CDC Releases Updated Opioid Recommendations for Chronic Pain

1280px-US_CDC_logo.svgThe CDC has released new clinical guidelines for the treatment of chronic pain which is a significant problem for today’s patients. It is estimated that 14.6% of adults have chronic pain which is defined as pain lasting more than 3 months or lasting past the time it takes to heal an injury.  Often, patients are given a prescription of opioids (also known as narcotics) to help control pain, which is known to work well for acute pain, but may not be as beneficial for longer lasting pain.   What evidence does exist points to opioids doing much more harm than good when used for extended periods.

Chronic pain is most likely best treated with behavioral therapy (aimed at reducing anxiety, fear and depression associated with chronic pain),  as well as exercise therapy and goal setting.  It is important to realize that the primary goal of such therapy is to improve function.  This means there will most likely always be some degree of residual pain.

Opioids taken for longer periods have been shown to have significant risks including:

  • Slowing the respiratory drive to the point that breathing stops
  • Addiction
  • Increased risk of motor vehicle injury
    (especially when treatment with opioids are first initiated, doses are increased, other depressants are used (ie. alcohol  or benzodiazepines.))

Common effects associated with opioids include constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms when trying to stop.

Most of the guidelines published here do not really offer much that is new, but rather stress how much good evidence there is for negative long term effects of these medications.   The most interesting piece of new information that I learned in this guideline is how goal setting has been shown to significantly increase function and well being in those with chronic pain.  I have seen this for myself though that patients who have a positive outlook and try to carry on despite their pain do appear to do better.

My Thoughts:

As an orthopaedic surgeon, I approach chronic pain from a holistic point of view. Specifically, I want to make sure that my patients who need treatment for underlying / concurrent depression get the help they need. In this type of case I will discuss the benefits of working with a mental health professional and a referral.

It has always been a priority of mine order to decrease the pain and need for pain medications. I will always try to find the underlying source of the pain and then proceed with the best combinations of treatments.  For example with arthritis pain, I will usually try cortisone injections and physical therapy. It means more work for the patient and fighting through pain, but it can often lead to significant relief.

Ultimately though if all else fails, surgery might be an option. Through discussion of your goals and circumstances, we will always find the best individual treatments for you. Remember it is a process, it takes time, and there is almost never a ‘magic bullet.’ With time, patience, and hard work chronic pain can be managed without sole reliance on opioids.

AAOS Yearly Conference: 2014 in New Orleans

AAOS Yearly Conference: 2014 in New Orleans

It is always great when the American Academy of Orthopaedics has its yearly conference here at home in New Orleans. It means many things to me. Here are a few of my thoughts on this upcoming week of working sessions, presentations, and a chance to learn about the latest innovations in orthopaedic surgery and orthopaedic care.

I don’t get to go every year, but I will be there this year. (How could I miss it since it is right here in New Orleans, Louisiana?) This a chance for me to catch up with former colleagues, mentors, and friends who live all over the country. Everyone gets caught up in their weekly routine. So having an opportunity to reconnect with people you rarely see and getting a chance to take a look at the latest advances in my field is something I really enjoy.

So I will be in the office in the Orthopaedics Department all day Monday March 10th, 2014, seeing patients at Ochsner Kenner. From Tuesday through Friday I will be sitting in various conference rooms, walking the display floor, and clearing out a few times to handle various surgeries I have scheduled for this week.

If I don’t see you tomorrow, or at the conference, I will be back in the office all week as usual as of Monday March 17th, 2014!

AAOS New Orleans, LA 2014

American Academy of Orthopaedic Surgeons Annual Meeting – 2014

Achilles’ Tendon Injuries

Achilles' Tendon Injuries

Unfortunately for (LA Lakers Fans) Kobe Bryant tore his Achilles’ tendon recently. This is the tendon that connects the calf muscle to the heel.

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It is very common to develop Achilles tendinitis (an inflammation within the tendon). As this continues over a long period, the tendon can even become degenerated and sometimes will rupture.

 

There are two distinct locations in which the Achilles tends to become inflamed and these have very different courses:

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The first is right at the back of the heel where the Achilles inserts onto the heel bone (calcaneus). This is commonly referred to as a ‘pump bump’, but don’t let that fool you. Women are not the only ones to develop the inflammation here. In this area, the tendon gets a good amount of blood supply from the bone and so these very rarely, if ever, go onto rupture. These, however, are tougher to get rid of and can take a long time to treat.

 

20130417-204058.jpgThe second place is higher up the leg. This is in an area between the insertion and where the tendon and muscle meet which makes it an area that has less robust blood supply. This is why tendinitis in this area can more often lead to ruptures. The inflammation in this area however is normally easier to relieve.

Treatment for both types of tendinitis start with relative rest. This means taking some time off of working out and maybe even placement into a walking boot or cast to keep the Achilles from having to work. Also a course of physical therapy focused on stretching the tendon and modalities such as ultrasound or electric stimulation can help relieve the inflammation. Anti-inflammatories are often prescribed as well.

If the tendon does rupture, patients often describe this as feeling as if they were shot or kicked in the calf. It also becomes difficult to walk on the leg. It is important to seek care quickly so that treatment can be started and you can obtain the best outcome. These can sometimes be treated with splinting and casting without having any surgery. Other times, surgery to repair the tendon can be the best option.