RSD Puzzle #015

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE #15
The Importance Of Controlling RSD Pain

"I am in constant pain. I need pain medications. Why shouldn't I take strong pain medicines?"

RSD cannot be brought under control unless the pain is brought under control. RSD is defined as a state of constant burning and pain which is severe, incapacitating, and is aggravated by even a breeze or a simple touch to the involved area (allodynia). This pain is accompanied by swelling, inflammation, disturbance of the immune system function, movement disorder (flexion spasm, tremor, etc.) and emotional disturbance in the form of insomnia, depression, agitation, irritability.

Of the four major manifestations of 1. PAIN; 2. INFLAMMATION; 3; MOVEMENT DISORDER, and 4. DISTURBANCE OF FUNCTION OF THE LIMBIC SYSTEM (insomnia, agitation, irritability, and depression), none is as critical and important to control than the pain itself.

The form of pain control should aim at a long standing control of the pain rather than a short term, few hours of relief.

There are two distinct and opposite types of pain.

1. Acute pain that is experienced immediately after an injury to the body. An acute heart attack, blood clot in the lung, car accident, surgical procedure, or on going cancer with damage to the organs in the body are examples of acute pain.

The treatment of choice for acute pain is strong narcotics. Without the use of medications such as Morphine, Dilaudid, Demerol, Lortab, Percodan, Percocet, and other types of strong narcotics. The patient's life is in danger because of the severe type of pain causing shock to the system and aggravation of the acute illness which requires the pain medication to begin with. In this regard, the narcotics are life-savers in the treatment of acute pain.

2. Chronic pain is opposite in every regard and has only the pain experience in common with the acute pain. In chronic pain, the original injury has been several weeks, months, or years old, and the pain has become persistent due to the scar formation, nerve entrapment, or other factors such as abuse of pain medications. Examples of chronic pain are arthritis, neck and back injuries, and RSD (complex chronic pain).

The chronic pain can be as severe, harmful, and damaging as the acute pain. On the other hand, in at least one forth of the patients, the chronic pain is perpetuated due to the fact that the patient is continuing to take addicting narcotics and/or tranquilizers (especially Lortab, Percodan, Duramorph, MS Contin, Valium, Xanax, Tranxene, Ativan, and Halcion).

Such patients are identical to an experimental poor dog that has been perfectly healthy before it was given injections of Morphine. After a few days, as the extraneous Morphine destroys the dog's brain endorphines, the dog becomes totally dependent on the Morphine injections to be pain free. The same dog that had no pain before the injections of Morphine were given, every 4-5 hours after the injections, starts barking and screaming because of the pain. This is not because the dog is deranged, sick, or "a druggy". This is because the Morphine injections have blocked any secretion of the dog's cerebral endorphines. Once the endorphines are gone, the brain is in a stressful state, and gives the warning signal of withdrawal pain to let the animal know that there are no endorphines.

Endorphines are completely different from man made narcotics. The only thing they have in common with the narcotics is the fact that the endorphines are 200-300 times stronger than the strongest narcotic in regard to pain relief. That is where the similarity stops. The rest of the side effects of endorphines and the extraneous pain medications are opposite to each other. The endorphines enhance the formation of sex hormones, growth hormones, and hormones necessary for the secretion of corticosteroids (Cortisone). The man made analgesics, addictive narcotics have the opposite effect by suppressing the secretion of sex hormones, growth hormones, etc. The endorphines are essential for survival, and the arrest in the formation of endorphines results in severe distress, stress, severe pain, and depression.

TREATMENT OF CHOICE FOR CHRONIC PAIN:

TREATMENT OF CHOICE FOR CHRONIC PAIN IS ANTIDEPRESSANTS.

The antidepressants are analgesic of choice for treatment of persistent and long standing pain for any cause. They are the treatment of choice not because the patient is depressed. A lot of patients suffering from pain are not depressed. THE ANTIDEPRESSANTS PROVIDE ANALGESIA (RELIEF OF PAIN), REST AND SLEEP, as well as counteracting depression. This is a similar principle as is the case with aspirin. Aspirin is an analgesic, arthritis medicine, and prevents heart attack and stroke.

Whereas in acute pain, it is vital for the patient to take strong narcotics, in chronic pain it is vital for the patient to use antidepressants as analgesics of choice.

However, antidepressant alone at the beginning is not enough. The patient has to be weaned off the addictive narcotics, and in the transition the patient needs to have strong pain medications which do not suppress the formation of endorphines.

One group of such strong pain medications that are not addicting are the so-called Morphine agonists antagonists medications. One example is Stadol which is not even a controlled drug because it can be withdrawn at any time, "cold turkey" without causing any withdrawal or complications of addiction. It is true that psychologically the patients will develop an affinity to it and can abuse it from a psychological standpoint, but physiologically the Stadol does not interfere with the formation of endorphines and as such does not cause the three pillars of addiction (tolerance, withdrawal pain, and withdrawal physiological crisis of shaking, agitation, insomnia such as seen with withdrawal from addicting narcotic).

Another example of such a group of medications is Ultram which is also non-addicting and can be discontinued at any time without any problem.

It is going to take a lot of education for sufferers of chronic pain and their caregivers to understand that they have to take antidepressants in enough dosage (guided by blood level of antidepressant) and long enough time to allow their own brain to make its miraculous endorphines.

In RSD, the chronic pain is not because of the abuse of drugs. the chronic pain is because of delay in diagnosis and delay in treatment. The other factor that causes the chronic pain in RSD is inflammation which is part and parcel of RSD. Anti-inflammatory medications also are helpful in the treatment of RSD.

With the help of the combination of the proper antidepressants (e.g., Zoloft, Paxil, Trazodone, and Prozac) as well as the use of strong non-addicting pain medications as outlined above, the patient will become pain free which is the key to the treatment of RSD.

Unfortunately, it is going to take quite a while for everybody to become educated about this. We have seen all forms of treatment of RSD some of which are quite nonsensical. Some patients are treated with a combination of strong addictive narcotics in unlimited dosage. Some are given Duragesic patch, MS Contin, and other forms of strong addicting narcotics. In such patients, the disease progresses rapidly from stages I to II all the way to stage IV (disturbance of immune system, suicidal attempts or successful suicide, heart attack, stroke, and severe hypertension). The problem becomes more complicated due the simultaneous use of strong addicting tranquilizers such as Valium, Xanax, Ativan, Halcion, and a slew of other addicting benzodiazepams (BZS). Such addicting tranquilizers should also be discontinued with the help of tapering the patient off the addicting tranquilizer, simultaneously replacing it with no addicting benzodiazepams (e.g., Klonopin) until the patient is complete detoxified after several weeks or months.

In treatment of RSD pain "less is more". The combination of proper antidepressants (not antidepressants that cause chronic fatigue and weight gain such as Elavil or Tofranil) and non-narcotic pain medications is essential.

Finally, when the patient is too far advanced, too fat gone for control of the condition with any of these forms of medications, the only other treatment that is left to be applied to the patient is infusion pump (please see RSD Puzzle #17 regarding Infusion Pump).

One form of treatment that recently has been noted applied among RSD patients is the use of Naloxon. Naloxon is a chemical that blocks the analgesic effect of Morphine and that is how in experimental animals the presence of endorphine was originally identified. It makes no sense to use Naloxon to get rid of the beneficial effects of endorphines just because the Naloxon is also given in detoxifying the patients who are narcotic abusers. It does make sense to enhance the detoxification with Naloxon, but then morphine agonist-antagonists (e.g., Stadol) are partially neutralized, too.

H. Hooshmand, M.D.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand, M.D.