Inadequate Vitamin D Levels Linked To High Use Of Narcotic Medication By Patients In Chronic Pain

Mayo Clinic research shows a correlation between inadequate vitamin D levels and the amount of narcotic medication taken by patients who have chronic pain. This correlation is an important finding as researchers discover new ways to treat chronic pain.

According to the Centers for Disease Control and Prevention, chronic pain is the leading cause of disability in the United States. These patients often end up taking narcotic-type pain medication such as morphine, fentanyl or oxycodone.
This study found that patients who required narcotic pain medication, and who also had inadequate levels of vitamin D, were taking much higher doses of pain medication — nearly twice as much — as those who had adequate levels. Similarly, these patients self-reported worse physical functioning and worse overall health perception. In addition, a correlation was noted between increasing body mass index (a measure of obesity) and decreasing levels of vitamin D. Study results were published in a recent edition of Pain Medicine.
“This is an important finding as we continue to investigate the causes of chronic pain,” says Michael Turner, M.D., a physical medicine and rehabilitation physician at Mayo Clinic and lead author of the study. “Vitamin D is known to promote both bone and muscle strength. Conversely, deficiency is an under-recognized source of diffuse pain and impaired neuromuscular functioning. By recognizing it, physicians can significantly improve their patients’ pain, function and quality of life.”
Researchers retrospectively studied 267 chronic pain patients admitted to the Mayo Comprehensive Pain Rehabilitation Center in Rochester from February to December 2006. Vitamin D levels at the time of admission were compared to other parameters such as the amount and duration of narcotic pain medication usage; self-reported levels of pain, emotional distress, physical functioning and health perception; and demographic information such as gender, age, diagnosis and body mass index.
Further research should document the effects of correcting deficient levels among these patients, researchers recommend.
This study has important implications for both chronic pain patients and physicians. “Though preliminary, these results suggest that patients who suffer from chronic, diffuse pain and are on narcotics should consider getting their vitamin D levels checked. Inadequate levels may play a role in creating or sustaining their pain,” says Dr. Turner.
“Physicians who care for patients with chronic, diffuse pain that seems musculoskeletal — and involves many areas of tenderness to palpation — should strongly consider checking a vitamin D level,” he says. “For example, many patients who have been labeled with fibromyalgia are, in fact, suffering from symptomatic vitamin D inadequacy. Vigilance is especially required when risk factors are present such as obesity, darker pigmented skin or limited exposure to sunlight.”
Assessment and treatment are relatively simple and inexpensive. Levels can be assessed by a simple blood test (25-hydroxyvitamin D [25(OH)D]). Under the guidance of a physician, an appropriate repletion regimen can then be devised. Because it is a natural substance and not a drug, vitamin D is readily available and inexpensive.
In addition to the benefits of strong muscles and bones, emerging research demonstrates that vitamin D plays important roles in the immune system, helps fight inflammation and helps fights certain types of cancer.

Plagued by Chronic Pain? Study Says Treatment Team Can Help

Up to 15% of the U.S. population have chronic pain, and as many as 5% have pain so persistent that they need heavy-hitting painkillers, known as opioids, just to get through the day.

Now a new study suggests that primary care doctors can do a better job helping people in pain if they have a “pain team” approach that includes patient visits with a psychologist. Pain can stem from a bad back, arthritis, muscle troubles, or other reasons, but medical treatments may be of limited benefit and additional factors—such as depression—can make it hard to stick with recommended therapies.

“Pain is a complex phenomenon,” says Michael Von Korff, ScD, a senior investigator at the Group Health Center for Health Studies, in Seattle, and an expert on treating chronic pain. “That’s why it’s so very difficult to treat.”

In the study published Tuesday in the Journal of the American Medical Association, Steven K. Dobscha, MD, of Portland VA Medical Center, in Oregon, looked at 401 people with an average age of 61 or 62 who were in pain for at least three months. (They excluded those diagnosed with chronic fatigue syndrome or fibromyalgia.) Not only did the study subjects have chronic pain due to arthritis, a bad back, or neck or joint pain that had lasted sometimes for years, but they often also had other physical and mental health problems along with a disability, such as depression or post-traumatic stress disorder.

The researchers randomly assigned patients and their primary care doctors to either a collaborative-care group or a standard-care group. In the collaborative-care group, a full-time psychologist and a physician helped manage the patients’ care and the primary care doctors participated in two 90-minute pain workshops.

The psychologist talked to patients about their treatment and their goals for care, and the team came up with a treatment plan that was e-mailed to the patient’s doctor or posted in an alert in the patient’s medical record. People who needed more intensive care—for example, an additional consultation with a mental health professional—received it.

Over the course of a year, patients with the pain-treatment team had an average of about 10 or 11 meetings or other contacts with their team members, unlike people with regular care. And it paid off. Those with team treatment had modest but measurable declines in their pain-related disability, and were less depressed too.

Treating people in chronic pain is a huge challenge for physicians, says Von Korff. Tests to track down the pain’s source, such as high-tech imaging, are costly and of questionable benefit. And once a doctor rules out causes of pain that would require immediate medical treatment, he adds, there’s not much else he or she can do. Aggressive strategies for pain relief, like surgery, are expensive and risky, and they often don’t help.

While opioids can relieve pain, they can also lead to dependence. Other drugs have side effects too; even nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen, can cause gastrointestinal bleeding. “This is an area where more is not necessarily better,” says Von Korff.

Programs like those in the study can help, simply because they give people advice and encouragement about returning to normal activities, reassurance, and explanations about why they might be having pain, he says. Just encouraging people to engage in activities that they enjoy can help—and there are no side effects, Von Korff explains.

“There are a lot of different things we can do, a lot of different things patients can do, that can be helpful,” says Von Korff, who was not involved in the research. “The approach being advocated here is a more conservative approach that has the advantage of potentially being less costly and potentially getting better outcomes at the same time.”

The next step, says Von Korff, would be to see if this approach is even more effective in subgroups of patients, or whether better results can be achieved by beefing up components of the intervention

Treatment programs help veterans for the return home

A number of addiction treatment organizations are doing their part to ensure that veterans returning from Iraq and Afghanistan have access to supports to ease the transition back to their communities.

A Better Tomorrow which operates a 60-bed facility and outpatient services in Murrieta, California, has for the past year offered free outpatient services (up to three days a week for up to a month) to veterans returning from Iraq and Afghanistan. A couple of months ago it also decided to discount its residential treatment services by 50% for veterans who might need a more intensive level of care, says A Better Tomorrow president Jerrod Menz.

 

Although only about half a dozen outpatients and one residential client have received services under the program so far, Menz believes the center is providing an important alternative for returning veterans who might not want to pursue health services through military challenges for fear of repercussions.

 

“A lot of times you’re better off being a drunken sailor than to be in rehab,” Menz says of the military culture. A treatment site outside the Department of Defense or Department of Veterans Affairs might offer clinical benefits as well, he believes. “It lets veterans be more honest about their issues,” Menz says.

 

Headlines about efforts to improve behavioral health services for veterans with substance use issues and/or post-traumatic stress disorder (PTSD) have been everywhere in recent months. In New York, the Outreach Training Institute has received special funding to offer honorably discharged veterans a full scholarship for its counselor education program that prepares students for state licensure.

 

And on Capitol Hill, U.S. Rep. Niki Tsongas of Massachusetts has introduced two veteran-related bills, including one to create a pilot program for the training of counselors in higher education institutions to recognize the signs of PTSD.

Feds to get stricter with the prescription of narcotic painkillers

The feds are going to get stricter with the prescribing of narcotic painkillers such as OxyContin, while the California workers’ compensation system is considering a “more liberal standard” for the use of these medications.

At least that’s how the California Workers’ Compensation Institute interprets the approach of each agency, as described in a bulletin the Oakland policy research group released Monday.

Managing pain with narcotics based on opium poppy resin or its synthetic equivalent is a hot topic in medicine, and is prompting a closer look as the use of these drugs increase.

The Institute’s bulletin on Monday provided an update on a study the group released last June. That study showed claims involving larger numbers of “opioid prescriptions and morphine equivalent milligrams were associated with longer periods of disability, higher costs and greater likelihood of attorney involvement.”

In its bulletin, the Institute characterized the actions by the feds and state as being in contrast.

The U.S. Food and Drug Administration, the workers’ comp group noted, announced its plans last week to “adopt a massive new program to better control the prescribing, dispensing and distribution” of opioids.

Meanwhile, the California Division of Workers’ Compensation, the Institute wrote, is mulling over adding “controversial pain management guidelines to the Medical Treatment Utilization Schedule, which would create a much more liberal standard for the use of these medications in treating injured workers who suffer from chronic pain.”

Not so, said the division that oversees California’s system for workers injured on the job. The Division of Workers’ Compensation said in an e-mail Monday afternoon that it does not agree with the Institute’s characterization that the chronic pain medical treatment guidelines create “a much more liberal standard” for the use of opioids.

The proposed chronic pain medical treatment guidelines, the division’s representatives wrote, conform to the state’s patient’s bill of rights statutes providing treatment for chronic pain. “The proposed chronic pain medical treatment guidelines address the use of opioid drugs extensively, providing a detailed criteria for use, management, continuation and discontinuation of opioid drugs use,” the division said.

But the proposed chronic pain management guidelines fail to “provide greater specificity and clarity,” the Institute said. The guidelines would create a more liberal standard, the organization said, because:

“The threshold for use of the proposed pain management guidelines is set by a vague definition of ‘chronic pain,’ creating an opportunity to ‘medicalize’ and over-treat otherwise routine occupational conditions, and triggering disputes.”
The guidelines “often include vague, ambiguous language to qualify their conclusions, and/or the levels of evidence underlying the recommendations are not determined or provided.”
“The lack of specific recommendations, thresholds and limitations for treatment in the proposed chronic pain management guidelines make it virtually impossible to price out the scale of their economic impact in workers’ comp,” and will diminish the quality of care for injured workers in California.
In its report in June, the Institute’s message was that Vicodin, codeine, OxyContin and other heavy-duty painkillers may be necessary, but doctors, insurers and injured workers should proceed with caution.

The organization questioned how such so-called “opioid” drugs are used to treat chronic back pain among California workers injured on the job. Multiple prescriptions for garden-variety back injuries were associated with higher overall medical costs, more lost time from work and more litigation. Low or moderate use of opioids for common back injuries (excluding spinal cord injuries), the Institute found, isn’t a bad thing.

“As a first step in developing the program, the FDA will begin meeting next week with manufacturers, patient and consumer advocates, and the public to gather information and suggestions on how to best implement the program,” the Institute wrote in its bulletin.

The feds want to make sure doctors are trained in the safe use of opioids before they can prescribe them.

Patent for a process that can determine whether someone is in chronic pain?

A California orthopedic surgeon has received a patent for a process he says can objectively determine whether someone is in chronic pain. This could be a big help for people with fibromyalgia, who sometimes have a hard time convincing others that their pain is real and is severe enough to substantially limit their activities. 

Dr. Robert England’s process utilizes functional magnetic resonance imaging (fMRI), which can capture detailed images of the brain, including the activity of neurons. He says it can demonstrate different activity in people with and without chronic pain when they receive the same stimulation, thus proving that they are in pain. 

Conventional methods of measuring pain rely on input from the patient, who is subjective. A widely accepted method of demonstrating pain objectively would aid doctors in diagnosing and treating chronic pain such as that from fibromyagia, and could help patients with insurance companies, legal claims, and SSI disability filings. 

So far, there’s no word on when this process will become widely available.