DermHelpCentral

Tapering Opioid Analgesice

Safely discontinuing, or tapering, opioid analgesics is an issue that pain services and primary care providers regularly confront.

This is a good guide to Tapering Opioid Analgesics Download Safely_Tapering_Opioids

New Opioid Limits Challenge the Most Pain-Prone

The pendulum swings.  Once, we physicians were exhorted to prescribe more opioids -- now it's the opposite.  Pain does not seem, any longer, the be the fifth vital sign!

The fine article by Paula Span in the Tuesday, June 7, 2016m NY Times covers this complex topic are well.

Patients in Pain, and a Doctor Who Must Limit Drugs

This is a fine article about the frontline of opioid prescribing: the physician’s office. “The management of chronic pain has had a long, fractious history in the United States. In the 1990s, doctors were admonished for undertreating pain. Opioids, they were told could be safely prescribed and bring life-changing relief. Now the pendulum has swung sharply back and doctors have been scrambling for alternatives.”

Full article.  The May 16, 2016 NY Times article features a family physician from a small town in Nebraska.  It is true to life and worth reading.

Gabapentin for Neuropathic Pain

"Gabapentin (Neurontin) is now widely used for neuropathic pain. Controlled clinical trials in diabetic neuropathy and postherpetic neuralgia show that gabapentin at 2400-3600 mg/day has an efficacy similar to the tricyclic antidepressants. Consistent, though less compelling clinical evidence supports its use for a variety of other neuropathic pain syndromes, including cancer pain syndromes, pain associated with HIV infection, chronic back pain and others. The exact mechanism and site of action of gabapentin is unknown. Its use for neuropathic pain has become widespread because it is generally well-tolerated, easily titrated, has few drug interactions, and does not require laboratory monitoring. However, cost may be a limiting factor for some patients.

Patients suitable for Neurontin should ideally have a clear neuropathic pain syndrome, characterized by sharp, shooting, lancinating and/or burning pain, in a nerve root (radicular) or stocking/glove distribution."

This as a good reference for Gabapentin and Neuropathic Pain.

Notalgia Paresthetica: Successful Treatment with Exercises

The authors describe here two cases in which the condition was improved by exercises involving non-pharmacologic active range of motion and strengthening of the scapular muscles as well as stretching of the pectoral muscles.  See full article: Download Notalgia Exercise

Here is a good Overview of Notalgia from Dermnet.

Chronic Pain

Chronic pain is a relatively common complaint of dermatology patients.  Post herpetic neuralgia (which follows some cases of shingles) is an example that quickly comes to mind. There was a recent eight minute post on TED which serves as a good introduction to this general area.

 

Itch

The talented medical writer, Atul Gawande (not pictured on left), has an amazing article, which addresses itch, phantom limb pain, and related syndromes, in the June 30, 2008 New Yorker magazine.  This essay, in the Annals of Medicine series, is an important read for physicians and patients alike.  We have linked a pdf Download itch_gawande.pdf or you can access the article at: Itch Gawande.

"The mysterious power [of itch] may be a clue to a new theory about brains and bodies."

A thorough discussion of Gawande's article as well as a presentation of an illustrative case will appear on VGRD shortly.

Vulvodynia

For decades, women suffering from vulvodynia have been told that nothing seems to be wrong with them — nothing, that is, that the examining physician can discern — or that the condition may be real but that nothing can be done.

Here are two valuable resources:

1. New Insights into Genital Pain in Women by Jane Brody.  NYT Jan 29, 2008  Permalink

2. A thorough review for health care professionals Download Vulvodynia.pdf

Susanna Kaysen wrote a fine book on her own journey with vulvodynia:  The Camera My Mother Gave Me Paperback: 160 pages Publisher: Vintage (October 8, 2002)  This can be purchased from ABE Books for ~ $5.00 (which includes shipping)  Well worth reading.

 

Post-Herpetic Neuralgia

A Personal View

David Elpern -- Dermatologist

Around 15 - 20% of patients who have shingles will develop pain that lasts for months after the acute lesions subside.  By definition post-herpetic neuralgia (PHN) is the term used for pain that is present six weeks after the blisters have resolved.  Wikipedia has a fine section on PHN .  So does The National Library for Health's Prodigy system if you want more in-depth and evidence-based information.

I would like to add some ex-cathedra comments.  I have helped care for patients with PHN for over 30 years and read about this disorder with great interest. It is unusual in young persons who have had shingles.  These individuals seem to perceive pain differently.  In patients who are depressed, sad or chronically ill initially the incidence of PHN is higher.  These people seem to focus on their pain and don't let go of it.  Understanding the Gate Control Theory of Pain helps one to understand this.

"In their seminal  paper "The Tragedy of Needless Pain," Melzack and Wall assert that pain is a fundamental human experience, and requires an integrative understanding of that whole experience, and every choice we have made, that has formed our own "gates". They frame the choice to deal with pain or ignore it as moral: if the brain can control pain, we who know that must make use of that capacity, and in turn take control of pain.  Only by doing so can we achieve control of the larger causes of all of the pain that humans cause each other by carelessness, hatred, and failures of empathy - which might extend beyond humans.

The impact of this theory on medical treatment for pain has been profound, and has made it a multi-disciplinary field. A major advantage of the theory is that those being taught pain control techniques can actually be told why they work. This seems to play a major role in achieving results - which is explained most readily by psychoneuroimmunology, in which the nerves are seen as the link between the immune system and sensory and cognitive experience."

Please read about the Gate theory if you are interested.  But what does this mean for post-herpetic neuralgia?

In my opinion PHN is a scourge for people who focus on the pain of shingles and then believe they will not get better.  In some cases, this is a self-fulfilling prophesy.  The media, pain clinics and some physicians nurture this fear by promising interventions which inadvertently may actually prolong the pain.  It is very important to work with shingles patients early on to help prevent them from focusing on the pain.

I tell them to be active.  To go to work if they can.  To keep one's mind off the pain.  Watch funny movies, get out if they can, go to dinner with one's partner or friends.  Don't sit around feeling sorry for yourself.  Yes.  This is difficult, but there does seem to be something to this.  It may well explain why older individuals (who are retired and can sit around if they need to) or people with chronic disease suffer more than active busy people.

I know this is controversial and there have been few or no studies.  These have been my observations and I think they explain why kids and young adults rarely develop PHN (most are just to busy to do so!).  Besides, these techniques are benign, cheap and have no down side.