over the years including a fusion. My problem was damage to the sciatic nerve and scar tissue. I have had a morphine implant pump for the last 10 years. Do you know of any long-term problems for using morphine for years? It has made me be able to continue to work and care for my family.

Answer: You said the magic words. I believe that the best treatment is one that allows you to function better at your daily activities. There are some patients whose function deteriorates when they take strong pain medicines. Clearly your function improves. There are some side effects of long-term morphine treatment. These include some rare problems such as mechanical failure of the pump and infection. the more common problems you might encounter include constipation, drowsiness and decreased sexual function. That being said, many patients tolerate morphine for many years without any problems.