Pain and Pain Management.

This is the bit that hurts (Excuse the pun).
Pain tells us that something is not right with our body and that you should stop, …. take stock of the situation, …. then sort out the problem.

All of us have endured pain through our lives, from falling over in the school playground to surviving the dentist chair, and (for our ladies) giving childbirth, we can go on….

AVN puts a different twist to the feeling of pain, probably only another AVN sufferer will understand when you try to explain your own feelings of pain.

For non-sufferers it can be described in a number of ways, trying to bring the realism of the pain from AVN.

Edvard Munch The Scream

Edvard Munch The Scream

The Writer’s own explanation

This is how I describe my own situation, I have AVN in my right knee, left knee, left ankle, and left foot.

(Please be warned – this is not nice reading for anyone) Now imagine a very sharp knife blade being very gently pushed in from the inside of the knee sliding underneath the knee cap. OK, some pain – but as it was a very gentle insertion one would imagine bearable. Now for the bad bit, imagine this knife blade is now being violently twisted through 90 degrees, like with a quick flick of the wrist, as if to lift the cap right off the knee ….. Yes, it reads horrible, but for me, it’s my best way to describe the pain in words (really sorry if I have upset anyone).

Other explanations
Descriptions taken from other sufferers – Imagine climbing the stairs normally, one step at a time, or getting up from your chair, then suddenly collapsing onto the floor in a world of pain which can only be described as a fire inside your hip or knee. The pain is so sudden it hits you like a bolt of lightning. Many describe it as “The knives”.

Another description is a “Pressure Cooker” inside the joint.

Hopefully reading this you can try and imagine what the pain feels like.

The one really bad thing with AVN is that the pain often never goes away. It will fluctuate day by day, even week by week but never goes, you can end up accepting it as normal.

In the future, we will just refer to this pain as “The knives”.

Pain Relief

Pain Relief

Managing pain
There are many ways to manage persistent pain. Here we try to summarise.

Pain Relief – Drugs – Analgesics

1) Non-steroidal anti-inflammatory drugs (NSAIDs) have been used for 150 years in Europe, and probably for a great deal longer in the East, in the form of willow bark extract. Useful when given appropriately, examination of the chronic pain population indicates that a very high number of patients are intolerant to these drugs because of gastrointestinal or other side-effects. There are two possible hypotheses for this. Firstly, chronic pain sufferers tend to be somewhat hypochondriacal and intolerant of body symptoms in general and thus less tolerant of real or perceived side-effects when taking medication. The second is that there may be a sub-group of patients whose pain is not managed well early on. NSAIDs may produce side-effects, limiting their use. With no pain relief, the patient fails to exercise. This hampering of their rehabilitation because of inadequate analgesia may contribute significantly towards the chronicity.

2) The use of opioid drugs for the management of chronic non-malignant pain is fraught with difficulties, some real and some perceived. Morphine itself has tended not to be prescribed for chronic pain, because of fear or stigma concerning Morphine. Physicians may fear dependence, tolerance, and side-effects. There is a wide difference of opinion, which is still to be resolved; however, some patients can have their pain adequately controlled with opioids, without an unacceptable level of addiction problems. The potential risk of addiction remains a very real problem for a minority. Also, a significant number of patients with chronic pain complain of bothersome side-effects from medication. Mobility and distress must be monitored and benefits must accrue in both these parameters, as well as in the reduction of pain.

3) In the UK and in the USA, traditionally most patients with chronic pain receive an opioid derivative such as Codeine, Dihydrocodeine or Dextropropoxyphene. In the past, Pentazocine and Buprenorphine enjoyed a passing vogue but are now little used. Pentazocine proved to have unacceptable side-effects, and Buprenorphine, originally thought to be non-addictive, was shown to have addictive potential and since being classified as a controlled drug has enjoyed little popularity. Nefopam has limited efficacy and popularity, and Meptazinol is short-acting and often associated with an unacceptable level of side-effects.

4) Recent work suggests that Codeine and Dihydrocodeine are merely pro-drugs for Morphine, and exert their action through metabolism to this compound. Given that a significant number of the population do not have the metabolic pathway to facilitate this, it is not surprising that there is a significant failure rate to produce any analgesia at all and that patients getting analgesia seems to get limited relief-hence possibly the popularity of these preparations being compounded with Paracetamol. There is good evidence that in some patients, much of the analgesic effect in these combined preparations lies with the Paracetamol itself, whilst many of the side-effects lie with the opioid.

5) Tramadol hydrochloride is an orally active, clinically effective, centrally-acting analgesic. It can produce analgesia that has been compared to Codeine or Dextropropoxyphene. It has been used in post-surgical pain, obstetric pain, cancer pain and chronic pain of mechanical and neurogenic origin. Analgesic tolerance is not a significant problem, and psychological dependence and euphoric effects are minimal. There are a significant number of patients in the chronic group who develop side-effects, but many of those who tolerate the drug get useful benefits in pain reduction. This slow-release formulation is an appropriate vehicle for chronic pain management.

Tramadol has an affinity, albeit relatively weak, for mu opioid receptors. It is also a neuronal uptake inhibitor. The monoamine neurotransmitters 5HT (Serotonin) and Noradrenaline (NA) are involved in the inhibition of spinal cord dorsal horn neurone responses to painful stimulation (i.e. closing the gate). Analgesia can result from activating the pain inhibitory pathways originating from higher CNS levels, and containing these neurotransmitters. Tramadol inhibits the uptake of 5HT and Noradrenaline but not Adenosine, Cyclic AMP, Dopamine, or Gaba.

Meta-nalysis by Moore and McQuay indicates an appropriate dose-response curve for Tramadol and suggests a reduced number needed to treat to show therapeutic efficacy as compared with Codeine, in doses of 75 to 150 mg. Nausea, vomiting, and dizziness are greater than with Codeine, somnolence about the same and constipation much less. In the chronic pain situation, nausea and vomiting are attenuated with usage, as is somnolence for both drugs, but constipation remains a particular problem with Codeine and Dihydrocodeine, and less of a problem with Tramadol.

Side-effects from Tramadol can be minimised by starting with a low dose and increasing gradually. There is evidence that this reduces side-effects and improves tolerance. According to need, it can be started in a low dose of 50 mg daily or twice a day, and gradually titrated to reach 50 mg three times a day by day 3. Once a patient is established on a therapeutic dose, they can be put on the slow-release formulation to provide round-the-clock analgesia.
From – The Pain Web

B. Psychoactive drugs
1) Anticonvulsants are well-acknowledged as being effective in the management of shooting pain, for example, trigeminal neuralgia and the shooting element of neurogenic pain, such as post-herpetic neuralgia, diabetic neuropathy, and similar conditions. Carbamazepine appears to be the most effective drug although there is a higher incidence of side-effects than with Sodium Valproate. Recently Gabapentin and Lamotrigine are enjoying popularity, either as “add on” drugs, or as sole agents. Further drug development of these types of agents might produce useful efficacy in the future.

2) Tricyclic antidepressants are one of the most commonly used analgesics in pain clinics. This is not for the specific antidepressant action but is more associated with the activation of pain inhibitory pathways. This appears to be less of a feature with the tetracyclic agents and has meant that their usage in chronic pain has as yet remained unproven. This is, of course, is disappointing as the side-effect profile is significantly better. The sedative effect of Amitriptyline can be harnessed to good usage by giving the tablet one or two hours before retiring, and it should not be used during the day.
From – The Pain Web

Analgesic pain management

Analgesics for Avascular Necrosis AVN pain relief

Analgesics for Avascular Necrosis AVN pain relief

In general, patients with pain can be given a trial of Paracetamol. An appropriate non-steroidal can be used if there is an inflammatory process and continued if these are effective and if side-effects are minimal. The next optimal step in the analgesic ladder will be the use of agents like Tramadol, Dextropropoxyphene, or Dihydrocodeine, with long-acting preparations being ideal for chronic pain. At present, slow-release Tramadol would appear to be the most effective drug in chronic pain for this group of patients. If side-effects preclude its usage, one of the other agents can be considered.

Finally a small group of patients might be suitable for the use of opioids themselves.

In conjunction with this analgesic ladder, anticonvulsants and tricyclic antidepressants can be considered, for their specific and appropriate actions on shooting and burning pain, usually of neurogenic origin.
From – The Pain Web

Acupuncture for AVN pain relief

Acupuncture for AVN pain relief

Alternative pain management –¬†Acupuncture
For some sufferers, acupuncture can bring some pain relief. Success is dependent on the patient being receptive to the needles and the knowledge and skill of the practitioner.

Reported results are that on the day of the acupuncture drowsiness is common, care should be taken with driving or operating any heavy machinery. The pain relief is reported as being observed the following day for one two or three days.

Clearly, no two sufferers are the same, and no two practitioners are the same.