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SpU: The media has reported possible problems with the use of Celebrex®
and Bextra®. What advice do you give to patients currently taking these medications
for chronic pain?
Dr. Bennett: Celebrex®, Bextra® and VIOXX® are all in a class called
COX-II inhibitors, which is a sub-class of NSAIDs. There apparently is a problem
with prolonged use (greater than three weeks of continuous use) of these medications
and the incidence of stroke and heart attack. The reasons behind this are
not clear. Harm has not been shown with short-term or intermittent use of
these medications. At the present time, I would suggest that if you are taking
any one of these medications on a regular basis, you should make an appointment
to discuss this with your physician.
SpU: What is involved in and what are the benefits to a proper patient
'work-up' and how does it add to the value of the diagnosis? How does the patient
benefit?
Dr. Bennett: A definitive diagnosis is an absolute requirement for
any targeted therapy. Although we strive in medicine to arrive at a definitive
diagnosis with every patient, sometimes that is not possible. However, all
attempts should be made at arriving at one! It follows from this that a thorough
work-up should begin with a detailed history and physical examination. This
may then be followed by selected imaging (X-rays, MRI's, etc.) or targeted
injections (numbing certain areas to see how your exam changes when those
areas are "no longer felt"). During this process your physician may bring
you back to the office for a follow-up and to discuss how and where things
are going. The summation of this process is a definitive diagnosis
(or simply put, "what the problem is").
The patient benefits tremendously in this process. When working up patients
in my practice, I often lump problems into two boxes: carpentry and
electrical. If you have a carpentry problem (like a disc has broken
down and now your spine is moving abnormally back and forth), giving pain
medications and doing epidural steroid injections would decrease your pain
but would not treat the more ominous problem of an unstable spine. On the
other hand, if you have stinging and burning pain down one leg (an "electrical
problem") but there is no disc compression or other structural issues, then
performing a carpentry procedure would not be in your best interest -- better
off using a nerve stimulator.
SpU: Some patients with chronic back/neck pain/extremity pain may be
discouraged that there is no treatment besides drug therapy to help relieve
their symptoms. What are your thoughts about this?
Dr. Bennett: We divide pain into two major types: nociceptive
and neuropathic.
• Nociceptive pain is caused by an injury or disease outside
the nervous system. It is often an on-going dull ache or pressure. Examples
include pain from cancer or arthritis.
• Neuropathic pain is caused by damage to nerve tissue. It
is often felt as a burning or stabbing pain. One example of a neuropathic
pain is a "pinched nerve". Medication therapy can be very effective, depending
on the type of pain, the diagnosis, and what the patient is able to tolerate
(remember, there are no perfect medications!). Today, there are numerous
options for treating chronic pain. Just because one does not provide relief,
does not mean there is no hope. It may just be a matter of finding the right
medication or other treatment for a patient's particular condition.
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