by Paul Wynn, Pain-Free Living Magazine, September 2017
THE FOUNDER OF AN INTEGRATIVE-MEDICINE CLINIC EXPLAINS WHY CHRONIC PAIN SHOULD BE TREATED AS AN INFLAMMATORY DISEASE
Imagine talking to your doctor and finding out that chronic pain is actually an inflammatory disease. It’s an unconventional idea that surprises many people, but it’s slowly gaining traction thanks to the work of Gary Kaplan, D.O., a clinical associate professor at Georgetown University in Washington D.C. (Click here or on the image below to continue reading this article.)
Today, medical care is a highly specialized and compartmentalized business, and many physicians are pressured by significant time constraints. When your health problems are complex, it can be difficult and frustrating to find answers. Be your own advocate, don’t be afraid to ask questions, and seize control of your health.
5 Important Steps For Better Health When You Have a Chronic Illness or Pain
Find An Expert. Chronic pain can undermine every aspect of your life – your work, relationships, recreational activities, self-esteem, and hope for the future. You want – and need – a pain specialist who is going to investigate the causes of your particular pain problem, strive to understand exactly how it has affected your life, and work with you to create and implement a personalized and comprehensive treatment strategy that fits the context of your life. You don’t have to just live with it. Chronic pain or illness should not define who you are and what you do.
Understand Your Diagnosis. A diagnosis is not just a label; expect your doctor to provide you with resources to help you better understand your own condition; and expect him or her to lay out clear recommendations for your short and long-term treatment, including steps that you can take to assist with your own healing process.
Understand the Value of Non-invasive Manual Therapies to Your Recovery. Seek out a physician who is knowledgeable about non-invasive manual therapies that will support your recovery. Ideally, you want a doctor who can recommend highly skilled manual practitioners who will communicate with your doctor about your progress and the need for adjustments in your ongoing medical care.
Be Careful about Using Pain Medication. While medications may help with pain, some also have the potential to cause other problems with your health and quality of life. Be confident that the medication your doctor has prescribed for you is truly the most effective and least invasive way of treating your chronic pain problem.
Understand All the Factors that May Be Contributing to Your Condition. Many times there are underlying, undiagnosed factors that may be contributing to your pain. Nutrition, emotional issues, hormone imbalances, biotoxicity or neurotoxicity, and sleep disorders can all cause inflammatory reactions in the body which can lead to a cascade of painful symptoms.
Chronic pain is a multi-faceted problem that requires a multi-disciplinary approach to diagnosing and treating your pain.
We are here for you, and we want to help.
Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2
Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. – Hippocratic Oath
When it comes to the treatment of chronic pain, the medical profession may be in violation of what can be regarded as the first medical ethic: First do no harm.
Together, the prevalence of chronic pain and the increasing use of opioids have created a “silent epidemic” of distress, disability, and danger to a large percentage of Americans. The overriding question is: Are we, as a nation, approaching management of chronic pain in the best possible manner that maximizes effectiveness and minimizes harm?
More recently, the Centers for Disease Control in an attempt to address the massive public health crisis identified by the NIH issued a new set of twelve guidelines aimed at reducing the risk of opioid over-prescription and over-use. Although these recommendations are not yet mandated, they are a necessary first step in rethinking how we look at chronic pain treatment and how narcotics are prescribed.
A Brief History of Opioid Medication Use/Misuse
In 1997, the American Academy of Pain Medicine, in an acknowledgment of 1) the severity of the suffering of patients with chronic pain, and 2) the medical profession’s inability to provide many of these patients with acceptable treatment solutions, issued a consensus paper endorsing the use of opioid medications for the treatment of chronic non-cancerous pain. The Academy openly acknowledged that one of the problems with the long-term use of opioids is addiction. In response, the medical profession began making the distinction between addiction and dependence. Addiction was defined as a craving for opioids with the intention of getting “high” consistent with drug-seeking behavior. Dependence, on the other hand, was defined as any situation in which an opioid medication was prescribed for medical reasons, with a dosage sufficient to control the pain, and a significant improvement in the quality of life of the patient. While the intention was noble, the consequences have been quite disastrous.
Since the release of the AAPM’s paper, the sales of prescription opioid medications measured in grams has skyrocketed. Between 1997 and 2007, sales rose by 866% for oxycodone, 525% for fentanyl, 280% for hydrocodone, and 222% for morphine. As reported in Pain Physician in July 2012, “Gram for gram, people in the United States now consume more narcotic medication than any other nation worldwide.” The report goes on to document that over 90% of patients taking opioid pain medications were prescribed these medications for the treatment of chronic pain.
In 2011, approximately 17,000 drug overdose deaths involved prescription opioid medications. The CDC also reported that “In 2007 there were more opioid analgesic deaths than overdoses involving heroin and cocaine combined.” While a significant number of these drug overdose deaths are associated with diversion of the medication to people who were not originally prescribed the medication, 60% of the deaths occurred in patients that were given prescriptions based on the prescription guidelines by medical boards.
Furthermore, significant side-effects from opioid medications include increased risk of birth defects, falls and fractures, addiction, constipation, heart attacks, a decrease in the production of testosterone, and in some cases, hyperalgesia, an actual worsening of the pain.
Deciphering the Problem
While the NIH report and recent CDC guidelines offer a number of important policy and institutional points to address, I believe that the fundamental basis of our problem comes from a lack of understanding of what we’re treating. Acute pain and chronic pain (not associated with ongoing tissue damage such as in cancer) are two very different phenomena in the body.
1. Chronic pain is not a thing but one manifestation of a complex physiological process that frequently impacts many body systems, including sleep, gastrointestinal, psychological, and endocrine. Thus, we must take a whole-person approach in our diagnosis and treatment, which requires looking at multidisciplinary treatment options.
2. Unquestionably the evidence supporting the use of long-term opioids in the treatment of chronic pain is insufficient. We need better studies to help us understand when long-term use is beneficial.
3. Physicians need to be better educated about the diagnosis and treatment of patients suffering from chronic pain. Ultimately the use of long-term opioid medications is an admission of treatment failure. The recent CDC guidelines are a step in the right direction in this regard.
As a pain specialist, I believe there is an important role for opioid medication, but that role should be limited. Opioids should only be prescribed with close monitoring by the diagnosing physician, for the purpose of relieving pain and improving quality of life when all other medical approaches have been exhausted.
First, do no harm. Opioids should be medications of last resort.
Dr. Kaplan explains how treating the symptoms of chronic pain is contributing to a system of mismanagement in this country. He discusses why we must shift the way chronic pain is treated by addressing its root cause – inflammation of the Central Nervous System.
Q: I have a question about low-dose naltrexone for chronic pain, I understand you use this in your clinic. The standard dose appears to be 4.5 mg in almost all of the information I can find. There are a few chronic pain MDs in the U.S. that seem to be using higher doses with success — a couple say to go up as high as 10 mg while another one is using it up to 4.5 mgs 3xday with great success for those who do not respond to one dose of 4.5 mgs. Do you have any thoughts on this? What I’ve read is that one should not give up on this medication if not getting benefits at 4.5 mgs. Thank you.
A: LDN, or low-dose naltrexone has recently become popular as a method to boost the immune system for a number of conditions, such as HIV, cancer, Crohn’s disease, multiple sclerosis, neurodegenerative disorders, chronic neuropathic pain, fibromyalgia, and other autoimmune diseases.
How Low-Dose Naltrexone Works
LDN works by temporarily blocking endorphins in the brain which causes a reciprocal boost in natural endorphins, and by down-regulating the inflammatory effect of immune cells called microglia in the brain that get turned on in certain situations. At a low dose, the side effects are minimal. Higher doses can cause sleep disturbances and may cause elevation of liver enzymes. Although I don’t usually go higher than 4.5 mg, most likely the doses you are talking about – 10-14 mg – are far from the 50 mg or higher dose that is used to block opioid overdose, and are therefore are probably safe. I don’t see any research on the efficacy of using higher doses, however.
by Julia Westbrook | As first seen on RodaleNews.com.
What you don’t know is hurting you.
Gary Kaplan, DO, author of Total Recovery and founder of The Kaplan Center for Integrative Medicine, recently held “office hours” during a Rodale News Facebook chat. One of only a handful of physicians in the country who is board-certified in Family Medicine and Pain Medicine, Dr. Kaplan was able to apply his pioneering perspective to help answer one of the most difficult questions plaguing our country: What is causing my pain? If you weren’t able to make the chat, we’ve pulled out 8 key takeaways to consider when you’re trying to figure out why your pain just won’t go away.
#1: Inflammation, part of the normal repair process, may have gone awry.
Cytokines are chemical messengers secreted by the body. They have effects ranging from inciting nerve repair to causing inflammation. In the case of chronic pain, we know that the microglia, which are the innate immune system in the central nervous system, are “stuck” in a mode where they continue to excrete predominantly inflammatory cytokines. Under normal circumstances, microglia will shift from producing inflammatory cytokines to making anti-inflammatory cytokines and call in other cells to initiate the normal repair process.
Balance is restored by eliminating all of the factors that caused the microglia to get turned on in the inflammatory state and then doing things such as meditation, exercise, getting adequate sleep, and using things such as low-dose naltrexone (LDN) and turmeric to get the microglia to go back to their resting state.
#2: Allergies can make your pain worse.
Anything that incites an inflammatory response in the body has the potential to spill over into the brain and worsen the inflammation in the central nervous system, as with fibromyalgia. The allergies are not the cause of the fibro, but something that is further aggravating it.
#3: Your diet can cause inflammation.
I would start by thoroughly looking at your diet and make sure there is nothing still in your diet causing inflammation. I saw one woman who is a vegan, and it turned out she was allergic to blueberries. For ongoing inflammation in the brain, turmeric may be helpful.
#4: Your fatigue may be a symptom. Don’t ignore it.
Sleep is not a thing, but rather a series of different brain waves divided into stages 2, 3, 4, and REM. People who are deficient in 3 to 4 sleep will present with chronic pain. If you have sleep apnea, where you stop breathing at night, it can cause chronic pain. If you have restless leg syndrome, it can also cause chronic pain. A proper evaluation of the quality and amount of sleep is necessary for anyone suffering from chronic pain and depression.
#5: A migraine problem isn’t just in your head–it’s in your nervous system.
Dehydration, alcohol, bright lights are all triggers that can cause migraines. The underlying cause of the migraine is an irritated nervous system. The nervous system is irritated because of an underlying inflammatory condition in the brain. The key to preventing migraines is to identify what it is that’s causing the inflammation. I would start with an anti-inflammatory diet of rice, fish, chicken, fresh fruits, and vegetables.
#6: Overlapping problems can come from the same source.
Migraines and depression: Brain inflammation
The basis of both migraines and depression is inflammation in the brain. I address this at length in my book, Total Recovery. Yes, the two are related and the cause of the inflammation needs to be identified.
Chronic pain and weight loss problems: Gut imbalance
One of the reasons that you may not be able to lose weight might be related to either food allergies or sensitivities or mold toxicity. We know that the composition of the bacteria in your gut has a very significant effect on your ability to lose or maintain weight. Skinny people have different gut flora than people who are overweight. If you have other symptoms, it’s very likely you have a chronic inflammatory condition but the cause has not been discovered or addressed.
#7: The underlying root cause may still need to be identified.
Arthritis (…which isn’t always arthritis)
Sometimes arthritis in knees and joints can be from Lyme disease, sometimes from rheumatoid arthritis, and sometimes from tendinitis. It can also be associated with food allergies and food sensitivities. The first issue is getting a clear diagnosis.
Complex regional pain syndrome
Also known as CRPS, it is a horrific pain condition. I see a number of patients who suffer from CRPS, and the solution can, unfortunately, be elusive. Again, it’s important to try and understand what it is that has caused the nervous system to be so hyper-reactive. Get evaluated for Lyme disease and its co-infections, celiac disease, gluten intolerance, and neurotoxins associated with mold, along with a number of other conditions that I address in my book. I am familiar with Calmare therapy, and the research on it looks very exciting. While we do not do this therapy in our office, I have referred patients for this therapy. It is certainly worth the trial for anyone suffering from CRPS.
Tinnitus
Tinnitus can be an extremely difficult problem to address and can be a result of multiple issues and not a single problem. Meditation and yoga are extremely effective in reducing inflammation, as is curcumin. You also need to identify the causes of the inflammation, such as the trace mineral imbalances, as well as eliminate anything that may be poisoning your system.
#8: Your body may be more responsive to alternative therapies.
We find that acupuncture can be extremely effective for a large number of pain conditions. But most commonly our treatments are layered, involving a number of therapeutic approaches, which work synergistically for a comprehensive solution. I also recommend meditation or yoga.
We are here for you, and we want to help.
Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2