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Pain Management And Why It’s So Personal

Most of my patients think about pain medicines in terms of the symptoms they treat. “This is my headache medicine, and this is my arthritis medicine,” they often say. Healthcare providers are more likely to categorize pain medicines by the way they work: some are anti-inflammatory, some affect nerve endings, and others influence how the brain perceives pain. But the truth is that no matter how you classify pain medicines, there is no way to know if they’ll help until you try them for yourself.

Most people don’t realize that pain management is personal. Research is beginning to help us understand why people respond to medicines so differently, and one day we will probably be able to personalize treatment plans more successfully. For now, there are several known genetic reasons why pain medicines are more or less effective for one individual over another. Genes affect:

  1. The number of enzymes that break down medicines and remove them from the body. Some people have larger numbers of these enzymes and therefore require more drug to feel its pain-relieving effects. Others may be strongly affected by even small doses of drug.

  2. Pain medicine receptor variations can make one medicine effective and another (nearly identical medicine) ineffective in relieving pain.

  3. Differences in carrier molecules that transport pain medicine across the blood stream and into the cells that are triggering pain sensations. Some people have fewer carrier molecules to bring the medicine to the site of pain.

  4. The number of “middle man” neurotransmitter molecules that pass along the pain response. Too many of these molecules can reduce drug binding and mute the pain relief effects of some drugs.

When pain is severe, prescription medications may be necessary. However, mild to moderate pain may be effectively managed with over-the-counter (OTC) medicines. I believe in the start low, go slow approach to finding the smallest effective dose of pain medicines. I always recommend that my patients read and follow all the instructions on the Drug Facts labels to make sure that they don’t accidentally overdose on active ingredients.

When I choose a pain reliever with my patients, the first thing I think about is potential side effects. Some medicines (such as non-steroidal anti-inflammatory drugs like ibuprofen and naproxen sodium) can be hard on the stomach lining, or cause bleeding in people who are at risk for it. Other medicines (such as acetaminophen) can harm the liver if used in excess, while prescription pain medicines can cause constipation and drowsiness. The best pain medicine to start with is one that is least likely to cause harm to the specific person.

The next thing I ask is whether or not the medicine has worked for the patient in the past. Previous experience is one of the best indicators of future success. Since I know that my patient has a unique, genetically determined number of enzymes, transporters, and receptors, previous experience with pain medicines will give me a good idea of how well they will tolerate it again, and if it will be effective.

Finally, I consider the type of pain that they are experiencing. If the pain is caused by inflammation (from an injury, surgery, or arthritis) I’ll consider a medicine with primarily anti-inflammatory properties. If the pain is caused by tension (such has headache) or complicated by fever, I may consider acetaminophen first. If the pain is coming from a nerve (such as sciatica or neuropathy) then I’ll use pain medicines that work for nerve pain specifically. If the pain is complicated by depression, I may discuss additional medicines and approaches.

Sometimes, combinations of medicines are significantly more effective than one medicine alone at treating pain (this is why some prescription pain relievers are combinations of an opioid and acetaminophen). When using more than one pain relief medicine, it is important to compare active ingredients in both prescription medications and OTC products to make sure that accidental overdoses do not occur. I also recommend consulting with a healthcare professional if there are concerns about drug interactions or if the patient is already on a significant number of prescription medications that could interact with his or her OTC pain medicine choices.

The bottom line is that science is still catching up to pain management. Perhaps one day a simple blood test will help us to determine the very best pain medicine regimen for a specific patient at a given time. But until then, adopting a strategy of careful trial and error (avoiding unwanted side effects, using the lowest effective doses, and consulting a physician when pain is severe) is the only option. Don’t worry too much about whether a specific medicine is “best” for your pain. Pain management is very personal, so you will need to discover your own best solution.


Disclosure: Dr. Val Jones is a paid consultant for McNeil Consumer Healthcare Division.

Living With Severe Chronic Pain

Living Beyond Pain

Prepared Patient - When Pain Doesn't End - photo from fotolia.comFor people with severe chronic pain like Kelly Young and Teresa Shaffer—both of whom have become patient advocates—coping with agony is a fact of life.  Young suffers from rheumatoid arthritis while Shaffer’s pain is linked primarily to another degenerative bone disease.

Chronic pain is one of the most difficult—and common—medical conditions.  Estimated to affect 76 million Americans—more than diabetes, cancer and heart disease combined—it accompanies illnesses and injuries ranging from cancer to various forms of arthritis, multiple sclerosis and physical trauma.

Pain is defined as chronic when it persists after an injury or illness has otherwise healed, or when it lasts three months or longer. The experience of pain can vary dramatically, depending in part on whether it is affecting bones, muscles, nerves, joints or skin. Untreated pain can itself become a disease when the brain wrongly signals agony when there is no new injury or discernable other cause. Fibromyalgia—a disease in which pain in joints, muscles and other soft tissues is the primary symptom—is believed to be linked to incorrect signaling in the brain’s pain regions.

Finding a Doctor

The first step to deal with chronic pain is Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Chronic Pain, Chocolate, and Vicodin

Chocolate and vicodin? No, it’s not the latest Ben & Jerry’s flavor. “Chocolate & Vicodin: My Quest For Relief From the Headache That Wouldn’t Go Away” is the latest book by author, blogger, web designer, and busy woman Jennette Fulda.

I became acquainted with Jennette’s blog during BlogHer 2008, where I had purchased her first book, “Half-Assed: A Weight-Loss Memoir.” When she asked if I would like a copy of “Chocolate & Vicodin” to review, I jumped at the chance.

In “Half-Assed,” Jennette chronicled her journey to a near-200 pound weight loss. Just prior to that book’s release, she began another journey — one whose goal proved elusive. On February 17, 2008, Jennette went to bed with a headache. She still has the headache.

Name a diagnosis, she’s heard of it (brain tumor, dead twin in the brain, etc.) Name a treatment, she’s tried it (meds, massage, marijuana, mint chocolate chip ice cream, etc.) In “Chocolate & Vicodin,” Jennette is on a journey to find relief from chronic headache. Writing in a comfortable style, Jennette has a subtle humor that will have you laughing out loud. Trust me, her description of using marijuana “for medicinal purposes only” will have your beverage of choice coming out your nose! (Cover the book!)

But it will also choke you up. Under the humor, under the crazy e-mails from readers that suggest the crazy remedies, this is a serious story of chronic pain disrupting life. Persistent, excruciating pain and the work of coping with it takes a toll on Jennette, and when it becomes too much you find yourself sobbing with her. Read more »

*This blog post was originally published at Emergiblog*

Back Pain: Why Yoga Might Make Me A Better Doctor

I’m a physician trained in sports medicine, and a chronic back pain sufferer. I first injured my back in 2001 when lifting a heavy bag and trying to sling it onto my shoulder. The pain was so severe that I couldn’t get off the floor for three days. I eventually ended up in the ER with an “unremarkable” MRI. The cause of my pain was never explained — all I knew is that I hadn’t herniated any disks.

Years later my back pain still flares up occasionally, and I’ve never really understood how to prevent it or treat it effectively. This has been very embarrassing for me, since I’m supposed to be an expert in this field. But today I finally got some insight into the real cause of my pain — not from a physician or physical therapist, but from a yoga instructor. Read more »

How To Have A Pain-Free Hospital Stay

This is a guest post from Dr. Anita Gupta.


How To Have A Pain-Free Hospital Stay

Too often patients feel like they’re in the passenger seat when entering the hospital. Even in the best of circumstances — such as planned admissions — patients often don’t feel in control of their own care.

One of the most unnecessary issues facing patients when they enter the hospital is untreated (or undertreated) pain. Often the focus of the medical team is to treat a condition, and controlling a patient’s pain comes second. Fortunately, this doesn’t need to be the situation. Here are a few tips for patients to ensure that their pain does not go overlooked:

Let someone know if you are in pain. This may seem obvious, but patients often hesitate to question their doctor. Pain control during your hospital stay is not a luxury, and you need to know you have a right to pain control during your stay. If you doctor or nurse is not answering your questions regarding pain, ask to see pain specialist who will likely address your concerns as well as the concerns of the doctors and nurses taking care of you. Unfortunately when it comes to treating pain, not all doctors are trained equally.

Have a family member or good friend to act as your advocate. Have this individual get involved in your medical care and act on your behalf during your hospitalization. Read more »

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