Doc: Chronic pain management a complex issue
Dear Dr. Roach: The letter from the person taking tramadol for 10 years hit a nerve. Your answer prompted me to write.
My 63-year-old husband has been on painkillers since 1994, when he tore his ligaments around L-5/S-1. He had back surgeries in 2002 (fusion and hardware), 2005 (remove hardware that was bothering him) and 2005 (two weeks later, emergency debridement surgery for infection).
Over the years, he has taken every form of opiate out there, and when workers’ compensation decided to stop paying for his OxyContin last year, his pain management specialist put him on buprenorphine 2 mg, twice a day. Nothing really helps; it just keeps the pain down to a dull roar. He also takes gabapentin for neuropathy.
His pain doctor has now retired, but the doctor’s associate keeps prescribing the tablets each month with no discussion of ever trying to wean him off. I’m not sure if these meds were ever intended to be for life. He has never abused the dosages, but he seems to think that if he were weaned off the medication that he would be in an unbearable amount of pain.
Otherwise, he is in excellent health. We eat well, do yoga and Pilates, and ride our mountain bikes several times per week.
Dear R.A.: Management of chronic pain is a complex issue. One study found that chronic opiate use did not actually reduce the pain the person is in, at least by self-reported pain measurements. Over time, the body adjusts to the amount of pain medication. On the other hand, there are some people who have much better pain control on opiates, so an experienced pain management specialist must use his or her best judgment, and sometimes a trial of reducing dosage is appropriate.
Gabapentin is a common treatment to reduce overall pain. However, it is important to recognize that complete cessation of pain is unrealistic, and keeping the pain manageable and keeping up activity are appropriate goals.
Dear Dr. Roach: Can a blocked saliva gland cause a cough? I had one stone removed and continue to have swelling. I have a cough and wonder if they could be related.
Dear G.S.: The symptoms of salivary gland stones mostly have to do with the glands themselves: swelling and sometimes pain. Initial management includes fluid intake, moist heat and “milking” the duct to promote passage. A sour candy like a lemon drop, which promotes saliva, can help make the diagnosis, as it may cause an increase in pain, but it also can pop the stone right out if the stone is small or near the exit of the duct.
Cough is not a usual symptom in salivary duct stones.
Dear Dr. Roach: How long after getting shingles should you take the shingles vaccine?
Dear C.M.: You should wait until the shingles is completely healed before getting the vaccine. However, a recurrent case of shingles is quite unlikely in the first year after getting shingles, so there is no rush to get the vaccine right away.
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