Back pain is extremely common, with experts estimating that up to 80 percent of the population will experience back pain at some point in their lives.
If your back pain is disabling and persistent, your health care provider may recommend diagnostic tests like an XRAY or MRI to determine if surgery may be the best option for you.
Back surgery can help relieve some causes of back pain, but the key is the ability of your physician to identify key signs of symptoms to determine whether surgery is needed.
Some other reasons you may want to ask your health care provider for more information about surgery include: bone spurs in your spine; trouble walking; a degenerative spinal condition that’s causing side effects like weakness; a slipped disk that isn’t improving; a tumor on your spinal cord; or a broken or dislocated bone in your back. In most cases, your surgeon will discuss with you appropriate treatment based on your clinical history. However, it is important that you let you your surgeon know if you have unrelenting pain, neurological issues or a serious problem like a spinal cord injury.
Types of surgery Some minimally invasive procedures are outlined below.
Balloon kyphoplasty Balloon kyphoplasty (BKP) is a minimally invasive surgery that can stabilize a fracture or compressed vertebrae due to osteoporosis, cancer, or noncancerous tumors. It can alleviate your back pain from a spinal fracture and restore vertebral height and proper spinal alignment. Other benefits include improved mobility, ability to perform daily tasks and better quality of life. During surgery, balloons are used to elevate the fractured vertebra to return it to the correct position. The balloon creates a cavity that is filled with a special cement to prevent collapse from happening again. Good candidates are people with severe pain, those too frail or old or whose bones are too weak for spinal surgery, or younger people who have osteoporosis (where bones become weak and brittle) caused by steroid treatment or a metabolic disorder.
Diskectomy Here, the damaged portion of a herniated disk is removed from the spine to relieve irritation and inflammation of a nerve. A herniated disk happens when some of the softer material inside the disk pushes out through a crack in the exterior. Typically, surgery involves full or partial removal of the back portion of a vertebra to get to the ruptured disc. It’s most effective for treating pain that radiates down your arms or neck pain. It’s less helpful for treating back pain. But your health care professional may suggest it if other treatments haven’t worked or your symptoms worsen.
Laminectomy Here, bones overlying the spinal canal are removed. That enlarges the spinal canal and creates space, relieving pressure on the spinal cord or nerves. Typically, the pressure is caused by bony overgrowths in the spinal canal, also known as bone spurs. These growths can happen in people who have arthritis in their spines and are also a normal part of aging. A laminectomy is generally only used when more conservative treatments haven’t relieved symptoms or symptoms are severe or worsening.
Spinal fusion Spinal fusion permanently connects two or more bones in your spine with metal plates, screws or rods. That fusion forms one, immobile unit. The surgery improves stability, corrects a deformity and relieves pain. It can be used to stop the progression of a spinal deformity (such as scoliosis), spinal weakness or instability, or a herniated disk.
Artificial disk replacement Here, worn or damaged disks are removed and replaced with artificial ones. The procedure aims to help relieve back pain while maintaining normal motion. In general, good candidates for disk replacement have no prior surgery on the spine, no spinal deformity, back pain that’s caused by one or two problematic disks, and no significant joint disease in the spinal nerve.
Make sure to speak with a health care professional about both the benefits and risks of these procedures.
Spotting gray hairs on your head. Forgetting where you put the car keys. Waking up a bit earlier. These things all can be a part of life as we get older.
But what about your back. How much back pain is normal? Is it OK to be in pain or is something bigger going on? Yes, basic aches and pains are facts of life. So, a little spine pain is totally normal and common.
Still, back pain shouldn’t be severe and significant. You shouldn’t have sharp pain when you wake up and you can’t recall doing anything out of the ordinary, says Roy Nissim, DC, a chiropractor who practices in Santa Monica, Calif.
If you did yardwork and you normally don’t, it’s normal to be a bit achy. But if you’re in construction and you’re in back pain (even after taking some over-the-counter medicines to help relieve pain and inflammation), something may be wrong. “We can wake up with aches and pains,” says Dr. Nissim. “But a sharp and dull pain isn’t normal. For most, if pain lingers for more than 48 hours, that’s a red flag. A light bulb should go off that something’s not right.”
He also says you want to look out for pain that goes away and then returns feeling worse. That can be a red flag that something is going on.
Don’t wait to visit a health care professional if you’re in pain. “Don’t let pain linger longer than a week,” says Dr. Nissim. “If something is bothering you, seek help. It’s easier to treat and resolve something that’s new, fresh and acute rather than treat something that’s chronic.”
Why prevent falls No one likes to fall. It’s embarrassing and, as you get older, it’s dangerous. If you prevent falls, you ward off most fractures and serious injuries. According to the National Council on Aging, falls are the leading cause of both fatal and nonfatal injuries for older Americans. In fact, 25 percent of Americans ages 65 and older fall at least once each year. What’s worse, falling once doubles your chances of it happening again.
You can take some general measure to help prevent falls. Work on balancing exercises, says Dr. Nissim. For example, stand on one foot. Or sit and then stand without using your hands to help you up and down. Be aware of your surroundings. For example, sit a moment before you get out of bed. Then stand and get your balance before you walk. Women should avoid high-heeled shoes, which may make them prone to tripping, Dr. Nissim says.
Vertebral compression fractures Vertebral compression fractures (VCFs) are the most common fracture in people with osteoporosis, affecting about 750,000 people annually, says the American Association of Neurological Surgeons. VCFs affect about one-quarter of postmenopausal women in the United States. The risk of this condition increases with age; about 40 percent of women age 80 and older are affected.
VCFs happen when the bony block or vertebral body in the spine collapses. That can lead to severe pain, deformity and height loss. These fractures happen more commonly in the middle portion of the spine.
Most of the time, VCFs happen without an injury or pain. It can be caused by something as insignificant as a sneeze. One of the first signs of a VCF is height loss. Do your adult children seem taller? Do you need to hem pants you’ve worn for years? Are you suddenly unable to reach a shelf? This may mean you’ve experienced VCF.
Risks if left untreated A VCF is painful. Even when you don’t feel it, says the National Osteoporosis Foundation, it can be serious. People who’ve had one VCF are at five times the risk of having a second one. Risk for death goes up to more than 50 percent a year after a vertebral fracture. Each broken vertebra raises the risk for another since it changes how weight is balanced on the spine. You’ll experience pain in your back and chest since these muscles have to work hard to hold you upright. It gets harder to walk. You develop stomach troubles and difficulty breathing. If you do nothing, you may experience disability.
Treatment options Current therapies for vertebral fractures include nonsurgical and surgical treatments. Nonsurgical management includes analgesia, bed rest, physiotherapy, and back bracing.
A balloon kyphoplasty (BKP)—a minimally invasive surgery that can stabilize a fracture or compressed vertebrae due to osteoporosis, cancer, or non-cancerous tumors—is another treatment option. It can reduce your back pain from a spinal fracture and restore vertebral height and proper spinal alignment. Other benefits include improved mobility, ability to perform daily tasks and better quality of life. During the surgery, balloons are used to elevate the fractured vertebrae to return them to the correct position. The balloon creates a cavity that is filled with a special cement to prevent collapse from happening again. Good candidates are people with severe pain, those too frail or old or whose bones are too weak for spinal surgery, or younger people who have osteoporosis caused by steroid treatment or a metabolic disorder.
Although the complication rate for BKP is low, as with most surgical procedures, serious adverse events, some of which can be fatal, can occur, including heart attack, cardiac arrest (heart stops beating), stroke, and embolism (blood, fat, or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs, and/or heart. Talk to a health care provider about both benefits and risks of this procedure. A prescription is required. Results may vary.
Taking control of painful symptoms is challenging under even the best of circumstances. Yet, taking affirmative steps in this regard can be empowering. These five tips can help you manage your pain both on your own and in connection with others.
1. Become aware of your baseline pain and create a self-care plan. Gain familiarity with your symptoms. This will allow you to recognize when further intervention or changes need to be made, or if your treatment is working. Next, develop a self-care plan. Create a schedule, routine, or checklist for your treatment so that you can comply with your physician’s directions and engage family and friends where you may require assistance.
2. Self-manage your pain alongside a comprehensive treatment plan. A comprehensive treatment plan can empower your health. There are many components that can go into a treatment plan such as proper diet and exercise. Another way to keep up with an active lifestyle is to make massage part of your daily routine. In fact, according to research, a significant reduction in pain levels can be achieved with therapeutic massage. In addition to relieving tension, massage can help decrease swelling and improve blood circulation to promote the healing of soft-tissue damage, bruising and muscle fatigue. It also helps improve flexibility and mobility faster while reducing overall stiffness.
Massage can also impact the healing process by improving relaxation, sleep, emotions and overall recovery. There are many options for massage, and often at-home tools may be the most convenient for individuals who are limited by function or time. For example the Wahl Deep Tissue Massager is a useful tool to add to a pain management regimen that’s convenient, cost-effective and respectful of your busy schedule.
3. Communicate your limitations to people close to you. By communicating clearly to your close friends and family, misunderstandings and stigma can be avoided. Clear communication can create a path toward additional support for better health outcomes. Pain is a subjective phenomenon, and until you communicate about it to your doctors, they cannot help you make a road map to reach your destination of pain relief. Communicating about your pain will help you garner support and it is the first step to alleviate the cycle of mental stress related to your painful symptoms.
4. Create a goal-oriented daily routine that you can achieve. Setting a reasonable framework will help you cope with your pain and stress in an effective manner. Clarifying roles and responsibilities for yourself and those within your support network can ease anxieties that could exacerbate pain. Perhaps you are taking on a function that is better delegated, oralternatively, maybe an already delegated task could be better accomplished on your own. Creating reasonable expectations for the people in your circle can help you ultimately gain traction in your health goals.
5. Learn coping mechanisms to address your mental health wellness. Coping is key to dealing with chronic pain. There are negative emotional consequences of chronic pain that require one to think positively and practice gratitude. Meditation can give you a spiritual experience and support. The regular practice of meditation creates a relaxation reflex. It calms your mind and releases tension in your body tissues. Practice positive affirmations and continue to stay focused on your goals to better health.
Additionally, music therapy can be a useful way to supplement a comprehensive pain treatment plan. Listening to the music of your choice can help your body calm and release the tension in your muscles. As suggested by a research study, music interventions may provide a practical complementary approach for the relief of acute, procedural and chronic pain management. These are only a few examples of coping mechanisms which you may choose to integrate into your treatment plan.
As my mother always warned me that to get older is to feel some aches and pains. And I’m feeling them! My knees, my back, my.… And I’m finding lots of kinship among my middle-aged pals.
I keep hearing that CBD helps relieve chronic pain. Is it really the miracle cure it claims to be? If so, I’m tempted to run out and buy some CBD.
But I’m cautious and have a lot of questions. It seems like the claims might be too good to be true. Are they?
Yes, CBD is all the rage and, if you happen to live in a state where it’s legal, you might be seeing it sold on just about every street corner in many iterations. CBD lattes. CBD gummies. CBD-infused spa treatments. CBD for XYZ.
Here’s what we know, so far.
CBD, or cannabidiol, is a chemical compound derived from cannabis, a hemp plant that differs only from the marijuana plant because it contains less THC, or tetrahydrocannabinol, which produces marijuana’s mind-altering effects.
CBD doesn’t produce the euphoric “high” or psychoactive effects of cannabis. Instead, it’s supposed to produce a feeling of calm or relaxation. Read more about CBD for Women: What Are Women Using CBD For?
Instead of messing with your mind, CBD encourages the body to use its own endocannabinoids more efficiently by interacting with them to produce pharmacologic effects in the central nervous and immune systems. (Sounds like a mouthful, but basically CBD influences the activity of endocannabinoid receptors and in turn, activates other receptors that control things like pain perception and inflammation.) There are endocannabinoids and receptors throughout our bodies: in our brains, organs, connective tissues, glands and immune cells—just about all of the body’s organs. One researcher calls them the “bridge between body and mind.”
That’s why a lot of people are interested in using CBD and hopeful that it will help ease or manage their pain.
Still, the jury is still out. Although CBD is widely used, the only strong research and evidence of its effectiveness has been done with a specific and rare form of childhood seizure disorders called Dravet syndrome and Lennox-Gastaut syndrome (LGS), which do not respond to antiseizure medications.
Experts say that more studies are needed in humans to determine the scope of what CBD can and cannot do. Some (that have been done on animals) have found CBD to be effective for nerve pain and the pain and inflammation of arthritis.
The studies that do point to CBD’s possible effectiveness say that it may limit inflammation in the brain and nervous system; that it stops the body from absorbing a compound associated with regulating pain and therefore may reduce the amount of pain a person feels; that it may help with insomnia and chronic pain and help people with multiple sclerosis (MS) by reducing spasms, one of the most common symptoms of MS.
The Arthritis Foundation has published advice from Daniel Chow, MD, a chronic pain expert. Here’s what it shares:
Use low doses, which seem to work best for pain relief.
Start with a CBD-only product, 5 to 10 mg twice daily, and then slowly increase, going up to dose of 50 to 100 mg per day. If that doesn’t help, try a CBD product with a low dose of THC. (But remember that THC remains illegal in many states and is only approved with a prescription for medical use in some others.)
Use only at night at first; slowly increase dose if needed.
Edibles’ effects last longer than vaping, so don’t try them until you know what CBD strain and dose work for you.
Use caution if you are 25 years old or younger and using CBD products that contain THC. This age group is at highest risk of addiction, dependency or even psychosis.
If you do choose to treat your pain with CBD, it’s best to be aware of a few facts.
CBD doesn’t come without its side effects, which include nausea, fatigue and irritability. And like grapefruit juice, CBD can raise the level of certain medications in your bloodstream (if you take the blood thinner warfarin, beware). Always check with your health care professional before taking CBD or other over-the-counter supplements or medications.
Many products do not contain the amount of CBD they claim.
The amount of CBD in products varies widely. Some contain very small concentrations of CBD, while others contain very large amounts. For instance, manufacturer Bluebird Botanical’s CBD lotions contain 700-plus mg of cannabinoids per 100 mL, while other currently available topical products contain just 50 mg of cannabinoids per 100 mL.
Because it’s not sold as a supplement, rather than a medication, CBD’s safety and purity are not regulated by the U.S. Food and Drug Administration.
If you take sedatives or other sleep-inducing medications, use CBD with caution, because it may enhance their effects.
Taking a high daily dose (20 mg per kg of body weight or hundreds of milligrams) may result in decreased appetite, diarrhea, vomiting, fever or extreme fatigue.
Products should be labeled with information on exact dosing and the type of CBD they contain. Terms for real CBD include full-spectrum, broad-spectrum, isolate or nano.
Because there are not enough studies on humans, it’s tough to know what an effective dose of CBD would be.
Brandon Beatty, CEO of Bluebird Botanicals, a leading manufacturer and distributor of hemp extracts and CBD oils, offers this advice: “Look for the concentration of cannabinoids per milligram. Check the ingredients to make sure they indicate the use of a full-plant extract as opposed to hemp seed oil, because only a full-plant extract will actually contain any amount of CBD. Hemp seed oil does not contain CBD, but it is often used as an emulsifier in many beauty products.
“Also be sure to look on the company’s website for third-party lab testing to make sure there are no harmful contaminants in your product, such as pesticides, heavy metals, mycotoxins, and residual solvents. We also recommend looking for products with ‘clean,’ natural ingredients, which is what we like to call ‘wellness the way Mother Earth intended.’”
Also, check the laws where you live. Even in areas where medical or recreational marijuana is legal, some federal agencies and state laws still restrict CBD. It’s all very confusing.
The bottom line? If you do choose to try CBD, proceed with caution and remember that there has been little medical research done on CBD. Check with your health care professional, if for no other reason than to make sure it won’t interact with any medications you currently are taking.
Pain in your neck. Pain in your back. Pain during that time of the month. We’ve all had pain, some of us more than others. But how much do you really know about how to manage all your aches and pains?
We spoke with an expert on pain management to get you the answers you need. Yvonne D’Arcy, MS, CRNP, CNS, is a pain management and palliative care nurse practitioner with more than 20 years of pain management experience. She has held positions as pain and palliative care nurse practitioner for Johns Hopkins Medicine Suburban Hospital in Bethesda, Maryland, and Mayo Clinic in Jacksonville, Florida. She is the author of 10 books on pain management and presents frequently on a variety of pain topics.
Here is what she had to say about pain management and her current work.
Question: What is the latest book you’re working on?
Answer: For many years, I thought primary care practitioners needed a book for pain management. The majority of people with chronic pain are showing up in primary care practices. Arthritis, osteoarthritis, migraines, other types of chronic pain, low back pain. They show up in a primary care office. Practitioners need some direction for patient management and support. I thought this is a book that was needed for a long time. It will be published in the first quarter of the year by Springer. It’s for health care providers—physicians, nurse practitioners, physician assistants; those folks that are seeing and prescribing medications.
Question: Why did you see a need for this book for health care providers?
Answer: Primary care physicians are being inundated with all these patients with chronic pain. They do see ones with acute pain like slips, trips and falls. The vast majority of low back pain and migraine and arthritis cases are seen in the primary care setting on a long-term basis. Many of the pain clinics send people back to primary care. This book is a long time coming. I’m enjoying writing it. It contains a lot of new and interesting materials that I think clinicians will be able to use efficiently.
Question: Is pain management different for men and women?
Answer: That’s an interesting question because it depends on which side of the gender gap you’re on. I wrote a book on women’s pain and can tell you that there are definite differences. Men use morphine efficiently. Women get a huge number of side effects. Women are seen as catastrophizing more. Women try to tough it out and self-treat it. It’s hard on women because they have to take care of kids, cook, clean and have a lot on their plate. When they have pain, it is more of an issue.
Question: Is it true women have a higher tolerance for pain?
Answer: Tolerance is defined as how much pain someone is willing to experience. Women do have a higher tolerance and are willing to experience a higher level of pain. Pain is produced along the same pathways in men and women. Men tend to want things taken care of. A woman by far and large probably would just keep going with her pain with a migraine. They keep pushing ahead, looking for something to take care of it.
Women’s pain is treated a lot differently. It’s minimalized and marginalized. Male doctors try to make it seem we’re complaining of something that isn’t quite as severe as it is. If you’re a minority woman, they have found that Hispanic and African American patients don’t get pain medications as readily in emergency rooms as patients who aren’t. It’s just part of that medical disparity because doctors just don’t seem to take their pain as seriously as other patients. It’s perceived that they’re just looking for medications, even when they’re not.
Question: What should women consider when seeking pain management?
Answer: Women looking for pain management physicians need to interview them. They want to work with someone who is empathetic to their condition and who is willing to commit to long-term follow up and support. They shouldn’t be focused only on medications. They should give a more holistic response. Women are more interested in essential oils and massage and acupuncture. Look for someone who includes that in your plan of care.
Anyone can prescribe medications. You need to make sure that the provider is someone you can rely on and trust. I feel sorry for women when get sent to a pain management specialist. I think they get categorized even before they get treated. You need to look for someone who is open-minded and listening to you and to what you’re saying about your pain. If not, you need to find someone else.
I encourage women to go on websites with patient testimonials about providers. I think women should spend more time looking at that, so they have a good idea of what other folks have experienced. They don’t need to feel bad if a provider they see doesn’t work for them. You can use the patient advocacy system that you’re working with and have them find a different provider. You don’t have to stick with someone you don’t like.
Question: What should women know about addictive pain management options?
Answer: There are a variety of things. Some patients with chronic pain do better with low doses of opioids. They have jobs and families and they do very well. They should know that there is the potential that they can develop a reliance on them. Women need to know that medications won’t take away all their pain.
The negative thing is that there is the potential for developing substance abuse: Those who take more pills than are prescribed; get early refills; get pills from a multitude of providers. You should be going to one doctor, not shopping around town. But there is always the potential that can happen. Medications do cause addiction for some. But they are a good fit and can provide a higher quality of life, for others. It just depends. Use the lowest dose for a shorter period of time. Health care providers can offer a trial to see if it’s effective. They’re looking at in healthier ways.
Question: Anything else you want to tell women about pain management?
Answer: Women need to be self-advocates. They can’t let the system take over. They can’t be afraid to disagree. They need to say, “That just doesn’t work for me,” and tell people what they need. If we can get more women to do that, we will be in good shape.
Whether you live in a bustling metropolis or a quiet rural area, chances are you’ve been touched by the opioid epidemic in some way—or you will be.
While many people can safely use prescription opioids, others end up addicted to them. In fact, most people who end up using heroin (an illegal opioid) started by using prescription opioids.
Women are more apt than men to suffer from chronic pain, which sometimes means using prescription opioids. Even if you never misuse opioids yourself, your spouse, child or other loved one might be struggling. As the likely gatekeeper for your family’s health, it makes sense that you’d want to find the best resources available—or perhaps even join forces with others in your community to develop new ones. While traditional drug rehabilitation programs (both inpatient and outpatient) play an important role, novel ideas are transforming how communities across the country are tackling this problem from all angles.
Here’s a look at a few unique approaches that are making a difference for women and families.
Many parents worry about keeping their teens drug-free, and school-based early intervention programs seem to be an effective way of making that happen. Research funded by the National Institute on Drug Use found that seventh graders who participated in a LifeSkills Training (LST) prevention intervention program were substantially less likely to misuse opioids compared to children in control communities.
The LST program has been implemented in schools in many states. The LST Prescription Drug Abuse Prevention materials can be ordered online, so it’s easy to get them for your local schools (with the support of your educators and administrators).
Substance abuse often runs in families due to both genetic and environmental factors. Camp Mariposa is a free program for children, ages 9 to 12, who have been impacted by a family member’s substance abuse issues. Campers attend several weekend retreats a year, during which they spend time with mentors, learn mindfulness skills to cope with trauma and gain confidence while participating in fun activities.
There are currently 13 Camp Mariposa locations throughout the U.S., and the organization is open to expanding by partnering with additional mental health and youth support groups.
The first national self-help addiction program created specifically for women, Women for Sobriety, can be used independently or in conjunction with other recovery programs. Weekly support groups are held across the U.S. and Canada. The organization also hosts an annual weekend retreat in June that features presentations on beginning sobriety, relapse prevention and overall health and wellness.
Having a baby isn’t easy; add an opioid use disorder to the mix and things get exponentially more complicated. The Moms in Recovery program at Dartmouth-Hitchcock aims to streamline care so that pregnant women and new moms with opioid use disorder can get prenatal and postpartum care as well as psychiatric counseling and medication-assisted treatment for opioid addiction under one roof. The outpatient program also features an on-site food pantry and diaper bank and access to a pediatrician who handles monthly child wellness checkups and gives babies and moms key immunizations.
Opioid abuse disorder and problems with illegal drugs often go hand-in-hand, as heroin use among women doubled between 2003 and 2012. In Oregon, women who have been involved with the criminal justice system can get inpatient help at the Volunteers of America Oregon’s Women’s Residential Center in Multnomah County. Women live in transitional housing while participating in a program designed to prevent relapse and re-arrest. The program boasts a high success rate: Everyone who completes it moves to stable, sober housing, and most obtain solid employment or attend school afterward. Women who have children age 6 and younger can bring the kids with them to the facility.
Opioid use disorder doesn’t happen in a vacuum, and those who have become addicted to opioids aren’t the only ones who suffer. While family support groups abound—you can search for one near you at www.supportgroupproject.org—some Rhode Island residents have been working to heal and shatter the stigma by participating in a “therapeutic theatre production” through COAAST (Creating Outreach About Addiction Support Together). Participants rehearse and perform a short play, “Four Legs to Stand On,” about the impact of opioid abuse on a family, then engage in a “talkback” session designed to get audience members to share how they have been touched by this epidemic.
Hospitalization and surgery are demanding life events that lead to considerable stress and anxiety in patients. The fear of the “unknown” is a powerful force for the patient especially during the perioperative surgical time period. Unfortunately, medical errors and medications errors are often linked to miscommunication, anxiety and poor patient satisfaction which are common occurrences. Moreover, patients perceive the day of surgery as one of the most intimidating days in their lives and there is a real absence of information on predictors of anxiety in the current literature. Additionally, there is mounting evidence that patient education is one critical way to combat stress and anxiety during this time period. Studies have shown that preoperative surgical education can significantly reduce stress and anxiety preoperatively, therefore increasing patient satisfaction.
Preoperative patient education, particularly in regards to medications, is also an essential component of patient safety and satisfaction in today’s healthcare arena. It’s been suggested that changes in preoperative patient education, particularly in a pre-admission assessment testing unit (PATs), is an excellent starting point for an improvement in patient safety and for the increase in satisfaction ratings.
The hospital where this project was implemented was at a for-profit, minimally resourced university teaching hospital in Philadelphia, PA. Moreover, high risk populations, such as substance use disorders, combined with hospitals that are have low access to adequate resources in busy overpopulated urban centers, such as in Philadelphia, pose further burdens on the providers taking care of these patients during surgery. Adding to this is the mounting pressures of productivity, checklists, and efficiency, create minimal time for adequate shared-decision making for communication during the surgical process.
At the time, when I joined the anesthesiology department, there was no organizational health system infrastructure for a pain service or handling a mounting opioid crisis or a broad systemic, pre-operative consultation service to address patient questions immediately prior to surgery. Many patients would only be requested to visit a routine testing center with minimal guidance on how much pain they would have and the risks involved during the course of surgery. Moreover, the high-risk patients that had opioid pain medications or a history of substance use disorders (which was highly prevalent in this population) prior to surgery were less likely to be appropriately screened prior to surgery and less likely to have follow up afterwards since no high-risk clinic existed within the health system. In order to streamline the process, I was charged to organize these processes before, during and after surgery to ensure these high-risk patients had improved pain and communication and ultimately overall better patient satisfaction.
In order to streamline the process, I wanted to first improve communication with patients with an established tool that was standardized. I was already engaged with the World Health Organization (WHO) on prior work regarding pain and was familiar with tools they used for pain and surgery. One such tool was the WHO’s 2014 tool which has a primary focus on patients in the perioperative surgical journey. This specific tool was one of the newest evidence-based WHO instruments called “Patient’s Communication Tool for Surgical Safety” (PCTSS) and composed of a structured, nine-item “Before Surgery” questionnaire. The communication tool consists of a nine-item questionnaire used to improve communication between the practitioner and the surgical patient. These nine questions ask specifics regarding patient’s previous surgical procedures, fluid and food restrictions, pertinent health history, personal hygiene, medication history including supplements, whether a patient is pregnant or breastfeeding, medications to avoid preoperatively, the surgical location, their projected length of recovery and the pain expectations post-operatively.
Given that research and implementation tools developed by the WHO are well-known and respected in health care, I developed a project to use this tool throughout surgical units to improve communication during the surgical process. The goal was to decrease costs, surgical delays, cancellations, and postoperative complications. The educational questionnaire would help increase communication for preoperative patients about surgery, stress and anxiety levels, perceived postoperative goals, and aspects of a patient’s perioperative experience. This questionnaire would also help patients to better relay their preoperative history so that their health care practitioners can fulfill the necessary requirements of their care before any surgical intervention is performed. The structure of the tool would also provide an open dialogue for a more highly effective communication between the doctors and patients, and any family members present.
Improving patient safety is the primary reason to implement this project into the urban-city hospital’s perioperative decision-making process. One of the long-term goals in utilizing this project was to position this hospital’s pain division and anesthesiology department to be aligned with national leaders on the opioid crisis and patient satisfaction. The WHO questionnaire can save healthcare costs despite being a simple, low-cost tool. By reducing surgical delays and cancellations related to errors in obtaining a patient’s past medical information, the goal of decreased surgical and anesthetic risks can be achieved by better communication. The project in turn could be a cost-saving method of reducing perioperative complications and medical mishaps associated with lost and misused healthcare allocations from communication errors while also enriching the communication between health care practitioners and their preoperative patient population.
Several barriers exist to establish a new process in a hospital environment. First and most challenging is to get approval from leadership or get & lsquobuy-in’ that the process is legitimate and necessary. Second, once approval is obtained, training staff and individuals involved in implementation of the process is critical. However, given this particular hospital was under-resourced and staffing was a constant issue, many individuals were unwilling to take on another task to their already burdened daily duties. Third, assigning core leaders throughout the hospital who would implement the tool was another constant challenge. Communication with patients regarding surgery was key performance metric for leadership given hospital reimbursement was directly linked to patient satisfaction. Therefore, leadership understood that patient safety and satisfaction are paramount during patient care. Additionally, information collected during a preoperative assessment is generally used by the hospital’s surgical and anesthesiology team to determine perioperative risks and usually does not get disseminated or coordinated with teams efficiently thereafter. Therefore, collection of data to improve processes long-term would be critical to sustain the program later which would be cumbersome given antiquated computer systems that existed at the time.
The importance of addressing this issue of opioid use, pain and patient satisfaction was critically important to leadership of the hospital given that reimbursement of payment of services was tied critically to the patient surveys. However, most team members felt more compelled to work with the project to address healthcare disparities in the hospital’s most medically and socially vulnerable population in Philadelphia and the growing need to address the opioid epidemic particularly in this area was more of a secondary endpoint. Moreover, if outcome measures show improvement, a revamp of this Philadelphia hospital’s preoperative education will be warranted and funding may be warranted. This eventually would bring long-term sustainability to the program and build the framework for a larger program in the future with staffing.
When we used the tool in a pilot study population in Philadelphia to assess patient satisfaction, we found that providing this tool to engage the patient in the preoperative communication process may have an impact on overall outcomes especially in improving the awareness of complications which was statically significant (p=0.044). Many recent initiatives have stressed the importance of patient communication, both within healthcare teams and within the physician-patient relationship to improve the patient experience. This tool has the potential to engage patients further in ensuring their safety in the patient awareness of complications.
There is a definite need for new strategies to counter adverse effects that hinder the quality of a person’s overall surgical experience and outcome. Preoperative anxiety, especially during surgery, is associated with difficulties in establishing intravenous access, delayed relaxation of muscles, coughing and exacerbation of respiratory issues during induction of anesthesia, heart rate and blood pressure instability, and an increase in anesthetic requirements. Patient anxiety also correlates with elevated pain levels, increased nausea and vomiting risks in the postoperative period, a lengthened recovery period and an increased risk for advanced disease processes. These symptoms all increase healthcare spending through delayed patient recovery times. The implementation of the WHO’s 2014 patient communication assessment through an efficient and well-coordinated project has the potential to enable patients to communicate more effectively with their healthcare providers, improving their awareness of the surgical process and hospital routine leading to improved postoperative outcomes and decrease the aforementioned complications. The financial impact of even small improvements in operating room efficiency is significant to a hospital with a busy OR schedule. A reduction in canceled cases increases volume and improves revenue in today’s competitive healthcare environment. When surgical procedures are delayed, valuable OR time may be wasted, and staff time is under-utilized. This project is an excellent example of the benefits that prevention of complications affords and, “if at least five major complications are prevented within the first year of using the checklist, a hospital will realize a return on its investment within that same year”. The opportunity for not only cost reduction, better surgical outcomes for patients with decreased stress and surgical fears, along with decreased numbers of surgical delays and cancellations should not be dismissed by administrators. Solving key public health problems often requires that healthcare practitioners use research-based knowledge, advocate for public policy changes and engage government agencies to implement change. In today’s healthcare field, scientific researchers, clinicians, and policy analysts have become increasingly conscious of the crucial role that implementation science has in reducing the chasm between what has been shown to be effective in research and what is feasible in healthcare practices. Here is a helpful graphic that shows the questions to ask before and after surgery
As you may have noticed, products with CBD are now touted for all sorts of conditions, including pain relief (for fibromyalgia, for example), anxiety, depression, insomnia, Parkinson’s, Alzheimer’s and cancer. But how effective is CBD, what risks are associated with using CBD and why are we suddenly seeing it advertised and sold everywhere? (For example, this flag has appeared outside a small pharmacy across the street from where I live.) Many important questions do not yet have answers.
The proliferation of CBD products is an important women’s health issue for several reasons. First, chronic pain is a concern for many women – it’s the focus of Chronicillness.co first scientific summit, Chronic Pain in Women, on July 17 and 18. Second, as a fat-soluble compound, CBD (like THC), crosses the placenta, and is present in breast milk. And third, it is possible that CBD products could cause a woman to fail a drug test. (If a CBD product contains THC (the chemical in marijuana that causes a “high”) above the 0.3% threshold allowed under the new federal law, or a drug test is sensitive enough to detect low levels of THC, an individual could test positive. Likewise, if an individual has used a lot CBD products containing low levels of THC, or if a test is specifically looking for CBD, a positive drug test is possible.)
CBD is cannabidiol, one of many compounds found in the cannabis family of plants, which includes marijuana and hemp. Products containing CBD can be “pure” (if it is the single compound), or it can be “full spectrum” when they contain all the compounds extracted from the plant material, (i.e., hemp), and some products many indicate “active hemp extract” without mentioning CBD.
The manufacturing and sale of CBD products have exploded since a December 2018 federal law removed CBD from the list of controlled substances and allowed hemp production, as long as the hemp doesn’t contain more than 0.3% THC.
So, what might CBD good for? The FDA has approved a medicine with CBD (Epidoliex®) for two very rare forms of childhood epilepsy. Some of the advertised CBD products tout benefits for neurological conditions, which may be based on research showing CBD interacts with certain types of neuroreceptors, and some limited clinical data. This information was summarized in a 2017 report from the National Academy of Medicine: “The Health Effects of Cannabis and Cannabinoids.” However, CBD (like its psychoactive cousin THC) has not been rigorously studied outside of the clinical trials for the FDA-approved medicine, and most of the claims about CBD are based upon anecdotes or poorly conducted investigations. What this means for women’s health is that there are significant unknowns and many questions still to be researched.
The FDA is moving forward with developing rules about CBD. A hearing was held in late May, but it is unclear how long it will take FDA to develop and implement new regulations. (See the FDA’s Q&A page about CBD, related products and its regulatory activities here.) In this regulatory void, some states have enacted rules about how CBD products can be sold, marketed, or labeled.
Until the FDA acts, CBD products (with the exception of Epidoliex®) are not being regulated as prescription drugs, over-the-counter medicines, vitamins or as foods, (including dietary supplements). Therefore, adding CBD to any of those products is in violation of federal rules. Because of potential risks to consumers, the FDA has sent warning letters to some companies selling CBD products, particularly when claims are made about the CBD product as if it were a medicine, such as a treatment for cancer or other medical conditions.
Using CBD products rather than FDA-approved or physician-prescribed treatments is another risk associated with the proliferation of CBD products. As the FDA Commissioner wrote about CBD products in April 2019, “We also don’t want patients to forgo appropriate medical treatment by substituting unapproved products for approved medicines used to prevent, treat, mitigate or cure a particular disease or condition.”
The major safety and quality concerns about CBD products can be divided into a few categories:
The good news is that there doesn’t seem to be many direct side-effects of CBD for most people – although the clinical trials for Epidoliex® found some patients developed liver problems. However, outside of the studies on children with rare forms of epilepsy, large well conducted trials are limited, which especially raises concerns about health effects from long-term use. For women with chronic conditions and taking prescription medicines (including birth control pills), the unknown side effects and drug-drug interactions could be particularly important.
Quality, dosing and contamination issues are also serious concerns. How CBD is manufactured or purified is important because different extraction and purification methods produce different mixtures of compounds. Also, extraction from cannabis plant material has traditionally been done using butane or propane, which can leave petroleum residues in the final product. There are potentially other quality and safety problems that can arise in manufacturing – particularly when there is so little oversight or regulations. Specifically, researchers have found CBD products can contain THC, pesticides, lead or other heavy metals. The lack of data also means there is great uncertainty about what appropriate dosage levels might be for particular people or for different uses. And, of course, accurate dosing is a problem when quality control is inconsistent, i.e., how do you know how much CBD you are receiving, if the manufacturer may not be certain about the concentration of CBD in their products.
And why is CBD being added to foods (both for humans and pets) despite this violating FDA regulations because CBD is an active ingredient in an approved medicine? Maybe it is trendy and sounds like a great new thing? Or maybe it is a revenue-driven marketing strategy that is leveraging off state laws allowing the legalization (and taxation) of medical and recreational marijuana – despite marijuana still being illegal under Federal law.
The bottom line is that you likely can get CBD oil, capsules or foods where you live, but are there possible harms? Yes. But what these harms may be is still largely unknown. Therefore, until there are clear rules about the types of CBD products that can be sold and quality manufacturing requirements, including the information that manufacturers and sellers must make available (perhaps similar to the labels on foods or for OTC medicines), what is appropriate dosing, and of course, what CBD might actually be good for, it is “buyer beware.”
This is an amazing time to be a woman in our country. In the past six months alone we’ve had women at the helm of three network morning shows, we’ve had a record number of women running Fortune 500 companies, and our thrilling women’s national team just won the World Cup.
But this is not enough. Women aren’t running the three major networks, the record number of Fortune 500 CEOs was just 33, and when our female athletes get injured their doctors may not have the ability to treat their pain as well as their male counterparts simply because they just don’t know how.
Understanding women from the perspectives of both sex and gender are going to be critical as we look to drive sustainable change in the health arena and particularly in pain management. Nearly a third of Americans experience long-lasting pain, and approximately 20 percent of the population lives in chronicpain. The cost of chronic pain to the country is more than $558 billion each year, which is more than the annual cost of heart disease.
Yet, as much as we talk about pain management, if we don’t explore the disparity of male and female pain, we will not achieve the change that is needed to overcome this crisis.
To help get the conversation started on chronic pain management, Chronicillness.co will convene a Chronic Pain Summit on July 17 and 18, in Ellicott City, MD. The event will feature presentations from prominent pain specialists and is designed to foster dialogue between patients, clinicians, researchers, and industry experts, and will include representatives from federal agencies and other non-profit organizations as well. I am thrilled to be the keynote speaker during this summit.
Together, we aim to raise awareness about chronic pain in women, address existing challenges and knowledge gaps, and encourage everyone to work together as we strive to find new and innovative solutions. Here is a sneak peek at what we will cover during the summit.
In the meantime, here is what you should know right now.
Hormones regulate our systems in the inner workings of how our body is built. Hormones are also involved in biological mechanisms that play a critical role in how women and men feel pain. It was just ten years ago that researchers recognized that female mice responded differently to pokes and prods then male mice. This moment spurred the discovery that pain pathways can vary significantly, and has us now exploring the differences between male pain and female pain.
This discovery was only made because a researcher bucked the trend and included female mice in his research, which was not common practice. If we are going to make an exact change in pain management for women, women need to be a part of trials. If men don’t feel the same pain, we are going to need to adjust how we treat women’s pain.
Gender is societal. It is the expectation that we place on people and the social influences that define who we are, and it plays a role in how women’s pain is managed. The fact is that women report pain differently than men, and doctors respond to women’s pain differently than they to do men’s pain. We also know that doctors assume people who look “better” are healthier and require less treatment.
This issue of gender expectations is critical. Women with chronic pain are more likely to be wrongly diagnosed with mental health conditions than men and be prescribed psychotropic drugs. We also know that women are more likely to be prescribed prescription pain medicines, be given higher doses, and remain on them for longer. And women are less likely to remain on a treatment plan that conflicts with other responsibilities.
Ultimately, when you put misses of love and gender together, it can be toxic. Consider this:
Post-surgery studies have shown that women consistently reported slightly more intense pain than men for 30 different types of surgery, ranging from an appendectomy to knee replacement. At the same time, some studies show that following breast surgery, women who receive a nerve block and regional anesthesia recover better. We also know that among surgical patients, there are more female chronic opioid users than male, and females are more likely to be chronic users than males.
So the question becomes, in treating women like men are we fueling a more significant crisis?
The fact is that we are at a great moment of awareness that we must harness to drive change. We must explore new paths, recognize the impact of sex and gender differences in patient care, and power a new momentum to define best steps to manage pain in women.
Instead, chronic pain management needs to take individual differences into account and ensure an adequate and unbiased response to treatment.
To help get the conversation started on chronic pain management, Chronicillness.co will convene a Chronic Pain Summit on July 17 and 18, in Ellicott City, MD. The event will feature presentations from prominent pain specialists and is designed to foster dialogue between patients, clinicians, researchers, and industry experts, and will include representatives from federal agencies and other non-profit organizations as well.
Together, we aim to raise awareness about chronic pain in women, address existing challenges and knowledge gaps, and encourage everyone to work together as we strive to find new and innovative solutions. Here is what we covered during the summit.
Chronic pain is a significant public health problem nationwide and according to a 2011 Institute of Medicine report can be considered as a disease in itself that requires adequate treatment and research commitment.
Two important differences to consider when treating and researching chronic pain are sex and gender. Sex differences are influenced by both biological and physiological factors such as hormones and genetics and gender differences by societal, environmental and cultural concerns. No matter the source, sex and gender differences must be considered in chronic pain diagnosis, treatment, prevention and management.
That’s because research finds women are more sensitive to pain and rate their pain higher as compared to men. Women are also more likely to have conditions that cause chronic pain—defined as lasting more than three months—such as lower back pain, knee pain (mostly osteoarthritis), neck pain, fibromyalgia, and migraines. Notably too, several painful conditions including uterine fibroids, pelvic pain, endometriosis, and vulvodynia occur exclusively in women.
Women with chronic pain conditions are more likely to be treated with opioids and use these drugs for longer periods of time than men, but even this isn’t a clear-cut issue. Although long-term opioid use can open the door to addiction, many women who take these drugs responsibly worry that policy changes may result in losing access to the only treatment that has been able to ease their pain and being stigmatized as drug addicts.
Recent scientific evidence suggests that the use of integrative and complimentary health approaches may benefit women with managing their chronic pain with or without prescription medications.
Studies have suggested that many chronic pain patients can benefit from incorporating physical therapy, massage, exercise, acupuncture, yoga, Tai Chi, or meditation into their treatment regimen, but most healthcare professionals don’t know enough about these modalities and health insurance companies rarely cover them fully, if at all. Psychological therapies, such as cognitive behavioral therapy, may also be useful, but again research, education, and access are limited.
The Department of Health and Human Services addressed these issues in a recent report and proposed best practices and recommendations for balanced pain management based on biopsychosocial model of care, individualized patient-centered care, better and safer opioid stewardship and a multidisciplinary approach to chronic pain.
In the end, any approach to chronic pain must also recognize that gender, racial and cultural biases often exist in pain treatment and management. Unconscious bias by health care professionals can greatly affect the way pain is assessed, treated and managed in women, especially women of color who are less likely to receive any or adequate pain treatment.
Disability, stigma, workplace related issues, access to care and affordability of treatments are all important issues that impact pain management and the quality of life in women living with chronic pain. Whatever the reasons for these biases and these disparities, the tremendous effects on a woman’s psychological health cannot be underestimated.
