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OMA Winter 2013

On My Mind The Bane of Central Pain By Steven LaTulippe, MD Tlisted as a state in crisis due to a high We must break the mindset of pain: therefore opioids and America is sufferingHE WORD IS OUT:from an opioid epidemic. Oregon is number of opioid-induced fatalities. While anxiety: therefore benzodiazepines. this is now common knowledge, what few people understand, perhaps including many physicians, is the iatrogenic impetus be considered as a neuroplastic delayed Patients with central pain typically behind this crisis. Pain is a primary reason hypersensitivity response to an emotionally suffer from anxiety and depression, for patients seeking medical attention. But traumatic event. Unfortunately, central persistent insomnia, tension and migraine not all pain responds to opioid therapy. pain responds poorly to opioid therapy. headaches, and a severely compromised In fact, high dose (especially short- global function. They are people in crisis. How many times have you seen a patient acting) opioids and benzodiazepines are By the nature of their illness, these are whose pain is no better after an increase catalysts for central pain induction. While difficult patients. But with appropriate in opioid dosage? The proper response alprazolam, for example, yields great results therapy, their quality of life can be greatly is not to further increase the opioid, for anxiolysis in the short-term, it will enhanced. Restoring function is a three- nor is it to add a benzodiazepine “to induce more emotional lability and pain in step process: first, remove inappropriate calm this patient down.” And if you add the long-term. medications; second, initiate a medical carisoprodol (Soma) to the regimen, you regimen that effectively treats central pain; have prescribed the most potent recipe for Manifestations of central pain include and third, incorporate healthy lifestyle iatrogenic addiction. I call it the “terrible fibromyalgia, irritable bowel syndrome, changes via counseling and cognitive triad” of poor pain management. A patient bladder pain syndrome (formerly called behavioral therapy. Step one is a serious shall never function normally while on interstitial cystitis) and complex regional challenge because benzodiazepine and this regimen. His life will only spiral out pain syndrome. When a patient reports, carisoprodol withdrawals are extremely of control, leading to loss of employment, “I hurt all over,” think fibromyalgia. If a unpleasant and thus require supportive destruction of marriage and family, severe patient is repeatedly getting “UTIs” but therapy for withdrawals. Opioid depression and anxiety, increased pain has normal urinalyses, that’s likely bladder withdrawal is readily and effectively treated perception, and often suicide. pain syndrome. These diagnoses can with buprenorphine. be challenging to make, but the proper The most important factor in assessing diagnosis is essential because these patients The battle against addiction must pain is to determine if the pain is central do not effectively respond to chronic be fought, and we in the medical or peripheral. While this is a complex opioid or benzodiazepine therapy. profession must not add to the problem topic that warrants a great deal more by inappropriately prescribing addictive study, we must learn to distinguish central This is a key point, as over sixty percent of substances. Now is the time to re- from peripheral pain—because it dictates my patients that I treat for addiction are evaluate our concept of what is effective proper treatment. Peripheral pain occurs products of this inappropriate prescribing therapy when treating human pain and after striking one’s thumb with a hammer. by physicians. We must break the mindset suffering.  Central pain can be thought of as more of pain: therefore opioids and anxiety: of a “learned” pain, often as a result of a therefore benzodiazepines. This is a losing Steven LaTulippe is a family physician in Dallas, conditioned heightened awareness of pain combination that does much harm and Oregon, who practices in pain management that is perceived outside of the central little or no good. When patients state that salatulippe@ymail.com.He can be reached atand addiction medicine. nervous system, but without a direct trigger their Valium “is the only thing that works,” for the pain. what they are really saying is that they are dependent on the benzodiazepine and In my experience, central pain usually must take it to avert withdrawal symptoms. derives from a past traumatic emotional Also noteworthy is that even the right and/or physical event that acts as a trigger medications will not be very effective for central pain—this is what I call “limbic until patients are taken off the wrong inflammation.” Centralization of pain medications. occurs when a trigger pain (emotional or physical) has not been effectively controlled for a prolonged period of time. It could Winter 2013 | 11


OMA Winter 2013
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