Acute & Chronic Pain and the Human Condition

Injuries occur in all kinds of people: young, old, healthy or debilitated. The good news is almost everyone recovers from injuries. Occasionally, when a significant injury occurs in someone with extensive underlying degenerative disease, acute pain can gradually evolve into chronic pain. Acute and chronic pains are two very different animals, and the evaluation, treatment and therapeutic goals are different.

Acute pain is what we’re all too familiar with. It is usually the result of tissue damage, such as a cut finger, burn or a turned ankle. The pain usually lasts until the tissue has healed to some degree. Even this, the simplest kind of pain, is a bit mysterious. A broken bone takes several months to heal but only hurts for a couple of weeks. Acute pain is usually pretty bad – it gets your attention and makes you stop doing whatever it is that makes you hurt. That, in fact, is the point. The body is trying to limit self-destruction. The body is hard wired to take care of itself – an interesting notion.

The medical evaluation of acute pain is usually pretty straightforward. Since tissue damage causes the pain, we just need to find the damaged tissue, figure out how badly the tissue is damaged, and finally, fix the damage. I may have slightly over-simplified, but you get the idea. We treat the body part that hurts.

Chronic pain is a considerably more challenging beast. There is no new tissue damage, or no tissue damage that wasn’t there two months ago, when you weren’t in much pain. So, from a doctor’s perspective, we don’t have anything to fix. Talk about having one proverbial arm tied behind our back. The next problem is that time is not our ally. Most acute pain lessens with time; strangely enough, chronic pain doesn’t. Next month or next year is likely to hurt just as much. The persistence of pain complicates its management because all narcotic pain meds become less effective with time and continued use. That means you get less relief from more medication. Medication doses can get scarily high chasing chronic pain – not a safe or productive pathway.

So, we look at the bigger picture. For your foot to hurt requires nerves in the legs, the spinal cord and a brain to get the message. If you’ve done a lot of treatment to the painful foot without benefit, it’s time to consider the nerves or the brain. When we try to block pain at the nerve, we might try a TENS unit to block transmission of the pain signal. This is an electrical device that uses pads on the skin to block pain with a low voltage electrical field. This actually works, and unlike pain pills, if it works it will keep on working. You don’t need a bigger machine or more electricity in the future. Doing a nerve block with an anesthetic or steroid is also an example of blocking the transmission of pain at the nerve.

Finally, we look at the brain. We have all said at some point, “I’m feeling no pain.” What we meant was our brain wasn’t working well enough to feel pain (usually the result of youthful overestimation of alcohol tolerance). Feeling no pain because you are unconscious also works in anesthesia. This is an imperfect solution as it is obviously hard to work while unconscious. That has prompted the search for medications that will selectively alter pain reception without sedation.

A surprising number of different classes of medications seem to do this for many patients. One of the first medications used “off label” for pain was amitriptaline, which is a 35-year-old tricyclic antidepressant. Many of the newer antidepressants called SSRIs (Prozac, Cymbalta and Celexa) have also been used with some success for pain management. The anti-seizure medications used for epilepsy treatment are also remarkably helpful for many patients in pain. Specific examples of these medications are Neurontin and Tegretal.

Chronic pain is a different beast than acute (new) pain. Some of the best approaches involve treating the transmission of pain at the nerve or the perception of pain at the brain. If you have a chronic pain condition, there are new approaches that may change your life.

Dr. B

Dr. Baxter Talks Flu Shots in Dallas

Our own Dr. Shiu-yeh Baxter of our Carrolton office was featured on KSKY-AM 660 in Dallas yesterday, and she even gave host Jon-David Wells his flu shot for the season. Check out a video of the show here - Part 1 (drag the dial to fast forward to 1:40:16) and Part 2.

Influenza and the Dog Days of Summer: Why You Need to Get Vaccinated

The kids are just starting school, and summer is winding down, although in many places around the country we’re still seeing heat waves. Way too early to think about flu? Not in the medical world, and here’s why.

Early last spring, scientists began planning for the 2010-11 influenza vaccine. They were looking at specific types of influenza that were circulating in the southern hemisphere. The flu seasons are offset by a half year in the northern and southern hemispheres. So often, some variation of the dominant influenza strains in the south will wreak havoc on the north the following winter.

Let me mention what the stakes are in this virus pick. In a normal year, 36,000 people will die in this country of influenza. More than 200,000 will be hospitalized for same. There are hundreds of variations of the two basic flu viruses (A and B). “A”s tend to be the most troubling, as they genetically change more often and more dramatically. If the wrong viruses are picked, things get dicey rather fast.

Having picked the three viruses, the vaccine manufacturing machine then kicks into high gear. With the combined efforts of 2 large vaccine producers and a couple of smaller companies, they design and produce roughly 500 million doses. Just think about designing and manufacturing a custom product with a short shelf life and distributing it worldwide in 5 months. Kind of makes you think differently about flu shots. They represent an immense amount of work and worldwide cooperation.

So what happens when you get a dose of the current flu vaccine? Your immune system starts cranking out antibodies against the specific influenza types contained in this year’s vaccine. It takes your body about 2 weeks to have sufficient levels of immunity to fight off an influenza exposure. Having developed this immunity, you might wonder how long it lasts. No worries. It will take you through this season and into the next year’s. The Center for Disease Control and Prevention says to get your immunization as soon as it’s available. (U.S. HealthWorks currently has the flu vaccine available. Check out where you can find a medical center near you).

All influenza viruses are made of a few genetic building blocks. That means a lot of different viruses have some common genes, so you do end up getting some protection against viruses other than the 3 covered in the vaccine. The more years you get vaccinated, the broader your immunity will be.

Many people wonder if immunity is something you can use up. Except in overwhelming infection, immunity is like exercise – the more you do, the better you are.

The influenza vaccine is one of the greatest success stories of modern medicine. It’s an example of true worldwide cooperation to eradicate this terrible disease. In the recent past, influenza killed millions. Today, this terrible scourge can be avoided with a simple shot or snort.

Dr. B

“Fooling” the Drug Test System

The following question was posted on the website Marijuana.com (as the National Medical Review Officer for U.S. HealthWorks, I could hardly resist posting a reply):

Will I be observed at Healthworks Medical Group?

I have a drug test that is supposed to be at “US Healthworks Medical Group” through my school in Los Angeles, CA.

I am wondering if I will be in the room alone or is it possible I can be observed?

I assume that only probation type tests would have someone standing behind the individual doing the test, but I just wanted to confirm that as I would rather sneak in a sample than take my chances with a detox drink.

The test is due by next Friday. I have smoked high quality chronic since 2004 for about everyday and I have stopped since last Thursday.

I am 5’8 and 150, probably average metabolism and dont work out too much.

Anyways, confirmation of the legality/possibility of being observed would really relieve some of my stress. Its bad enough not smoking!

Thanks for your help!

While in general, I applaud preparation for any test, this is not the type of preparation that assures a positive outcome. This is one test you can’t study for.

1) Let’s start with the “detox drink.” If there is still someone on the planet that believes this clean-out business is real, I’m surprised. THC is the active ingredient in marijuana, and it is a fat soluble chemical. So a clean-out drink would have to dissolve all the fats in the body to actually have a chance of getting rid of the marijuana. Unfortunately you need some of that fat – it insulates your nerves; short circuits are called seizures. It also pads your feet; try walking on unpadded foot bones. Dissolving all the fat would be invariably fatal. From a purely economic standpoint, if this were even possible, the market would be in the weight-loss industry, not some tiny Internet company trying to beat drug screens.

2) What’s to stop someone from bringing in someone else’s clean urine for the test? Actually plenty. Urine is stored in the middle of the body. It comes out at body temperature, and we immediately check that. If you can prove you’re dead, and your body is room temperature, we might consider accepting a room temperature specimen. Otherwise, no way. So, like Goldilocks, the urine’s temperature has to be “just right.”

3) If you somehow manage to smuggle in someone else’s urine and it is positive, you, as the official “donor,” are stuck with the results. This is not without some humor.

4) Lastly, there is the issue of the observed collection. Observation is not usually needed to prevent fraud; we’re pretty good at catching donors trying to pass off somebody else’s specimen.

I close with a nod toward the eternal struggle between opposing forces. As long as there are drug screens, there will be people trying to beat them. Many of the people trying to beat them are on drugs, which probably lessens their success rate. Simultaneously, the labs are working on technologies that prevent this undermining of the system. Oral fluid testing is becoming more popular as every test is observed, and saliva is a good fluid to perform drug testing on.

The only truly effective way to pass a drug test is to stop using drugs and have enough time pass for them to be out of your system. Every unemployed person should seriously consider this as part of their plan to return to the world of the employed.

Good luck,

Dr. B

H1N1 Pandemic is Over

This week, the World Heath Organization (WHO) declared the H1N1 pandemic over.

Wasn’t it just a year ago that people were fighting for H1N1 shots? We didn’t know too much about this influenza virus at the time, except that it killed young people.

I was giving talks about H1N1 telling people that “Swine Flu” parties were a bad idea. A Swine Flu party is when someone gets the flu, he/she invites all of their friends over, everybody shares cocktail glasses and big sloppy kisses, and they all do their best to catch the flu. The point is to get the virus early before it mutates into something worse – which, luckily, H1N1 never did.

Novel strains of influenza have, in the past, been devastating. Even in a normal year, influenza kills 36,000 people in this country, and over a half million in the world. Pandemic strains of influenza have killed tens of millions in the past, a truly terrifying prospect.

We were all introduced to the concept of “pandemic influenza” last winter. Most people equated pandemic with severity, but pandemic only really refers to prevalence. If something is pandemic, it is widespread, not necessarily deadly. The H1N1 virus was pandemic, but fear of the virus was even more pandemic.

Companies had influenza plans – they gave careful thought to how they would operate with 40-60% less staff. How do you run a hospital on half staff, or a police department, or a nuclear generator?

People were hoarding antiviral medications. They did their best to talk their doctor into prescribing them several hundred dollars worth of Tamiflu, “just in case.”

The WHO and various counties’ heath department were magnificent. Through a worldwide effort, they identified the virus, and designed and produced millions of doses of vaccine, all in a few short months.

The H1N1 pandemic was a near miss. We heard the bullet. The influenza virus still contains the potential to change into something nasty, and it is highly contagious. This time we were lucky and had the chance to run a worldwide pandemic emergency drill, making us that much more prepared next time. And if history is any indication, there will most likely be a “next time.”

– Dr. Don Bucklin, National MRO – a.k.a. “Dr. B”

Whooping Cough Outbreak May Be Worst Such Epidemic in 50 Years

An epidemic of pertussis, or “whooping cough,” has descended on California. As of last week, seven deaths have been blamed on the disease and 2,174 cases have been reported.

Graphic courtesy of the Los Angeles Times

On Monday, the California Department of Public Health said that compared to last year at this time, there are six times the number of reported cases, and we could be on the edge of the worst epidemic in 50 years.

What’s more, there’s legitimate concern that this will soon spread to other states around the country.

For many years, the last pertussis vaccine was given when children started school (approximately age 6). In more recent years, the Center for Disease Control and Prevention has recommended a booster vaccine (called Tdap) to prevent the illness for all adolescents and adults.

So what are the symptoms of whooping cough?

Stage 1

The first stage, also known as the catarrhal stage, lasts 1-2 weeks. It resembles a simple upper respiratory infection. Cough, runny nose, sneezing, body aches, and low grade fever are the most common. Many believe they simply have a cold.

Stage 2

After 2 weeks, the cough becomes more severe. This is the beginning of stage 2; it can last as long as 6-10 weeks. Coughs will come in paroxysms, or bursts of rapid, harsh coughs, as the infected person is trying to expel thick mucus. The coughing will increase in severity over two weeks and then very slowly diminish. At the end of the cough, as the person inhales, you will hear the characteristic whooping sound. The cough can be so severe that one can lose their “breath” and even turn a little blue (cyanosis), from a lack of oxygen. Frequently, the cough is so harsh that the person will vomit at the end of the coughing spell. These coughing attacks occur more frequently at night; some will have as many as 24 attacks of coughing in 24 hours.

Stage 3

When the coughing begins to diminish in severity and frequency, it is considered the third stage. But remember, this stage can last many weeks.

How is pertussis transmitted?

Whooping cough is highly contagious and is spread among people by direct contact with fluids from the nose or mouth of infected people. People contaminate their hands with respiratory secretions from an infected person and then touch their own mouth or nose. In addition, small bacteria-containing droplets of mucous from the nose or lungs enter the air during coughing or sneezing. People can become infected by breathing in these drops. Adults can get the disease, and generally, they get a milder case than children. 

How can you tell you have pertussis?

Your doctor can make the diagnosis. Your history and physical examination will provide information that will lead your physician to make the diagnosis. A special test for the bacterium, Bordatella Pertussis, can be sent to your local lab to get confirmation.

How do you treat pertussis?

Since whooping cough is caused by a bacterium, it is treated with antibiotics. There is no clear evidence that treating with antibiotics after the first couple weeks will be of any benefit to the patient. There is no proven treatment for the severe coughs, though many will try various cough preparations.

So, if you are experiencing these symptoms and you have not been vaccinated, see your physician.

What is best way to avoid getting pertussis?

• Get vaccinated! Ask your doctor about the Tdap vaccine for adults and children.
• Wash your hands frequently.
• Avoid contact with people who are coughing.
• Disinfect common areas such as work stations and door knobs.

The physicians at U.S. HealthWorks Medical Group are available to help with vaccination, evaluation and treatment.

 – Dr. Alesia Wagner, Regional Medical Director, U.S. HealthWorks Medical Group of California

Sunshine – Friend or Foe?

Sunshine is necessary for human survival and the survival of every other plant and animal on the planet. But are we supposed to spend time in the sun or just enjoy the secondary benefit – that our planet isn’t a frozen ball of rock in deep space? The pendulum of medical opinion on sun exposure seems to swing regularly. We have all met someone with a deep tan who looks like a human Shar Pei at 45.

The case against spending time dozing in the sun, like a lizard, is strong. Sunlight has a lot of ultraviolet radiation. This radiation penetrates the skin and damages the DNA. Damaging DNA is a bad thing to do because sometimes the cells will die, and occasionally they will turn cancerous. Skin cancer is clearly associated with sun exposure. Unfortunately, the time your skin is most susceptible to sun damage is before you are old enough to read the sunscreen bottle. If that isn’t bad enough, ultraviolet radiation also breaks down the elastic elements in the skin. Destroy enough elastin, and you resemble that Shar Pei.

For the last 20+ years, the entire medical community has been yelling, “Stay out of the sun!” Then a funny thing happened – we started looking at vitamin D and cancer.

A bit of background. Vitamin D is made in the human body by sun exposure on your skin. The more intense the sun exposure, the greater the level of vitamin D produced. Doctors have known since the Mayflower that low vitamin D levels cause rickets. In modern times, most of us have seen skin cancer but never a single case of rickets, thus the advice, “Avoid the sun.”

About 10 years ago, scientists were studying sun exposure and deaths due to skin cancer. This was a pretty detailed and serious study. They found the expected modest increase in the number of skin cancer cases but a substantial decrease in deaths from all causes. Some head scratching ensued. The scientists then decided to measure vitamin D levels by areas of the country and compare them to various causes of death. They found people in sunny places like California and Arizona had less cancer, heart disease, multiple sclerosis, rheumatoid arthritis, and even Alzheimer’s disease. Places like Minnesota and North Dakota had less skin cancer but more of everything else.

Vitamin D acts as a hormone in the body and has its fingers in numerous biologic reactions. The current thinking is vitamin D protects against a number of different diseases. Unfortunately, vitamin D supplementation is a recent development. It hasn’t been around long enough to actually prove protection against all these various diseases (from cancer to Alzheimer’s).

Today I would tell you a modest dose of sunshine on a daily basis is a good thing. You should live longer for it. Move to Arizona or Florida; become a nudist. If that doesn’t fit in your life plan, you might just want to stick with vitamin D supplements.

- Dr. Don Bucklin, National MRO – a.k.a. “Dr. B”

Symptoms of heat illnesses

As the mercury soared this week in many areas around the country, our Dr. B was on ABC 15 Phoenix’s Sonoran Living where he discussed the symptoms of heat illness and what measures you need to take if you start experiencing them.  You can watch it here.

Questions About Extreme Heat Answered

1.    What happens to the body as a result of exposure to extreme heat?
People suffer heat-related illnesses when the body’s temperature control system is overloaded.  The body normally cools itself by sweating.  But, under some conditions, sweating is just not enough.  Very high body temperatures may damage the brain or other vital organs.  Several factors affect the body’s ability to cool itself during extremely hot weather.  When the humidity is high, sweat will not evaporate as quickly, preventing the body from releasing the heat quickly.  Other conditions that can limit your ability to regulate your body temperature include old age, youth (ages 0-4) obesity, fever, dehydration, heart disease, mental illness, poor circulation, sunburn, prescription medications and alcohol use.

2.    Who is at the greatest risk for heat-related illnesses?
Those at greatest risk include infants and children up to age 4, people 65 years and over, overweight people or people on chronic medications or with chronic diseases.

3.    What is Heat Stroke?
Heat stroke is the most serious heat-related illness.  Body temperatures can rise quickly, sometimes in 10-15 minutes, as high as 106 degrees.  Death or permanent disability can occur if not treated immediately.

4.    Warning signs of a Heat Stroke
Warning signs may vary, but may include the following:

• An extremely high body temperature (above 103  degrees F)
• Red, hot and dry skin (no sweating)
• Rapid, strong pulse
• Throbbing headache
• Dizziness
• Nausea
• Confusion
• Unconsciousness

5.    What should I do if I see someone with any of the warning signs of Heat stroke?
If you see any of these signs, you may be dealing with a life-threatening emergency.  Have someone call for immediate medical assistance,while you begin cooling the victim.

• Get the victim to a shady area
• Cool the victim rapidly,using whatever methods you can.  For example, immerse the victim in a tub of cool water; place the person in a cool shower; spray him/her with cool water from a garden hose; sponge the person with cool water; or if the humidity is low, wrap the victim in a cool, wet sheet and fan him/her vigorously.
• Monitor body temperature and continue cooling efforts until the body temperature drops to 101-102 degrees
• If emergency personnel are delayed, call an Emergency room for further instructions.
• Do NOT give the victim alcohol to drink
• Get medical assistance as soon as possible.

6.    What is Heat Exhaustion?
Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fluids.  Those most prone to heat exhaustion are elderly people, those with high blood pressure and those working or exercising in a hot environment.

7.    Warning signs of Heat Exhaustion
The warning signs of heat exhaustion include the following:

• Heavy sweating
• Paleness
• Muscle cramps
• Tiredness
• Weakness
• Dizziness
• Headache
• Nausea or vomiting
• Fainting

The skin may be cool and moist.  The pulse rate will be fast and weak, and breathing will  fast and shallow.  If heat exhaustion is untreated, it may progress to heat stroke.  Seek medical attention if symptoms persist more than one hour.

8.    What steps can be taken to cool the body during heat exhaustion?

• Drink cool,nonalcoholic beverages
• Rest
• Take a cool shower, bath or sponge bath
• Seek an air-conditioned environment
• Wear lightweight clothing

9.    What are heat cramps and who is affected?
Heat cramps are muscle pains or spasms – usually in the abdomen, arms, or legs – that may occur in association with strenuous activity.  People who sweat a lot during strenuous activity are prone to heat cramps.  This sweating depletes the body’s salt and moisture.  The low salt level in the muscle causes painful cramps.  Heat cramps may also be a symptom of heat exhaustion.  If you have heart problems or are on a low sodium diet, seek medical attention for heat cramps.

10.    What should I do if I have heat cramps?

• STOP all activity and sit quietly in a cool place
• Drink a clear juice or sports beverage
• Do not return to strenuous activity for a few hours after the cramps subside because further exertion may lead to heat exhaustion or heat stroke
• Seek medical attention for heat cramps if they do not subside in 1 hour

11.    Can medications increase the risk of heat-related illness?
The risk for heat-related illness and death may increase among people using the following medications:

• Psychotropics, which affect psychic function, behavior or experience (such as haloperidol or chlorpromazine)
• Medications for Parkinson’s Disease, because the inhibit perspiration
• Tranquilizers, such as phenothiazines, butyrophenones, and thiozanthenes
• Diuretic medications or “water pills” because they affect the body’s fluid balance

12.    How effective are electric fans in preventing heat-related illness?
While electic fans may provide comfort, but they will NOT prevent heat-related illness.  Taking a cool shower or bath or moving to an air-conditioned place is a much better way to cool off.

13.    How can people protect their health when temperatures are extremely high?
Remember to KEEP COOL and Use common sense.  Drink plenty of fluid, replace salts and minerals (with sports drinks), wear appropriate clothing and sunscreen, pace yourself, stay cool indoors, schedule outdoor activities carefully, use a buddy system.

14.    How much should I drink during hot weather?
During hot weather, you need to drink more liquid than your thirst indicates.  Increase your fluid intake, regardless of your activity level.  During heavy exercise in a hot environment, drink 2-4 glasses (16-32 ounces) of cool fluids each hour.  AVOID alcohol drink, because they will cause you to lose more fluid.

15.    What about salt tablets?
DO NOT take salt tablets unless directed to do so by your doctor.  The easiest and safest way to replace the loss of salts and minerals is through your diet.  Drink fruit juice or a sports beverage when you exercise or work in the heat.

Hit Me with Your Best (Tdap) Shot

We’re all aware of the importance of tetanus shots, and now there’s a vaccine to prevent tetanus while also fighting other serious ailments at the same time.

Multiple health organizations are now recommending that adults have a one-time dose of something called Tdap. This is a combination vaccine that contains tetanus, diphtheria and pertussis vaccines. The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) all recommend this vaccine.

As usual, something prompts me to think about certain topics. Why this one? Ok, I admit it…I was not paying attention and I grabbed some papers with a partially closed staple in them. As it ripped through the tip of my finger, I knew I would need to recall when my last tetanus vaccine was. And, as a healthcare worker, I did know that I had not yet had a Tdap. So, my weekend included a sore arm….

There is no vaccine for just pertussis alone, and this ailment, like tetanus, is one I’m sure we’d all like to avoid. Pertussis is known as the “whooping cough,” and this bacterial infection is passed from person to person. It’s generally not serious in adolescents and adults, but can be very dangerous to young children.

The symptoms of whooping cough come in 3 stages:

• The first begins much like your common cold – runny nose, sneezing and coughing. The cough will last 1-2 weeks, getting worse instead of better.
• In the second stage, you will have uncontrollable coughing spells, frequently vomiting after coughing, and you will emit a “whopping” noise when you breathe in. Patients can even stop breathing or turn blue in the face from lack of air during these cough episodes. This can last 2-6 weeks.
• During the last stage, the symptoms actually start to lessen. The coughing spells decrease in frequency and severity.

The course of this illness can be 6-10 weeks. Adults, teens and vaccinated children will generally have milder symptoms, like those of bronchitis.

Pertussis is spread by the “spray” of our secretions in the air, when we sneeze, cough or talk. We can also get it from sharing our cups and silverware. Initial symptoms will appear in 7-10 days after the exposure, and we will be contagious from 2 weeks prior to the start of the cough until 3 weeks after the cough starts, or until we have completed a 5-day course of appropriate antibiotic therapy.

Here is an information sheet on Tdap from the CDC. It discusses who should and shouldn’t have the vaccine, as well as the side effects.

If you are due for a tetanus vaccine and have not had your Tdap, consider receiving one at your nearest U.S. HealthWorks center. Then the only whooping you will hear is out of glee because you know you’ll be pertussis and tetanus-free.

- Alesia J. Wagner, Regional Medical Director, Southern California