Modern Pain Treatment

Headache & Pain Management Center of Palm Beach

Medical conditions manifesting as pain account for 80 % of physician visits and pain costs Americans $120 billion in expenditures yearly. With this in mind, it is astonishing that only recently has pain management entered the medical school curriculum and gained status as a legitimate medical specialty. Despite great strides in medical research and technology, the mechanisms which make pain a problem in the human body are just now being explained.

The nervous system consists of nerve circuits or pathways, some of which exist to warn of injury or damage to the body and to enable one to react to prevent further trauma. The warning sign that we are all familiar with is the pain message. Acute pain is often a useful sign of underlying injury or disease that needs to be treated. However, recent research shows that with continued activation of "pain nerves" come abnormal changes in nerve connections and braispinal cord chemical messengers which allow the pain message to persist, even if the initial trauma has healed. This results in chronic pain, which is much more difficult to treat than pain from acute injury. As opposed to most instances of acute pain, chronic pain is not useful and can be considered a disease in and of itself. In fact, recent studies show that the effective treatment of acute pain can prevent chronic pain from developing. Thus, measures to prevent post-operative pain are being taken even before a patient goes to surgery. Physicians are learning that it is more effective to treat painful conditions early on, rather than waiting until the chronic pain becomes a disease in and of itself. This is particularly true for conditions such as reflex sympathetic dystrophy, nerve injury, fibromyalgia, and post-traumatic pain states.

Chronic headaches afflict a large proportion of the population. New, very effective medications are available to treat migraines. However, in many patients with very frequent headaches, medication may actually be the problem. The regular use of medication to relieve the pain of headache can result in "rebound headache" with increasing frequency of headache episodes. In such cases, the answer may lie in modification of lifestyle and dietary habits as well as other preventative measures.

The effective relief of many pain conditions requires an accurate diagnosis in order to find the most appropriate treatments. Depending on the exact symptoms, this may involve examination by various specialty physicians, x-rays or MRI, or electrical nerve and muscle tests, among others. Then patients can enter a treatment program customized for their particular needs. This usually requires a multidisciplinary approach, meaning there must be a team of medical professionals from various specialties who work together to provide whatever treatment is necessary. Anesthesiologists, neurologists and neurosurgeons, orthopedic physicians, psychiatrists, rheumatologists, and rehabilitation physicians are among the specialists who have become advocates for patients suffering from pain. Physical therapists and chiropractors, psychologists, massage therapists and acupuncturists may be involved in treatment as well.

A persisting myth about patients in chronic pain is that it's "all in their heads." For reasons mentioned above, severe pain may indeed persist without any visible signs of injury or disease. There are intimate connections between the pain pathways in the brain and spinal cord, and the portions of the brain involved in mood and emotions. As a result, many victims of chronic pain suffer depression as well. This may give a false impression that depression is the primary problem and the pain is imagined. This approach has been an obstacle to many chronic pain patients. In any case, treatment for depression or anxiety is sometimes required, whether it is a result of chronic pain or it was preexisting. Interestingly, many of the older antidepressant medications help chronic pain in non-depressed patients, particularly in cases due to nerve injury. Thus, it is important to recognize that pain is not just a physical phenomenon, that it affects multiple brain areas. This idea creates the framework for a multidimensional approach to pain treatment.

Other barriers to the effective treatment of pain stem from outdated attitudes about pain medications and their tendency to cause addiction (psychological dependence). All opioid medications ("pain killers" related to morphine or codeine) have the potential to result in physical dependence with long-term use. But studies have shown that very few patients with chronic or cancer pain actually become addicted. Better education of physicians and patients, as well as guidelines issued by governmental agencies, have led to more effective treatment of cancer pain in particular.

Managed care has not adequately addressed the treatment of chronic pain. Limitations are set on utilization of certain treatments, but there is no consensus on what types of programs are effective (as well as cost-effective) for treating patients with these conditions. In some settings, the multi-disciplinary approach has been shown to provide better outcomes (better functioning, less long-term reliance on the medical system, less pain medication required) but most insurance companies do not cover such comprehensive care.

Whether you suffer from headaches, back pain, neuralgia, neuropathy, fibromyalgia, RSD or abdominal or pelvic pain, no single treatment is effective for all conditions. Some types of pain do not even respond to strong pain medications. Depending on your diagnosis, other medical conditions, age, and personal preferences, treatment may include medications, physical treatment, electrical nerve stimulation, nerve blocks (injections of numbing medication or cortisone), counseling, or other modalities. The effect of a healthy lifestyle on chronic pain is well known. A fit body and good attitude can affect the endorphin/enkephalin brain chemical systems which can act as natural pain killers. A good diet, regular exercise, and an active life are useful adjuncts to other modalities of pain treatment.

For additional information, please see the following web sites:

palmbeachpain.com
www.pain.com
www.aan.com
www.achenet.org
www.spineuniverse.com

Dr. Friedman is board-certified in neurology and in pain management and is on staff at Jupiter Medical Center and Palm Beach Gardens Medical Center.

Education:
1982-1986
University of Pittsburgh
Pittsburgh, PA
M.D.

1978-1982
Dartmouth College
Hanover, NH
A.B.; Cum Laude; with distinction in major subject

Training:
1996 Clinical Fellow
Department of Neurology (Pain Management)
John Hopkins University
Baltimore, MD

1987-1990 Neurology Resident
Chief Resident
Dartmouth-Hitchcock Medical Center
Hanover, NH

1986-1987 Intern (Internal Medicine)
Allegheny General Hospital
Pittsburgh, PA
1999-2000
Interventional Pain Management Training Florida Pain Clinic Ocala, FL

Employment:
1998-Present
Robert J. Friedman,
M.D. PA and Headache and Pain Center of
Palm Beach, Jupiter and Lake Worth, FL.

1996-1998
Pa