Understanding Pain: Q&A on Holiday-Related Pain
December 22, 2014
Dr. Harry Gould III, MD, PhD. is the author of Understanding Pain and Professor of Neurology at LSU and is one of the foremost authorities on managing pain.
The holiday season brings delight and excitement to millions of people throughout the world. Unfortunately, for many of those who suffer with chronic pain from any number of causes, the arrival of the holiday season is approached with anxiety and trepidation rather that joyful anticipation presents significant challenges that preclude the ability to appreciate and enjoy all that the season has to offer. It is hoped that the following responses to questions from readers who live with pain will be help them and others come to a fuller appreciation of their holiday.
Q: I have pain related to Chiari Malformation that is particularly bad in my head and neck. I’m nervous about getting through holiday parties and event, having to be on my feet for extended periods of time making conversation and helping with serving food, etc. What can I do BEFORE the pain starts to help me get through the worst of it?
Dr. Gould: Much of the pain associated with Chiari malformations is related to the settling of the cerebellar tonsils (inferior portions of the cerebellum) onto the meningies (protective coverings of the brain) that line the base of the skull and foramen magnum. The meningies contain free nerve endings that receive noxious stimuli and then transmit pain signals to the brain.
The cerebral spinal fluid that is located within the meningies and supports the brain more readily exits the skull when one is upright due to the forces of gravity. Spinal fluid exit from the skull results in relatively smaller volumes of fluid available to support the brain. The pressure that the brain places on the meningies can be sufficient to stimulate the pain receptors and produce the discomfort that many experience in the posterior aspects of the head and neck.
Taking care to maintain optimum hydration (increasing fluid intake during and prior to periods of prolonged standing and avoiding alcohol consumption) and reducing the height of the spinal fluid column (resting in a sitting or reclining position) should reduce fluid exit from the skull, improve support of the brain and decreasing or preventing the generation of pain signals. Analgesic benefit may also be realized if a dose of an anti-inflammatory medication is taken about 30 minutes prior to an anticipated event to reduce the likelihood of experiencing pain or decreasing the escalation of pain that might otherwise occur.
Q: I’m seeing my doctor this week to prepare some pain management plans for over the stressful holiday weeks. I want to communicate just how bad the pain really is but I don’t think I’ve done a good job with that in the past. What details about the pain SHOULD I be discussing with my doctor?
Dr. Gould: The triggers for increased pain levels during holidays can be difficult to identify and convey to your physician because environmental complexity, i.e., increased social calendar, increased obligations (some welcomed; some not), increased emotional stressors related to past, present and future events, decreased ability to get adequate recuperative rest, places an increased burden on one’s ability to determine what to tell your physician and how.
One suggestion that you might find helpful is to take a moment before your doctor visit to make a list of the things in the routine of your social world that will be likely to change with the arrival of the holidays; those over which you may have some control and over which you have no control. Assess the character and intensity of your pain as you perceive it for much of the year, not associated with holidays, and how you typically manage that pain in contrast to what happens around the holidays.
Do you have certain types of pain only around the holiday or do the types of pain stay the same, only changing in intensity, duration or frequency? It might be helpful to reconsider how you usually report your average pain levels throughout the year and describe to your doctor the amount of change that you perceive around the holidays rather than an absolute value. This can be done by resetting the average, non-holiday pain level that you report to be at the center of your holiday intensity scale (5/10); a trick that can be especially helpful for those who routinely report high pain scores between 8-9/10, because average pain scores in the highest range allow only limited ability to report any significant change in pain intensity; it is hard to drive a car any faster if you already have pushed the accelerator to the floor.
From this baseline information, you and your doctor should be able to determine a reasonable and manageable goal and define realistic expectation and come up with a plan that may involve other healthcare providers that addresses the complexity of your pain problem.
Q: Even though it is prescribed to me, one of my New Year’s resolutions is to take less opioid pain medication. What would be the proper way to stop taking opioid medications to experience the least amount of withdrawal as possible?
Dr. Gould: I applaud your decision and choice to reduce or eliminate the opioid medications from your regimen and wish you all success in meeting your resolution.
In the long run, should you be successful, your decision should go a long way toward improving your overall quality of life and will be important to you for reducing the significant undesired consequences that are associated with long-term opioid use. Although it might seem prudent to begin the weaning process as soon as possible, I would recommend that unless you have significant medical or psychosocial reasons for urgently reducing your currently prescribed opioid medication, i.e., clear acute or subacute adverse effects or difficulty with medication compliance, that you and your treating physician delay the weaning of your opioid analgesic until after the holidays so as not to add the stress of the weaning process to the stresses that are inherently associated with the holidays.
Weaning off opioid medications is not easy and attempting this feat during the stressful holiday season may well reduce the likelihood of success and ruin your holiday experience in the process.
That said, since this seems to be a voluntary desire to reduce your medications, I would recommend that you not be in a rush to achieve your desired goal. Set realistic and achievable goals. Allow yourself a comfortable slide by decreasing the dosing over several weeks or possibly months. Incrementally reduce your regimen by 10-20% every 1-2 weeks to allow your body to adjust to lower drug levels and to assess how the lower doses affect your quality of life; a large reduction in side effects may well compensate for a slight and often transient increase in pain level.
If step 1 is successful, repeat until the lowest acceptable dose is determined or you no longer need the medication. Work with your physician to identify adjuvant or alternative medications that may help in the weaning process. An optimum result will balance the desire to determine the lowest dose of medication that provides acceptable benefit with an appreciation that there are also consequences associated with untreated or under treated chronic pain that are frequently not appreciated.
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