Whether caused by injury, surgery or a toothache so bad it slams you awake in the middle of the night, acute pain is difficult. Receiving prompt and helpful treatment can make all the difference in the world. But lack of care or inadequate care means that the acute pain may develop into chronic agony.

Fortunately, acute pain is not always long lasting or overwhelming, such as when you have a short severe cramp or multiple bee stings that can be handled with time, over-the-counter medication and other home remedies [See Sidebar: Pain Treatment Options].

Since individuals’ tolerance for pain varies widely, the question of when pain itself requires urgent medical attention is difficult to answer.Chest pain should prompt a visit to the emergency room, of course—but other types of pain are trickier to call.

“If it hurts like hell, come to the E.R.,” says Dr. Sergey Motov, assistant program director for emergency medicine at Maimonides Medical Center in Brooklyn. “The problem is that it’s so subjective, there’s no really good objective way to tell when [help is required]. If it’s the worst pain you’ve ever experienced, [come].”

Once you seek medical attention, you should be treated promptly and with compassion. “If you don’t treat acute pain properly, it can become chronic,” Motov says. “If someone comes in with acute pain and it’s sub-optimally treated, they go home and come back in three days and it’s sub-optimally treated again and later on they’re in chronic pain, that started with us because we did not address the acute pain properly in the first place.”

So how should extreme acute pain be treated? Jan Adams, a retired general practitioner herself, describes receiving excellent care after she had back surgery following an injury. She was immediately given strong opioid medication because of the intensity of the pain.

“What they did right was allow me to manage how much pain medication I needed for the first few days,” she says. “I needed more at first and what they did right was to allow me to manage the pain, understanding that there’s a big difference between abuse of pain medication and acute pain use of narcotics.”

Mike Gaynes, a media consultant, received similarly caring treatment with opioids when he reached the ER suffering with kidney stones. Although he does not normally have high blood pressure, the pain had made it skyrocket.

“This was cork-popping,” he says, “They gave me I.V. morphine and it helped somewhat, then they gave me more and it helped a little more. It took the edge off but did not shut [the pain] down entirely.”

Toughing it out with severe acute pain is not recommended, because of the possibility that it could become a chronic problem. However, Dr. Kenneth Goldschneider, director of pain management at Cincinnati Children’s Hospital, says that complete elimination of pain is often an unrealistic goal because of the side effects of drugs.

Adams’ bad experience of pain management came during an emergency colonoscopy, which she needed during treatment for a rare form of mouth cancer. Radiation therapy had left her weakened and malnourished, cutting off the blood supply to her colon. Because of the painful cancer treatment, she was already taking an extremely strong opioid called fentanyl and had developed a tolerance to it.

That same medication was used for anesthesia during the procedure. Because of Adams’ tolerance and the physician’s choice not to use an additional anesthetic along with it, she was left in agony. “He’s pumping air into my colon and I’m feeling like raw hamburger,” she recalls. “The entire floor heard me screaming but he wouldn’t give me anything more,” she says, explaining that she has typically been stoic when in pain

To avoid having a similar experience, Adams suggests a conversation about pain management before surgery. She says to ask explicitly, ‘What do you think is appropriate pain management?’ “One thing you want to hear is that ‘I’ll be sure that either I or the nursing staff will be trying to evaluate your pain [regularly] to make sure you’ll be as comfortable as possible,” she says.

Patients should also discuss any medications they are taking with their doctors before surgery. If someone has a tolerance to a particular medication, the anesthesiologist needs to be prepared to use higher doses or choose a different drug.

Pain Treatment Options:

Pain can be treated in a number of ways, depending upon its severity and cause. Treatment options might include one or more of the following:

• Non-steroidal anti-inflammatory drugs (NSAIDs), a specific type of painkiller such as Motrin® or Aleve®
• Acetaminophen (such as Tylenol®)
• Narcotics (such as morphine or codeine)
• Localized anesthetic (a shot of a pain killer medicine into the area of the pain)
• Nerve blocks (the blocking of a group of nerves with local anesthetics)
• Acupuncture
• Electrical stimulation
• Physical therapy
• Surgery
• Psychotherapy (talk therapy)
• Relaxation techniques such as deep breathing
• Biofeedback (treatment technique in which people are trained to improve their health by using signals from their own bodies)
• Behavior modification

Some pain medicines are more effective in fighting pain when they are combined with other methods of treatment. Patients might need to try various methods to maintain maximum pain relief.

Adapted from The Cleveland Clinic Foundation.

“I would always encourage people to change physicians or get another opinion if something doesn’t seem right when you talk about pain,” Adams says.

A decade ago, the Joint Commission on the Accreditation of Health Care Organizations (now known as the Joint Commission), which sets standards for medical centers, labeled pain as the “fifth vital sign.” Hospitals are now required to assess pain when other vital signs are taken after surgery or more frequently with especially painful conditions.

Dental pain is one of the worst forms of common, acute pain. Lys Fulda, then in her early 20s, had a toothache so severe that she went to her dentist’s office before it opened to make sure she’d be seen as quickly as possible.

The dentist injected her with Novocain, but it didn’t completely alleviate the pain as he began to drill. He tried another injection, this time directly into the tooth. “It felt like lightning went through my entire body. It created innate deep fear of dentists,” Fulda says.

While it’s not always possible to avoid such incidents because people’s nerves are sometimes anatomically unusual, experienced dentists can almost always prevent them.

“You need to take pain seriously,” says Dr. Dennis Bohlin, a Manhattan dentist and the educational coordinator for the New York State Dental Association’s committee on chemical dependency. “Part of it is reassuring [patients] that there is going to be end to it. Part of the anxiety about pain is the fear that it will last forever. It’s not going to, we can handle it. That reassurance is really important.”

Organizations That Can Help

American Pain Foundation

The American Pain Foundation web site is an online resource for people with pain, their families, friends, caregivers and the general public. This site is devoted to patient information and advocacy, and provides many links to additional resources. www.painfoundation.org

Anxiety itself actually increases pain—so techniques that reduce anxiety are an important part of dealing with acute pain. With children, Bohlin says, it’s particularly important to calm the parents as well so that they don’t transfer their own anxiety to the child.

Incidents like what happened to Fulda or negative childhood experiences with dentists can create what Bohlin calls “subliminal anxiety,” which can drive avoidance of dentistry below conscious awareness.

“It’s hard enough to come as it is,” he says, adding that this type of anxiety makes dragging yourself to the chair even more difficult. Fulda found that a reassuring, sympathetic dentist was able to help her overcome her fear.

If dental pain strikes in the middle of the night or on a weekend, Bohlin suggests taking a drug like ibuprofen, naproxen or aspirin—all of which fight inflammation, which is a big part of dental pain. Don’t take antibiotics, which can make the dentist’s job harder when he or she tries to diagnose the problem.

Acute pain can be harrowing, but fortunately in most cases it can be rapidly relieved.

Treating Acute Pain at Home

Most acute pain is not serious and can be handled with home care methods. Some advice from Dr. Kenneth Goldschneider, director of pain management at Cincinnati Children’s Hospital:

For minor injuries, use a cold pack but for no longer than 20 minutes, he suggests.

For sore throats, gargle with salt water— the only advice that has changed since grandma’s time is that aspirin is no longer used for children or adolescents. Use children’s ibuprofen or acetaminophen instead, he says.

He adds that for infants under six months, sugar water has been found to have a short-term analgesic effect: In many hospitals it is now used for giving shots and placing IV’s and other procedures that produce brief, acute pain. It doesn’t work for older children or adults, however.

For toothache, Manhattan dentist Dennis Bohlin says that when you cannot immediately get to a dentist, use an NSAID drug like ibuprofen or naproxen that has anti-inflammatory properties, since inflammation is often a big part of the problem.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Overdose of the common household drug acetaminophen leads to more than 78,000 emergency department (ED) visits a year, and the majority of the overdoses are intentional, according to a new study from the Centers for Disease Control and Prevention.

It’s a big problem, and the study found three main causes among ED patients.

“About 70 percent are for self-harm attempts, and 13 percent to 14 percent are kids getting into products,” said lead study author Daniel Budnitz, M.D. “The other 16 percent are the adolescents and adults that generally fall into two groups: the younger adults that are misusing over-the-counter products because they are trying to get better pain control and don’t understand the risks, and the older adults that are making some errors using the opioid combination products.”

Consumers take acetaminophen — the active ingredient in Tylenol — to reduce pain or fever, as a single drug in tablets, capsules or liquid. Acetaminophen combines with other drugs in a variety of over-the-counter cold, flu and sinus medicines including Theraflu, Triaminic and Sudafed. Acetaminophen also appears in combination with an opioid — a narcotic— in prescription medicines like Vicodin (with hydrocodone) or in Percocet (with oxycodone).

Young people ages 15 to 24 are at highest risk for suicide attempts or acts of self-harm involving acetaminophen, the researchers found. “Because these data are based on ED records, it is often difficult to determine exactly what motivated the patient — if they had a premeditated plan to end their life with an overdose or if the overdose was an impulsive act,” said Budnitz, medical officer at the Division of Healthcare Quality Promotion.

Among the others in this age group, 75 percent of ED visits occurred because they went above the recommended acetaminophen dosage in search of quicker or stronger relief.

Overdoses by people who think more medicine is better points to a deep knowledge gap and need for better consumer education about a familiar drug, said Henry Spiller, director of the Kentucky Regional Poison Center. He has no affiliation with the study.

“We frequently see that with abdominal pain or tooth pain. They can’t get to the dentist for a day or two so just try to manage the pain themselves. Some actually come in with frank liver failure,” Spiller said. “I think they’re unaware that they’re risking something as bad as liver failure—especially with tooth pain.”

Taken correctly, acetaminophen is safe and effective, but the margin between a therapeutic and a dangerous dose is smaller than many people might realize.

“The toxic dose depends on the age of the person, how much they weigh and their liver function, but in general, 10 to 15 grams can cause what’s called hepatic necrosis, which is basically the liver cells dying,” Budnitz said. “So 10 grams — an extra-strength tablet is 500 milligrams of acetaminophen — that’s about 20 tablets.”

The poison center might recommend to people who take acetaminophen continually that they should instead alternate with another pain medicine, like ibuprofen, Spiller said.

“If you double or triple the dose of acetaminophen, and you take it for several days, you will cause significant liver problems,” Budnitz said. Rather than a sudden, dramatic reaction, overdose symptoms often occur later, he said. “If untreated, the acetaminophen toxicity can take days, maybe weeks, to manifest itself.

“Depending on the person, and how much they took and what treatments they get, the outcomes range from full recovery to possible death without a liver transplant,” Budnitz said. “If you or someone you know did take an overdose of acetaminophen, the first thing to do is to call the poison center (1-800-222-1222), follow their advice, and, if directed, go immediately to the emergency department for an evaluation.”

The good news: “With prompt treatment most patients fully recover, especially children, because acetaminophen does have an antidote. If given promptly, that can protect the liver, ” Budnitz said.

Overdoses caused by extra doses for symptom relief or other mistakes were more likely to involve over-the-counter products in people ages 15 to 24, and opioid-containing acetaminophen products in people older than 39.

For those who require the antidote, it is not as simple as taking a pill. “NAC comes in oral and intravenous form,” Spiller said. “NAC is sulfur-based and it smells like rotten eggs. It’s tough to get kids to drink it.” Others who overdose might undergo “gastric decontamination” with an unpleasant charcoal mixture or by having their stomach pumped.

The study analyzed two years of data from the National Electronic Injury Surveillance System to estimate the number of annual ED visits nationwide. The actual sample included 63 U.S. hospitals and findings relied on 2,717 cases.

Local Resources:

• Washington Poison Center Hotline: 1-800-222-1222 (Website: www.wapc.org)

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

For anyone who experiences migraines, you know the perplexing and often painful symptoms of this debilitating condition – excruciating pain in the front of the head, vision loss, numbness, weakness, confusion.  Now imagine being a small child and experiencing this.  How would a child explain it to a parent?  How would a parent know what’s happening to their child?

You might be surprised to know that children as young as 2-years-old can have migraines.  Up to 5 percent of elementary school kids suffer migraines, and up to 20 percent of adolescents, according to the American Academy of Pediatrics.

Childhood migraines vs. adult migraines

Dr. Plawner

“Migraines can cause a wide range of neurologic symptoms in children, just as they do in adults,” explains Lauren Plawner, MD, pediatric neurologist at The Polyclinic in Seattle.  There are a few differences, though.  “With adults, the pain is usually on one side of the head whereas with kids, it’s more likely to be on both sides.  Adults are more likely to experience the migraine ‘aura’ – a collection of symptoms including blind spots, zigzag lines, flashing lights –  that may precede a full blown migraine.

Recognizing migraines in children

So how is a parent to recognize migraines in a child who may not yet be able to verbalize such odd perceptions or experiences?  “The most common indication is that a child will complain of his or her head hurting.  You may also notice the child is sensitive to light, sound, or smell, and they may even hide under the covers,” says Dr. Plawner.  “Nausea is a common symptom of migraines as well as is unusual temper or sadness.  Often the child will want to sleep during or right after an episode.”  A single instance of these behaviors is probably no cause for concern, but repeated observations could indicate a problem and require clinical diagnosis by a physician.

Migraine variants

“One interesting result of this is that the neurologic symptoms can be much more dramatic and prominent than the headache; the headache might not even be present at all,” explains Dr. Plawner.  Examples include the “Alice in Wonderland” syndrome which alters perception and makes objects seem larger or smaller than they actually are, and “cyclic vomiting syndrome” which causes severe vomiting that may lasts for days and can even require hospitalization for dehydration.  Migraines can also include symptoms of numbness, weakness, and visual changes.  Such peculiar experiences can make diagnosis even more difficult as these symptoms may be interpreted as psychological problems, seizures or a stroke.

Migraine triggers and treatment

Parents often fear the worst when a child describes such symptoms – brain tumor!  But that’s very rarely the problem.  Kids get migraines for many of the same reasons adults do.  There seems to be a strong genetic influence, particularly when both parents have migraines.  Triggers like certain foods and liquids (especially cheese, nuts, chocolate, shellfish, MSG and alcohol), caffeine, lack of sleep, stress, and bright lights are among the most common.

“The best way to prevent migraines in children, as with adults, is to identify common triggers by looking for patterns, observing when and where the migraine occurs and what environmental influences were present at the time.  Then neutralize those triggers: remove offending foods from the diet; be sure your child gets enough sleep; help your child learn relaxation techniques to reduce stress.”

Some children will benefit from medication however, for prevention, treatment of pain, or for issues like nausea if that child experiences this symptom.  A doctor can work with the parents and child to determine the best course of action.  Research indicates that magnesium and riboflavin may also be beneficial in preventing migraines.

When to seek help

If you are unable to manage your child’s migraines through avoidance of triggers and relaxation techniques, or if your child’s migraines persist and prevent your child from leading a normal, happy life, or if the headaches are severe enough to wake your child during the night, go see your child’s pediatrician.  They may refer you to a specialist, such as a pediatric neurologist, who could help confirm the diagnosis of migraine, help you identify triggers, make sure no other work up is needed, and suggest pharmacologic and non-pharmacologic treatments.

For more information about childhood migraines, ADD/ADHD and other childhood neurologic issues, contact Polyclinic pediatric neurologist Lauren Plawner, MD at 206-860-4465.

PHOTO: PET scan of the brain by Jens Langner.

The Polyclinic is made up of more than 160 physicians, including internal medicine, family medicine, OB/GYN, pediatrics, and 23 additional medical and surgical specialties.  Since its inception in 1917, The Polyclinic’s mission has been to promote the health of its patients through high-quality, comprehensive and personalized care.  For more information, visit www.polyclinic.com.

100 Years of Swedish

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Physical therapy is a component of pain management at Swedish.

Chronic pain is common and becomes more so as we grow older. In fact, after the age of 60, one in three people lives with chronic pain.

But how such pain affects one’s life can vary greatly, said Dr. Gordon Irving, medical director of the Swedish Pain & Headache Center. For some, chronic pain is a nuisance but for others, it can be debilitating.

Why this is so is unknown, said Dr. Irving, but the differences suggest that there are strategies that can help people overcome chronic pain and live happier, more fulfilling lives. This is the goal of the Swedish Pain & Headache Center.

Chronic pain and changes in the brain

Acute pain is the normal response to injury. Nerve fibers send signals from injured tissues to the brain where they are perceived as pain. Normally when the injury heals, the signals diminish and the pain fades.

In some cases, there is a chronic, pain-generating injury, such as damage due to arthritis, cancer and neuropathies. But in other cases, the perception of pain can persist even after the injured tissue has healed.

It is now known that the perception of pain can persist in part due to changes in the brain that occur in response to pain. In fact, such changes can be so profound, that brain scans of some patients with chronic pain show that areas of their brains have measurably diminished in size. “These and other findings have significantly changed how we think about pain,” said Dr. Irving.

Through the STOMP program, Dr. Gordon Irving helps patients get chronic pain under control.

The approach at Swedish is to help patients “to get outside of their pain, so they control their pain, instead of having their pain control them,” said Dr. Irving.

To help patients gain that control Swedish has put together a team with a broad array expertise, including pain-medicine specialists, anesthesiologists, physical and occupational therapists, psychologists and practitioners of complementary treatments, such as acupuncture.

“The center is unique in that it has a wide variety of practitioners all working on the same floor, all working together,” said Dr. Irving.

The team takes a step-by-step conservative approach to each patient, said Dr. Irving. After a detailed history and physical exam, patients may have an imaging study, such as a bone scan or MRI, if a serious structural problem is suspected. But in most cases, says Dr. Irving, such studies are not necessary and, instead, patients typically begin working on a plan to gain control their pain with physical therapy and a program developed at Swedish called STOMP, for Structuring your Own Management of Pain.

This program provides information about pain and pain treatments, but its primary focus is helping patients engage in a series of activities that have been shown to help people overcome pain. These activities include, improving sleep habits, engaging in regular exercises, addressing psychological problems, learning relaxation and “mindfulness” techniques and enrolling in an online “mind-strengthening” program that aims at reversing some of the brain changes seen with chronic pain.

The program is designed so that it can be tailored to each individual’s needs, said Dr. Irving, and allows the patient to decide on what goals he or she wants to pursue.

Coupled with the help of physical therapy and other interventions, the STOMP program helps many patients get control of their pain, but not all. In those cases, more testing might be needed with MRIs, bone scans and other imaging techniques. In some cases, it can help to look for the exact source of the pain by injecting an anesthetic under X-ray guidance to see if numbing specific nerves, joints and spinal disks relieves the pain. “It’s like finding a sore tooth,” explained Dr. Irving.

Other high-tech techniques are available for treating intractable pain. These include the use of spinal cord stimulators, which emit a low-voltage current that block pain signals, and pain-medicine pumps that can be inserted under the skin, which administer low-doses of pain medicine directly into the fluid surrounding the spinal cord.

With these and other interventions, most patients will get significant pain relief, said Dr. Irving, but not always. “In some cases, a patient comes back to the center and says, ‘Doctor, I’m feeling better – I still have my pain – but I’m able to live my life.’, said Dr. Irving, “That can be a good outcome, too.”

Links

• The Swedish Pain and Headache Center

To learn more about Swedish read other articles from the supplement:

• Brain Cancer: An Orphan Disease No Longer
• Headaches often Under-Diagnosed and Undertreated
• Medical Home: Changing the rules of primary care

The facility will be for adult men and women who have recurring headaches of all kinds, including migraine, tension and menstrual headaches.

Dr. Dennis Rochier and Linda Johnston, an advanced registered nurse practitioner, will provide care at the clinic. Both are members of the American Headache Society.

The goal of the Virginia Mason Federal Way Headache Clinic, in addition to improving the quality of life of headache sufferers, is to improve self-management of headaches and reduce the cost of headache care, VM says.

To learn more: 

• Read Virginia Mason’s announcement about the new clinic.
• Visit the American Headache Society’s Web site.
• Visit the National Library of Medicine’s information page on headaches.
• To schedule an appointment, call (253) 874-1601, and dial “0″ when
  prompted.