Codeine and hydromorphone need to be converted to an active form in the liver. Anidepressants use the cytochrome CYP2D6 system in the liver and may cut down conversion and hence opioid effectiveness. This has been determined in post-operative pains in people on SSRI anti-depressants. However common antidepressants used in chronic pain – amitriptyline, venlafaxine and duloxetine – all use the CYP2D6 system as well.
I once went to a talk on treatment of neuropathic pain and much to speaker’s surprise I told him I hated that term. Reason being, neuropathic pain with considerable peripheral sensitization (coming from the skin tissues) will respond nicely to neuropathic pain drugs like gabapentin but nerve pain syndromes coming from brain, spine of nerve root near spine ( sciatica) do not. Then comes along a study that lumps them all together – most probably spinally related and the notice no benefits from topical meds. That is nothing nerve shattering – most neuropathies respond poorly to the same drugs orally – a study using drug combinations orally only got 23.7% significant response rate: I wrote about it here:
Severe Neuropathic Pain – Only 1/4 Respond to Standard Drug Protocols – What Else Is There?
based on article:
Moulin, Dwight E., et al. .
Long-term outcome of the management of chronic neuropathic pain: a prospective observational study.
The Journal of Pain 16.9 (2015): 852-861.
Instead of treating pain patients, doctors have now been saddled with added responsibility of being a policeman for addiction prone patients. Part of the problem stems from fact that opioids only reduce pain on average by 1/10. Add- ons like cymbalta, pregabalin and gabapentin do little to help chronic back pain and sciatica. Despite some “raves” about marijuana, other studies have found help more marginal. So the non-interventional doctors, who may not even know what a quadratus lumborum is, might be tempted to push opioids beyond what is helpful.
I offer tongue – in -cheek advice on finding the addiction prone patient.
Continue reading “How to Smell a Dirty Rat Addict Prone Patient”
A 5° lateral heel tilt (comes out to about 5 mm lateral height) has been tried many times with mediocre results. They made it more likely by eliminating those with partellofemoral issues, and demanding a 2% reduction in KAM =external knee adduction moment (markers and 3d analysis needed for that). Still, drop in pain was […]
Isolated Lumbar Disc Disease Can be Determined by Non-Invasive Magnetic Resonance Spectroscopy (MRS) and Responds to Surgery. Non-Invasive Magnetic Resonance Spectroscopy scans for certain disc chemicals- lactate (LA) and proteoglycan (PG), as quantifiable biomarkers for discogenic pain. It was found to have “total accuracy of 85%, sensitivity of 82%, and specificity of 88%. These increased to 93%, 91%, and 93%
respectively, in non-herniated discs” – when compared to provocative discography (PD). Surgery to positive discs made it practical: :”when all MRS positive discs were treated, surgical success was 97% versus 57% when the treated level was MRS negative, or 54% when the non-treated adjacent level was MRS positive.”
Yeast like germs found in facial seborrhea (Malassezia and Candida species), and other fungi have been found in brains of alzheimer victims. Prior untreated facial cold sores increase dementia rate 3-10 fold. The beta amyloid we were so worried about is toxic to these organism and now thought to be just a protective agent. Mouse model of alzheimer’s is now shown to get candida granulomas in the brain. Very quickly there may be a paradigm shift of thinking of alzheimer causes from brain crud problem to infection. Researchers have also found an agent to interfere with prion virus like particles found in dementia. And now, more recently, gum disease bacteria is thought to be a major player in both dementia and maybe coronary artery disease. New theory links clotting factor leakage in brain to dementia.
40 mg Depo Medrol into tender TMJ was no better off a month later than saline injection. The crystals of the steroid made 5 subjects temporarily worse which they pegged as very bad “adverse events”.
It looks like the only agents to maybe survive are topical amitriptyline and gabapentin and hormones estrogen and testosterone.
It is commonly taught that drug combinations should be used in chronic pain – the most common pain being chronic back pain. Now it has been shown that little is gained from that. Only combo worth mentioning was buprenorphine plus pregabalin – the former is difficult if insurers won’t cover. There are other options that require actually treating the patient.
Analysis of 3 country surgery stats for spinal stenosis found a 77% one year response rate but no benefit from fusion.