2014 Top Stories in Primary Care: Pain Management.

The most important development in pain management in 2014 has been greater scrutiny regarding pain medication use and misuse as well as greater attention paid to appropriate alternatives for the management of pain. We have known for some time of escalating issues including a three- to four-times increase in the number of overdose deaths since the 1990s related to pain medications. This rise seems to be the sharpest in groups such as the military and in women, with an overall estimate of 46 deaths per day from prescription painkiller overdoses in the US:

These finding were highlighted in the 2014 White House Summit on the Opioid Epidemic (http://www.whitehouse.gov/blog/2014/06/19/white-house-summit-opioid-epidemic) and have been followed by a shift in medication options to combat the problem. This has included the FDA rescheduling of hydrocodone to Schedule II, the approval of a new hand-held naloxone auto-injector to reverse overdose, as well as the November 2014 approval of an abuse deterrent version of hydrocodone:

The most significant change in policy has probably been the recent revision to the Joint Commission pain management standards (http://www.jointcommission.org/assets/1/18/Clarification_of_the_Pain_Management__Standard.pdf). The previous standards had been in place since 2000 and said very little about nonpharmacological approaches that should be considered. The new policy, which becomes effective January 1, 2015, states that:

“When considering the use of medications to treat pain, organizations should consider both the benefits to the patient, as well as the risks of dependency, addiction, and abuse of opioids.” More specifically, the Commission mentioned specific interventions to consider:

“Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:

  • Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy),
  • Relaxation therapy,
  • Cognitive behavioral therapy, and
  • Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics.”

Of note, these recommendations are intended not only for inpatient settings, but “for the ambulatory care, critical access hospital, home care, hospital, nursing care centers, and office-based surgery programs.”

In addition to policy and regulatory initiatives underway, a number of publications have noted the need for a more comprehensive approach to truly reduce what is one of the leading causes of accidental or preventable deaths in most US states.1

This coming year will likely see more initiatives in this regard. What hopefully will come out of the discussion is a sharp reduction in overdose deaths. During this pendulum swing, which we have seen before in pain management, it is hoped that the care of those persons in pain is not sacrificed. To balance these goals, it is important to systematically improve the care options of those in pain by consideration, incorporation, and coverage of the integrative approaches outlined in the Joint Commissions report. In this way, we will not only have meaningful recommendations but meaningful pain relief.

Are Your Medications Causing or Increasing Incontinence?

If you are struggling with urinary incontinence or your existing incontinence is getting worse, take a look at the medications you are taking. They may contribute to the problem.

There are four groups of medications doctors commonly recommend that can cause or increase incontinence. If you are taking any of these, you should let your doctor know about your incontinence and discuss your medications (both prescription and over-the-counter) to see if there is another approach to control or eliminate the problem.
The most common incontinence problems arise from medications in the following four categories:

1. Diuretics to reduce excess fluid

Diuretics, also known as “water pills,” stimulate the kidneys to expel unneeded water and salt from your tissues and bloodstream into the urine. Getting rid of excess fluid makes it easier for your heart to pump. There are a number of diuretic drugs, but one of the most common is furosemide (Lasix®).

According to urologist Raymond Rackley, MD, approximately 20 percent of the U.S. population suffers from overactive bladder symptoms.

“Many of those patients also have high blood pressure or vascular conditions, such as swelling of the feet or ankles,” he says. “These conditions are often treated with diuretic therapies that make their bladder condition worse in terms of urgency and frequency.”

A first step is to make sure you are following your doctor’s prescription instructions exactly. As an alternative to water pills, Dr. Rackley recommends restricting salt in your diet and exercising for weight loss. Both of these can reduce salt retention and hypertension naturally.

2. Alpha blockers for hypertension

Another class of drugs used to reduce high blood pressure or hypertension by dilating your blood vessels can also cause problems. These medicines are known as alpha blockers. Some of the most common are Cardura®, Minipress® and Hytrin®.

These are usually more of an issue for women. Again, discuss this with your physician, because there are alternative drugs you may be able to take.

Men typically take these to treat an enlarged prostate (benign prostatic hyperplasia or BPH) which can restrict urination by putting pressure on the urethra. By relaxing the muscles in the bladder neck, they allow smoother urine flow for those patients.

3. Antidepressants and narcotic pain relievers

Some antidepressants and pain medications can prevent the bladder from contracting completely so that it does not empty. That gives rise to urgency or frequency or voiding dysfunction. They can also decrease your awareness of the need to void.

“Some of these drugs can also cause constipation,” Dr. Rackley says. “Constipation, in turn, can cause indirect bladder incontinence because being constipated takes up more room in the pelvis that the bladder needs to expand.”

4. Sedatives and sleeping pills

Using sedatives and sleeping pills can present a problem, especially if you already have incontinence. They can decrease your awareness of the need to void while you are sleeping.

The best way to address this situation, Dr. Rackley says, is to take other steps to relax and improve your sleep. Getting more exercise to make you tired, for example, can help. It’s also important to maintain a regular bedtime and wake-up schedule. Dr. Rackley says finding other ways to relax before bed — meditation, reading a book or listening to soothing music or sound effects (e.g., rain or waves) — can also help you sleep better.