Understanding Chronic Pain

PAIN, NARCOLEPSY, AND THE DATE RAPE DRUG

Sodium oxybate, commonly known as the date rape drug, is a soluble, colorless, odorless, and tasteless compound that, if one's intentions are devious, is the absolutely perfect knockout drug to add to your date's cocktail or glass of white wine. It has been used as a hypnotic and obstetric analgesic in Europe for many years. It rapidly induces deep sleep (that known as delta wave sleep), but the duration of action is short, but a few hours.

Armed with the knowledge that sodium oxybate rapidly induces deep sleep, the pharmaceutical industry has tested it for the treatment of narcolepsy, which is a disease characterized by want of deep sleep.  Narcoleptic sleep is dominated by rapid eye movement (REM) activity, a stage of light sleep in which dreams (in the narcoleptic, particularly vivid dreams) occur. The drug, although cumbersome to take because of its short duration of action, has proved to be effective in restoring sleep to the narcoleptic, in diminishing vivid dreams, and also in diminishing the curious phenomenon of cataplexy, which is a disorder characterized by sudden loss of muscular tone causing the victim to inexplicably collapse. It is quite common in the narcoleptic and has until recently been very treatment-resistant. Oxybate is now the only Federal Drug Administration-approved drug for the treatment of cataplexy.

So far, so good, but I have written on blogs and in my forthcoming book, Curing Chronic Pain, about the relationship of narcolepsy to chronic pain. The connection is real, and narcolepsy, or at least fragments of it, are very common in people who experience the great  varieties of chronic pain.

It should come perhaps as no surprise that sodium oxybate is now undergoing clinical trials for the treatment of fibromyalgia. The results thus far have been quite promising. Does this mean that oxybate relieves pain because it is in its own right an analgesic? Or does it mean that it relieves pain by restoring needful deep sleep (lacking in the painful, whether narcoleptic or not)? Or could it possibly mean that there is some link between narcolepsy and chronic pain (as I believe there is)? Is it possible that oxybate relieves pain because it relieves narcolepsy, and there is a common neurochemical pathway between the two diseases? More later.

Last Updated: 3 days ago

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Methadone: Treating Bipolar disease and Migraine

Most of the people who are referred to me for the treatment of chronic pain also suffer some form of phychiatric illness. In Understanding Chronic Pain, I explore this relationship because it helps us understand just what chronic pain really is. I also develop the thesis that aggressive treatment of the psychiatric disorder can diminish and sometimes even cure the pain. Thus, my enthusiam for the treatment of pain with psychiatric drugs. Only recently have I taken the opportunity to look at the issue the other way around. That is, what happens to psychiatric disease when I treat the pain? My hesitancy in pursing this has been my reluctance to use opiate therapy if it could be avoided. However, within the past year I have seen incredible, almost unbelievable results with opiate therapy in the treatment of bipolar (manic depressive) disorder.

Belinda was 42 years old and suffered that form of migraine known as cluster headaches. The pain would strike her about her eye and last for an hour or so. It would then abate spontaneously, only to recur several times during the day, especially at night. The name cluster headache derives from the fact that in most people the headaches cluster in time, appearing repetitively for a month or so.  Then they go away only to return months later. Belinda wasn't so lucky. She had that form of the affliction known as chronic cluster headaches, and for two years she had not known a day without several hours of pain. She had not responded to the usual drugs to arrest migraines, nor to any of the several drugs used to prevent migraine or cluster. She denied to me that she felt depressed, but acknowledged that " this thing is getting me down." Troubled not only by her headaches , she also had a teenaged son with unstable bipolar disease, and that was as much a stressor as her headaches.

I began my treatment with the drugs Nortriptyline and Clonazepam, neither of which she had taken before. They are, in my opinion, preeminent in the treatment of most forms of chronic pain, and she did respond, at least partially.She occasionally went a few days without a headache, and she and I considered that quite a positive.

Several weeks into her treatment, she told me something that alarmed me. She said for the first time that she felt depressed and sad, and that her emotions were on a roller coaster. I prescribed the antidepressant Lexapro. I took a call from her husband a few days later, telling me that she had become suicidal and was admitted to a psychiatric hospital. I saw her a few days following her discharge and she told me she had been diagnosed with bipolar disease and treated with the mood stabilizers Lamictal and Keppra. Nonetheless, her moods were still shifting and her headaches had returned full force. At least she wasn't suicidal, she told me. I elected to prescribe the opiate Methadone, beginning at the rather low dose of 10 mg every 8 hours.

It's still hard for me to believe what I saw when she returned two weeks later. She was smiling. She told me her moods were no longer shifting as they had before and that her headaches were much relieved. She still had one when she woke up each morning, but it was quite tolerable.

I was thrilled. I wrote her another prescription for the Methadone, telling her she could go up to 2 pills every 8 hours if she felt it was necessary. She returned at the appointed time to tell me that she had not increased her dose and she had attended her son's graduation from high school. Sitting on the third row in the front, she realized that she had made a mistake, because the school band, but a few feet away, was about to perform. She expected the worst, knowing that bright lights and loud sounds would precipitate a headache. Astonishingly, it didn't bother her at all.

We've been into it for several months now and Belinda continues to do well, suffering only a morning headache which soon abates. She remains on the Nortriptyline,Clonazepam, Lamictal and Keppra, doing vastly better than when we started.

I'll explore the curious opiate Methadone as we go along. I will advise you that there are sound physiologic and pharmacologic reasons for her to have responded the way she did. Methadone, I believe, will turn out to be one of the best treatments there is for the painful bipolar. 

Last Updated: 63 days ago

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Anger, Narcolepsy, Bipolar Disease, Attention Deficit Disorder, and Pain

I have long known that many victims of chronic pain feel very angry, and I have felt the need many times to address the issue of anger with patients in whom I felt this was excessive and maybe even self-destructive. My conversation wiould go along this line:

"I'm sorry you feel so angry. Let me tell you that I think it's probably   justified, considering your circumstances, but I want to remind you that anger is not a healthy emotion, and I wish that somehow you could discard it. If you could, I think it would be quite helpful. In my experience, angry patients do poorly."

Angry patients indeed do poorly, but I recognize now, and this has been a revelatory experience to me, that they do poorly not because they are angry, but because I have failed to recognize -- and treat -- their bipolar disorder. With this in mind, I want to explore anger as a symptom of bipolar disease and to illustrate that both are frequently comorbid (two diseases running together) with chronic pain.

Carolyn and I began our relationship with a very difficult interview. She was frequently tearful and expressive of her frustration and her anger over the way she had been treated by her physicians. She had hurt her back at work a year before. Her workup revealed little, and surgery was not advised. She consulted a rheumatologist, and a diagnosis of fibromyalgia was made. She adamantly denied depression and told me quite forcefully that she was not going to take antidepressant pills. Other doctors had tried them, and they didn't work.  She acknowledged that her sleep was erratic, sometimes sleeping too much and sometimes too little. She admitted to a lack of mental focus and distractibility. She also told me that she felt very irritable, and, indeed, she demonstrated it to me many times -- often snapping at me in response to my questions.

I prescribed imipramine and clonazepam. She demanded to know the exact purpose of each of the drugs. I did the best I could to explain, telling her that imipramine was an antidepressant but little used for that purpose now. Its primary usefulness was for the treatment of pain. She recoiled at my explanations and told me she didn't believe in medicines, and she wasn't going to take them. She was angrier when she left than when she came, and that is saying a lot.

To my surprise she returned 10 days later, smiling and coyishly charming. She had decided, she told me, to give the medicine a try. Within a few days she felt better. She admitted that she had been feeling depressed, and that was less of a problem now. Her pain was diminishing, and she would, she told me, be quite happy to continue the medicine. It was not to be. A couple of weeks later she told me that the drugs were disagreeable to her and that she had discarded them.

As time went by, Carolyn and I evolved into a repetitive pas de deux. I would prescribe a drug, and after a couple of weeks she would discard it, telling me that it changed her disposition. This went on through some 6 months -- and 6 different medicines. Her temper and explosiveness became more evident, and I realized that Carolyn could be a different person at different times -- occasionally charming, but more often curt, hostile, angry, and confrontational. I prescribed Lithium, and she told me for the first time that her mother was bipolar, and that Lithium had disagreed with her. She refused to take it.

On one of her visits, she initiated the conversation by saying, "I bought your book."

"Why thank you, Carolyn. What do you think of it?"

 "It is no good. I don't like it. It is too wordy."

"Well, Carolyn, I appreciate your candor. I can see how you might consider it too wordy."

I remember it all so well -- how she looked at with an air of smug defiance, as if she was glad she had hurt me.

Unable to control her pain or her very evident shifting in mood and behavior with psychopharmaceuticals, I prescribed the only thing I had left -- opiates. She found the hydrocodone quite disagreeable because it upset her stomach. She requested a different painkiller, and I gave her oxycodone.

"I think I can tell a little difference now. My pain is not nearly so bad."

"How about your mood? I have always sensed that you have had a problem with shifting moods. Has that changed any?"

She smiled and said, "Yes, I do have mood shifts, and I think they are a little bit better. I want to keep taking the oxycodone. It is helping me."

"Okay with me, Carolyn."

It was a month or so later when she returned to tell me, as she had so many times before, that her medicine was no longer working. We needed, she said, to make a change.

"Well, the oxycodone worked for a while. I am going to give you some OxyContin, which is actually the same drug, but I can give it in a bigger dose. We will try that for a month, and then I will see you again. By the way, Carolyn, you and I have talked several times about whether you have bipolar disease. I don't know if you do, but it is a possibility, and I would like to explore some more medicine for that. You recall that I gave you the Lithium before, but you refused to take it. What do you think about trying a different kind of mood stabilizer?

"No! I am not a manic-depressive, and I want you to quit talking about it. I just want you to give me some more pain medicine!"

"As you say, Carolyn."

She returned at the scheduled time to report a remarkable development. She said  that with the OxyContin she was back to her old self. Her mood swings were not nearly so bad, and she was getting splendid pain control, but that this had lasted only 2 weeks. She experimented, as she was wont to do, and doubled the dose of OxyContin without any additional benefit at all.

Never give up. Keep trying. Somehow there has got to be an answer.

"Carolyn, I am sorry you are not doing any better, but this kind of thing seems to come up over and over with you, doesn't it? You take medicine, and it works for a while, but then it quits working. All of them have quit working. Isn't that correct?"

"Yes, that is exactly what happens, and I wish I knew why."

"Let's talk about your mood swings."

"I'll admit that I do have mood swings, but I want you to know I am not bipolar! I don't have the big mood swings that real bipolars do. I have read about that. I know what it is like. That is not me."

"How are you sleeping now, Carolyn?

"Pretty good. I slept real good the first 2 weeks on OxyContin."

"Do you ever have dreams, really vivid dreams?

"Why to you ask that?"

"It is because I am trying to help you."

 "Well, I do. I have real vivid dreams. I have had them for a long time., I don't see what that has to do with my pain, though."

"Have you ever had a vivid dream from which you awoke feeling paralyzed and unable to move?

"Well, yes, but it always goes away. I have never let it bother me."

"Do you feel sleepy through the day or do you have sleep attacks where you just doze off when you shouldn't?" 

"No, I have nothing like that."

"Carolyn, there is a disorder called cataplexy. It is a sudden loss of muscle strength that people can experience just out of the blue, or sometimes when they are startled or emotional. It can cause them  to suddenly drop things they are holding, and sometimes their legs go out from under them, and they fall. Have you ever had anything like that?"

"Oh my God. I sure do. It happens to me occasionally. It just comes on me suddenly, and I will find myself on the floor. Then I get up and go about my business. Dr. Cochran, you are beginning to kind of interest me."

 "You are beginning to interest me, too. I am prescribing Methadone. It is a painkiller, but it is different from the ones you have taken before. I want you to take it 3 times daily and check back with me in short order -- something like 2 weeks."

"Methadone -- that is what heroin addicts use, isn't it?"

"Yes, that is what heroin addicts use, but I am giving it to you for pain."

"I am not going to take it!"

"Carolyn, you are going to take it, and it is going to cure you."

"You really think so?"

"Yes, I really think so."

Carolyn had the full expression of the bipolar spectrum. She was mood-labile and behavior-erratic. She was ridden with anger, and she suffered narcolepsy and probably attention deficit disorder also.

"I couldn't believe it. Within an hour of taking the Methadone, I felt the pain leaving my body. I had the sense that something was coming over me, and I felt an evenness like I had never known. None of the other drugs affected me this quickly. I really think we are on to something." 

"I am happy for you, Carolyn. My instincts tell me this is not going to be a flash in the pain. I think this effect is for realy, but I will have to follow you closely."

"I have to tell you something. Since I have been on the Methadone, my memory is actually improving. My mental focus is much better and I can concentrate. It is amazing what has happened to me."

"That's good, Carolyn. I forgot to ask you about that, but it is important information. That reminds me, how about your dreams and your falling spells? Have they changed any?"

"Yes, I am not dreaming as much, not nearly as much, and as far as those catty things you talked about, I haven't had any, but it is too early to know about that. They happen only a few times a year. So I can't speak to that. Dr. Cochran, you've got me  thinking -- a lot. Everything is better now, and I want to know why. You told me you thought I was bipolar, and maybe I am, but what's that got to do with my dreams, and my catty spells and my memory and mental focus?"

 "They are part of your disease, just as are your mood swings, and, if I may say so, also your anger."

"Okay, I don't want to accept it, but I will, and thank you for taking care of me. I want you to know something else. I am reading your book, and I really like it."

"Well, thank you, Carolyn, but just a few months ago you told me you didn't like my book. You said it was too wordy. I remember it well."

"This may be hard for you to understand, but back then I couldn't comprehend it. By the time I had finished a chapter, I had forgotten the first part. It was too wordy because I couldn't remember. I can remember now, and thanks for writing the book. It has helped me a lot."

"I do understand, Carolyn. Really I do."

Along with curing Carolyn's pain and mood swings, the Methadone seems to have cured her narcolepsy, her attention deficit disorder, and her anger. I would not, but 6 months ago, have imagined that possible. 

Last Updated: 84 days ago

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Trichotillomania, Pain, Bipolarity and the Curious Effects of Polypharmacy

A young mother came to me with 5 years of low back pain and depression. She had been under psychiatric care and had been given, first Wellbutrin, which made her depression worse, and then Cymbalta, which made her feel "weird." She was also on Elavil (amitriptyline) for treatment of her recurrent migraine.

On interview, she acknolwedged that she did have periodic feelings of being highly energized and sometimes panicky, wanting to get out of the house and run. During these intervals she would feel irritable and be subject to mind racing. She could occasionally diminish these symptoms by taking a Benadryl pill. She told me that during these anxious and irritable spells she would talk rapidly and often feel "mean."

I always look for clues to bipolar disease in those who suffer chronic pain, and this young lady was giving me several of them. The longstanding depression, the periodic mind racing, anxious high energy and mean interludes were certainly compatible with that disorder, as was her history of adverse reactions to conventional antidepressant therapy.

As the visitor will certainly note, I am very attracted to the association of narcolepsy with chronic pain and bipolarity, but this lady denied any real symptoms of that disease. I elected to treat her with clonazepam to help her ongoing disordered sleep, and also Methadone, hopefully for both analgesia and mood stabilization. On her return, she told me that within hours of starting Methadone at the low dose of 5 mg daily, she could feel her pain diminishing. More importantly, within a few days she realized that her mood was better. She was no longer having shifts and had gone several days without the intervals of irritability, anxiety, and meanness, and she had been having those with great frequency. She reported that she was, however, still troubled by periodic attacks of overwhelming fatigue. This was an issue that I had not explored initially, but which in my opinion is a common symptom of bipolar disease. I added the simulant Adderall (amphetamine).

On her return 2 weeks later, she told me excitedly that with the Adderall her fatigue had much diminished and that her mood was progressively better. Satisfied with her progress, I scheduled a return  appointment 2 months away.

She returned to report continued improvement, telling me that the "mean" spells had gone away and that "I'm in control. I don't say things now that I shouldn't." She also told me that her migraine, which had remained a bother in spite of several years of therapy with Elavil (amitriptyline), was also much better. She did comment, however, that her back pain continued to be a problem and that she was beginning to hurt all over her body, an unexpected development in one who was doing so well in other regards. I told her she could increase her Methadone up to a maximum of 30 mg every 8 hours.

On her next visit, she reported that the Methadone was quite ineffective, and that her pain was becoming progressively severe, this in spite of mood having been both lifted and stabilized, her sleep restored, her migraines diminished, and her fatigue almost gone.

This, I assure the reader, is a most atypical and unusual clinical scenario. I have written when the right drug(s) kicks in, everything gets better.

But sometimes it takes lots of drugs. I added oxycodone in the form of Percocet, which is a combination of Tylenol and oxycodone. It is an excellent opioid analgesic, and I had no problem at all adding it on top of Methadone. Much had been accomplished already, but there was no reason for not trying more pharmacy. 

She returned to report almost total relief of pain with Percocet. She told me she felt better than she had in 5 years, and mentioned in passing that her many-year compulsion or habit, as she called it, to pick at her scalp hair had totally gone away. She had, she said, so frequently picked at her scalp, scratching and collecting hairs, that it was excoriated to an extent that it was embarrassing for her to go to the hair stylist because her attention was always called to the curious excoriations on the scalp. The scientific name for compulsive hair pulling is trichotillomania, and with therapy (admittedly directed to other problems), that strange disorder was cured, as were her back pain, migraine, fatigue, and bipolar disease.

When the right drugs kick in, everything gets better. 

Last Updated: 85 days ago

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Obsessive Compulsive Disorder, Migraine, and Narcolepsy

I continue to be impressed with the remarkable capacity of pharmacy to relieve not only pain, but also many other bad things. This is the reason I so often employ, in my writing, the phrase "When the right drug kicks in, everything gets better."

 A fifty year old woman came to me because of increasing frequency of her migraines. She denied depression (a frequent cause of increasing frequency of migraine), but on her intake history she recorded that she was taking the SSRI drug, Luvox, (akin to Prozac and Zoloft). I inquired as to why that particular drug, and she told me it was for treatment of her obsessive compulsive disorder. 

Luvox is an antidepressant, but it has particular usefulness for the treatment of obsessive compulsive disorder (OCD).and is widely employed for that purpose.

In response to my inquiries, she told me that her OCD manifested in a not uncommon way. Whenever she walked on a patterned surface, such as a tile floor or a brick wallkway, she felt compelled to step on every other tile or brick, and if she failed to do so, she would experience fearful anxiety to the point of panic. When these were severe, she told me she would lose control of her muscles and actually fall. She also told me that the Luvox was helping but little.

I continued my interview and found none of the common antecedents that predict a life of painfulness. I did, as I am now increasingly inclined to do, inquire as to whether she had vivid dreams because I have learned that narcolepsy is a frequent companion to pain,and that vivid, sometimes terrifying dreams are one of the hallmarks of that disorder.

She told me that she did indeed suffer dreams, that they seemed real to her,  that she actually lived them. In response to my questions she told me that, yes, on occasion she did awaken suddenly from a dream feeling paralyzed and unable to move for a few moments. She acknowledged daytime sleepfulness and attacks of nodding off when she no business doing so.

She already fulfilled my criteria for the diagnosis of narcolepsy. The vivid dreams are a form of hallucination, and they are called hypnagogic hallucinations (hypnagogic refers to that twilight interval between wakefulness and sleep when the dreams most often occur). She also suffered sleep paralysis, which is the awakening from a dream unable to move. Daytime sleepfulness, as most everyone knows, is the cardinal feature of narcolepsy, but I had one more question, and that related to the phenomenon of cataplexy. It refers to the sudden loss of muscular tone causing the victim to suddenly collapse to the ground, or to unaccountably drop things they are holding. It is a very common in narcolepsy.

"Yes, " she replied, "that's just what I told you about when I misstep and become anxious. I fall down."

 Remarkable indeed -- and I should have picked up on it sooner. Drop attacks, are highly suggestive of narcolepsy, and my patient had the disease in spades, although she had never consulted a physician about it.

Here I was, with a patient with progressive, accelerating migraines, narcolepsy, and obsessive compulsive disorder. Could there be a connection?

I have learned, through years of experience, that when confronted with a patient with pain and a neuropsychiatric illness, be this depression, bipolar disease, or even narcolepsy, attention should first be directed to the neuropsychiatric illness, because by treatment of that disorder, the pain can often be cured.

I prescribed the time-honored and well-recognized treatment for narcolepsy, Ritalin. It is an unlikely drug for the treatment of migraine and certainly unlikely for the treatment of obsessive disorder, but my instincts told me to try it.

She returned at the appointed time to excitedly tell me that her migraines were much diminished and that her bad dreams had gone away. She then volunteered that her fear of misstepping on the wrong tile had gone away and that she no longer suffered anxiety when she misstepped. Nor did she experience drop attacks.

When the right drug kicks in, everything gets better. It is uncanny. There was absolutely no reason to expect such a dramatic improvement in her obsessive compulsive disorder as I treated her narcolepsy -- and with it, her migraine -- but that is exactly what happened.

The visitor may want to peruse the story from one of my previous blogs about the young woman with progressive migraine who also suffered narcolepsy with vivid dreams, sleep paralysis, and cataplexy. Her phobia of going to dentists, which she had not even told me about, went away simultaneously with all the rest when I treated her with Ritalin.

What does it all mean? What is the relationship of narcolepsy to migraine and to obsessive compulsive disorder and to phobia? It will turn out to be a fascinating study, I am sure, and very possibly pave the way to successful treatment, not only of migraine and narcolepsy, but also phobias and obsessive compulsive disorders, the latter two among the most pharmacy-resistant of all the psychiatric diseases.

I invite your comments on this interesting matter.

Last Updated: 86 days ago

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