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Pain Medication Management

In this day and age there is such an overuse and abuse of pain medication that I have decided to add a section to this site devoted to pain medication and its management. My guest editor for this section is Steven Poling DPM, RPh.

As a practicing podiatrist, like most doctors who treat musculo-skeletal pain Dr. Poling is very informed on pain medication in all their variations and the proper use of these medications. His expertise is further enhanced as he is also a registered pharmacist and as such maintains active licenses in both professions.

This section of the web site is a work in progress and pain medications will be continually added by Dr. Poling with his own comments regarding their proper use.


THE MANAGEMENT OF PAIN
UNDERSTANDING PAIN

Pain, an unpleasant sensory and emotional experience associated with actual or potential tissue damage whether acute or chronic, is a unique subjective universal condition experienced by everyone at various times throughout life. During a normal 2 week interval, approximately 12.5% of young adults and 25% of adults over age 60 will present to a health care provider for evaluation of pain requiring medication. (ANALGESICS-medication for relief of pain). Eighty percent of physician visits are due to pain complaints. Eighty-five percent of adults 65 and older will experience at least one pain inducing health problem in their lifetime.

Causes of pain (etiology) are many-low back, over-use, musculo-skeletal, arthritis, headache and injury are among the most common. Over HALF OF ALL individuals having attained the age of 15 will have experienced occasional NON-MIGRAINE like (i.e. tension or muscle contraction) headaches. The elderly suffer most from arthritis, knee, and back pain. The most common of sports injuries are related to trauma to the muscle-tendon complex.

Pain may be acute which is expected to alleviate completely with treatment in a relatively short time frame (days to weeks) or chronic which continues for a longer time with the possibility of never completely resolving even with treatment. Acute pain may present as a dental extraction or muscle strain/sprain. Chronic pain may respond partially to analgesics, more persistent pain may be a result of the extent of trauma to the nervous system. Transient pain is very common and may present as a stubbed toe or an injection. Pain is a complex response moderated by emotion, culture, and experience. Its mechanism is complex, being perceived by activation of receptors which are nerve endings called nociceptors. These receptors are stimulated and signal to the spinal cord which is relayed to the brain and interpreted. The signal enters a complex nervous system which includes past experiences (cultural and emotional). Pain, untreated or under treated, has been linked to depression, decreased interpersonal relations, reduced ambulation and insomnia, and may have negative impact on quality or life function.

Pain may also be categorized as nociceptive, neuropathic, mixed, or psychogenic based on the pathophysiology. The etiology of noceceptive pain is stimulation of the “special receptors “by trauma, ischemia (lack of oxygen in the tissues), myalgias (skeletal muscle in nature) or visceral (soft muscle such as organs) and is managed by analgesics and non-drug treatments such a as ice. Neuropathic is due to peripheral(extremity) or central nervous system(spinal cord/brain) with examples such has diabetic neuropathy, trigeminal neuralgia, multiple sclerosis, and is treated by “atypical “ analgesics(i.e. medications with additional uses other than pain) such as antidepressants and anticonvulsants. The migraine and chronic recurrent headaches, have a “poly-pharmacy” approach (multiple medications sometimes each in lesser doses).Psychogenic pain such a somatization disorders are managed by psychiatric therapy and due to the fact of chronic persistent pain.

MPR, Pain Managment Pocket Reference, 2011 edition, Prescribing Reference LLC, NY,NY, 10001, 2011 The RX CONSULTANT, "Pain Management" vol IX, #5, May, 2000. see also treatment of pain



UPDATE November 2011- The United States Government reported that overdose deaths from prescription painkillers tripled over the last decade ending in 2008. Prescription painkillers led to the deaths of almost 15,000 people in 2008.

UPDATE May 2012-The goal of the pain medication section of his website is to inform and educate the reader about medications used for pain and update this section as changes occur. Recently the FDA (Food & Drug Administration) has mandated all prescription strengths of acetaminophen (APAP) to limit the total amount per tablet to 300mg with the total daily dose not to exceed 4000mg daily, This has been based on studies associating hepatotoxicity, (liver failure) with doses greater than 4000mg . The FDA mandated this to be effective as of January 2014; however some companies have begun to voluntarily changing their formulations. Abbott Pharmaceuticals, the manufacture of Vicodin, Vicodin ES and Vicodin HP is one such company which has begun to change their formulations. Vicodin is a combination analgesic containing hydrocodone and acetaminophen, indicated for mild to moderate pain when perhaps an NSIAID (non –steroid anti-inflammatory) will not provide significant relief or when contraindicated. Present formulations are: Vicodin (hydrocodone 5mg/acetaminophen 500mg) Vicodin ES (hydrocodone 7..5mg/acetaminophen 750mg) Vicodin HP (hydrocodone 10mg/acetaminophen 660mg) As of May 29, 2012 these are being reformulated to: 5mg hydrocodone/300mg acetaminophen, 7.5mg hydrocodone /300mg acetaminophen, and 10mg hydrocodone / 300mg respectively. It must be remembered, the 4000mg is the TOTAL DAILY DOSE of acetaminophen, which includes the daily consumption of any prescription medication and any otc (over the counter ) medication that may contain acetaminophen, such as common cough/cold/allergies/sinus headache formations. Other companies will be following this mandate and the information will be provided when available. REFERENCE Abbott Pharmaceuticals direct to Physician Newsletter FDA mandate, May 29, 2012.



MEDICATIONS


ACETAMINOPHEN


ANTI-INFLAMMATORY MEDICATION-NSAID's NARCOTIC ANALGESICS TOPICAL ANTI-INFLAMMATORY MEDICATION OPIOID ANALGESICS








































Due to the complexity of pain and its management, certain diseases require specific analgesics for treatment. This factor is due to the ever increasing knowledge both of pharmaceutical compounds and diseases through the advancements of both analytical chemistry technology and medical diagnostic instrumentation. Today, we are able to understand much more integral biochemistry and physiology of the human body through significant research capacity.

One such entity which has become a major medical pain management challenge has been neuropathy- the pain of the body’s nerve tissues due to many causes. Unfortunately, diabetes mellitus incidence has risen so enormously not only in the elderly, but also in the pediatric and adolescent population and has become a major etiology of neuropathy due to elevated glucose (sugar) damaging the nerves. Fibromyalgia, a very painful debilitating condition both physically and psychologically, due to persistent nerve pain of muscles and connective tissue, is another indication For the neurolytic analgesics other sources of neuropathy include traumatic, arthritis to the spinal column and peripheral joints, alcohol induced, and vitamin deficiency and post-herpetic neuralgia (the pain of shingles –a painful rash caused by the activation of the dormant virus of chickenpox).

The neurolytic specific analgesics are one such class of medications used today. In my specialty of podiatric medicine, these patients present quite frequently daily hoping to achieve some relief of this extremely painful and debilitation of the quality of life.







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I've been doing some aggressive research lately (it's how I found your incredible website) and realize now that my symptoms are not consistant with the diagnosis.

Jennifer

Hunterville, NC


….after reviewing your amazing site (great for the avg. jill). So thank you very much!!!

Liesbeth

NY
I am really, really impressed with your plain-speak explanations for the various conditions.

Jacqueline

NJ
This was an extremely helpful site. I have an appointment on the 18th and your info. Was right on target…..

Jack

Fla
A well organized site containing much information written in a manner that the average reader can comprehend.

Jean

Ontario, Canada
I found your website and articles most interesting.

Andrew

Fla.
Thank you for a quick response. I think your site is the best information site on foot pain and I have viewed many.

Judy

(location unknown)
I came to your website, footspecialist.net via www.foot-pain explained .com which I think is also your website? I thought explanations for different types of problems were well addressed and thoughtfully stated for the patient in mind.

L.W.

New York
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Yvette

Memphis, TN
Thanks again so much for the information in the article. Very interesting.

Anna

Scotland
Great article. I have had plantar fasciitis since I was in high school……..

J. Simmons

(location unknown)
Dear Dr. Mitnick, The orthotics arrived four days ago and I slipped them into my shoes immediately. I was skeptical as to the usefulness of the item, they really didn't look very exotic. I have to say though, after using them for just four days, I have experienced grand relief from my foot pain. Even the very first day, I was able to do a lot of work while on my feet with at least a 75% reduction of pain. It has only gotten better every day, and I go nowhere without my shoes with the orthotics. I had been experiencing extreme heel and sole pain for about six months and had to take extended breaks off my feet many times a day as well as regular doses of Ibuprofen. Since getting the orthotics, my life has returned to normal and I feel good again. Just wanted to say thanks for the recommendation for a very effective item, I had no idea what a change this item could affect.

Yours truly,

J.C. Forbes

Tennessee
Thanks for the Response, you hit it on the head.

Steve

Redondo Beach, CA
Thank you for your time and expertise in answering my question…..

LH

(location unknown)
First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems. Last June I started having pain and swelling at …….

Joe

(location unknown)
First of all, thank you for having all this useful information available in one place. I've been through most of your website and based on my research, pain and evaluations I think I've narrowed things down quite a bit.

Pete M.

(location unknown)
Thank you for the best site I have found when researching foot pain.

Glenda B.

Madison, Alabama
Thanks for replying so quickly. I was a bit concerned. I think your website is great, and chock full of info.....

Carol

Denison, TX
Dr. Marc, Thank you so much for your reply which seemed to be right on. I have researched many sites but you put me on the right path to the possible answer. My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!" Thanks Very Much,

Dawn

West lafayette, IN
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Michael E.

Tampa, Florida 33624
Hi. This is a great site! I'm a healthy middle aged woman who is in good health, but.....

Kelly

Texas
Just a wee word of thanks for your wonderful website...It is a terrific service...Thank you for providing your knowledge and help...With highest regards, m ebeling

Michael D. Ebeling

Tampa, Florida 33624


Thanks for a most interesting website, which has helped a lot.

Steve

UK


Dear Dr.Mitnick

I usually do my research on the Mayo clinic website. I think your website is the most informative site I have found when researching foot pain.

I thank you for putting together this incredible website.

Regards,

Dragica W.

Edmonton,Canada


....I have been told that it is not hard enough to be cut off. Please help, I am not sure what to do now! THANKS FOR A WONDERFUL AND VERY HELPFUL SITE!

Roxy

South Africa


You have an unusually clear, informative and well-written website for laypersons. Thank you for that.

Matthew W.

Mansfield Ctr, CT


First, I'd like to thank you for all the information that you provide on your website and the opportunity to write to you.

Steve

Placentia, California


First, I want to let you know that you have the best web site I've found related to foot issues. (The only thing I had difficulty finding was the "ask a question" page.)

Unknown

Unknown location


I received the orthotics Monday afternoon and began wearing them Tuesday. After two days I would say that I have noticed a huge improvement in the discomfort I have been experiencing. My foot feels better than it has in months.

Ric J.

Unknown location


I greatly admire someone like you who would donate and dedicate so much time and effort to helping strangers with no compensation. Truly, it is uncommonly kind. And your site is so intelligently arranged.

Ron R.

Pacific Grove, CA


I used to work for a podiatrist (front desk) back during summers in college years ago, so I know the benefits of good care. Again, I want to thank you for an EXCELLENT website. It was so great to get to your site (top of google search) and actually find all the answers I needed EASILY and QUICKLY! Clearly you put a ton of work into it and I really appreciate it.

All the best,

Victoria

Alameda, California


By the way, millions of websites could use yours as a guideline on how to organize information and make the site user-friendly. Kudos to you!

Anonymous


Thank you for your very interesting and informative site!

Anonymous




Hi. I come to your site often looking for information. It is really informative and I appreciate it very much. I have RA and have been having considerable amount of foot pain...... Dee RN


Thanks very much for the wonderful informative site.

Catherine

New Zealand


Thank You for my answer! I have been schedule for a bone density scan, allingment, and I am in the process of getting orthotics made, and checking out the natural remedies. Thank again! What a great web site!

Sincerely

Josette


Yes I want both pair of orthotics. You don't have an option of ordering 2 at one time so I had to place the order twice. Thanks. My husband likes these and wants to put them in all of his shoes. (referring to Superstep orthotics)

Cindy H.

Arizona
I searched the internet everywhere for a clear description and illustration of my symptoms/problem. http://www.foot-pain-explained.com/ was where I ended my search with answers. If I lived in Jersey (left 30 years ago) and didn't live in Florida I would definetly make an appointment with Dr. Mitnick.

Thanks, Kathy

Florida
1st of all THANKS A LOT for your great site......

Anna

Poland
Thank you so much for your response. I will let you know how I am doing if you would like. Your website is awesome!

M P

South Carolina
Hello! I want to thank you for such an informative website! I found you based on my ankle pain search and am happy to realize that there may be a relatively simple cause and solution....

Natalie

unknown location


...Thanks for your fantastic service.

Gary

Arlington, VA


Thank you so very much, that would be much appreciated. I love those insoles, by the way. (referring to Superstep orthotics)

Kelly W.

San Clemente, CA


Dr Marc is fantastic...He seems to know exactly what you are feeling with the problems you are having. I wish he was in my home town so I could go to him with my problems!!!!!!!!!!!!!

Pam

location unknown


Great insights! Thanks Doc, you're the best.

Glen

location unknown


I have been experiencing foot pain of various sorts and am working to figure out what it is. I found this site and can only say BRAVO!! What an excellent site! The time it must have taken to put all this together must've been a daunting task! I am sure it has helped so many people. Thank you so very much for doing this.

Bre

location unknown


Dr. Mitnick, Thank you so much for your reply. I did let my physician know and they took an x-ray - all is well! Also, thank you for providing this wonderful site, it is very helpful with lots of useful information! I appreciate your gift of time! God bless.

anonymous




Dr. Mitnick, Thank you, you were 100% correct. The pain finally brought me to the ER. I spent 8 days in the hospital. The Doppler you spoke of was able to show that there was no pulse in that foot. This was an arterial clot that split and traveled throughout my leg. My leg was almost amputated. I am in rough shape but have all my parts intact!! You certainly know what you are talking about. Thank you for taking the time to answer. Yours Truly!

anonymous




Staying at home after hallux surgery I spend quite a lot of time seaching info useful for avoiding problems which might come back. Today I found your site and I am .... delighted it happened. It's one of the best site I found last days.

Anna

Poland




Thanks for taking time to read and answer so many questions. It is truly a public service!

Esh

Seattle, WA


I just wanted to say that I am very greatful for this website!!

Bonnie

location unknown




Also, and importantly, just want to praise this web site. Thorough and thoughtfully presented, it certainly must be of considerable assistance to anyone with a foot problem. Terrific -- and very interesting.I trust the address comes up easily for those seeking information.

Bill

New Jersey




Thanks so much for answering my question. You've been more help to me than my own Dr. has been lately. Thanks again....I hope to be able to walk without pain someday.

Debbie

location unknown




Wow, that is exactly the information needed!!! thank you thank you thank you!!! I appreciate this help so very much from Marc Mitnick DPM. Excellent information and help to improve One's life.

Chrissy

location unknown




Thanks so much for this website Dr. Marc! It is so nice that you have this ask the doctor feature..I'm sure I'ts been helpful for alot of people. I will try what you suggested and see if it helps...thanks again!

Tracy

Evansville, IA




Dear Marc

I just want to say thank you for the quick response and the good info. I find it amazing and a super nice thing that you do here by answering medical questions at no charge.

Russ W.

location unknown




Your website is full of a lot of helpful information, and I am very impressed with the time in which you responded to my post. Thank you again for your time and consideration in your response.

-Sunny.

location unknown




Thank you very much for the information, I will consider it. Excellent web site.

Jackie

San Diego, CA




Dr. Mitnick, Just want to say thank you so very much for your quick response and very informative reply! After reading what you had to say, I called the doctor's office and was able to get in and see him the same day as my injury. Toe was x-rayed and luckily, it is not broken or fractured. Very badly bruised and will probably lose the toe nail. And although my toe and toe nail are still very black and blue and very sore, they ARE both starting to feel a little better. So again, thank you! I am so very happy that I came across your website. The service you provide is outstanding and immeasurable!

Rivi,

Albany, NY




Thank you so much for all of your advice. In searching the web for people dealing with this same issue i can tell you that you are a Knight In shining Armor! If I lived in Jersey I would gladly be your Spokesperson. Hopefully next time you hear from me it will be good news. God Bless,

Jill S.

location unknown




THANK YOU SO VERY MUCH FOR YOUR TIME AND EFFORTS, YOU ARE SO VERY APPRECIATED. THANK YOU FOR ALL YOU DO.

Jackie

Whichita, KS




thanks again, this site is very helpful.

mark

Boston, MA




Like others have stated...This site is amazing and I am so thankful that it was created.

....Keep up what your doing. Your a life saver.

Michelle

Colorado




Thanks again for the information provided on your site. It's easy for non-medical folk to understand your writing, and helps provide better communication between patient and doctor.

annielou

Colorado


Wonderful advice

by: Anonymous

This is the best site for foot problem info.


Thank you for this information. This description fits my pain and inflammation behind my 2nd toe perfectly.

by: Max

location unknown
Again, I really appreciate that you responded to my inquiry, and that your mention of Parkinson's helped me to find my way to a diagnosis of this difficult to diagnose disease. Most patients see on average 16 doctors before they are diagnosed. I hope that you can help other people that ask for your expertise in the future.

Barb D.

Canada
I just wanted to say that I am very greatful for this website!! I have had a fusion in my rt foot and am finally getting a little bit better......

Bonnie

location unknown
Again, Thank you from the bottom of my heart for taking the time to answer my question....your an angel!

Nancie

Wisconsin
Thank you for your response. You have provided some great insight (to my question)....

Julie

location unknown
Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!

Renae

North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...

KG

location unknown


Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.

Bessie Mae

Florida
Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,

Lynne T.

location unknown
Your webpage is excellent, I commend you on sharing your knowledge to the public.

Robert

New Jersey


Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.

a mom

location unknown


I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!

Melody

Lenoir, NC


Thank you so much Doc for a quick and thorough response!

Rustam

Bellevue, WA


I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!

Jodi

location unknown