Pain Management: Therapy Targeted to Treat Chronic Pain
SpU: The media has reported possible problems with the use of CelebrexÂ® and BextraÂ®. What advice do you give to patients currently taking these medications for chronic pain?
Dr. Bennett: CelebrexÂ®, BextraÂ® and VIOXXÂ® 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.