Pain Awareness Month

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September is Pain Awareness Month

What is pain?

According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain is a unique symptom that is different for each individual. The intensity of pain can be classified on a numeric scale, with 0 being no pain and 10 being the worst imaginable pain. With this scale, mild pain is a score from 1 to 3, moderate pain from 4 to 5, and severe pain is a score of 6 or more. Another common way to measure pain is by using a 5-point faces pain scale, which starts with a picture of a pleasant smiley face to represent a patient in no pain (see the figure below). The scale continues on with each face getting progressively worse, with finally a picture that shows a facial expression of a patient in severe pain. This type of scale can be useful in children or elderly patients.  

How common is pain?

The most common reason patients seek out medical attention is due to their experience with pain. According to the US government’s annual report on the health of Americans, within the past 30 days, 1 in 4 adults experienced pain, and 10% experience pain every day. The most common type of pain is back pain, followed by headache and joint pains. 

What types of pain are there?

There are many ways to classify pain including duration, location, or cause of pain. The most common way to classify pain is as either acute or chronic. Acute pain results from some sort of injury or a medical condition. It begins suddenly and is usually a sharp pain. Examples of acute pain include burns or cuts, broken bones, surgery, and dental work. Acute pain can also have other symptoms such as fast heart rate, elevated blood pressure, dilated pupils, and excessive sweating.

Chronic pain continues even after an injury has healed.  Unlike acute pain, symptoms of chronic pain can occur at odd times that may not seem to match up with an obvious cause of pain. Examples of chronic pain can include headaches, low back pain, and joint pain. Although there is no clear point at which acute pain changes to chronic pain, it is generally accepted that pain lasting beyond the expected healing period of an injury (3 to 6 months) can lead to chronic pain.

In addition to chronic and acute, pain can be classified as neuropathic, nociceptive, or visceral pain. Neuropathic pain results from disease or injury to the peripheral or central nervous system. A common example of neuropathic pain is a condition called diabetic neuropathy. This condition commonly occurs in diabetic patients because high blood sugars can cause damage to the nerves. The damage on the nerves can then cause sharp pains, usually in the patients’ legs or feet. Another type of pain, known as nociceptive pain, usually results from injury or damage that affects somatic or bodily structures. Some examples of these bodily structures include skin, muscle, bone, ligaments, tendons, and joints. Lastly, visceral pain is pain caused from pressure or aggravation from the internal organs. A common example of this would be pain caused from cancer cells that are spreading and pressing against different internal organs. This type of pain is very hard for patients to pinpoint the exact source of pain and is usually described by patients as a deep, squeezing, pressure-like pain.

What are the common causes or risk factors for pain?

Some risk factors for pain include old age, genetics, race, obesity, and previous injury. ⁶ There can also be psychological risk factors for pain which include childhood trauma and emotional disorders, such as depression. Other risk factors may be due to having a high-intensity job, stress, engaging in strenuous activity, and or a history of smoking.

Why is early diagnosis/treatment important?

Early diagnosis is important because it is possible for acute pain to eventually lead to chronic pain. As mentioned earlier, acute pain may become chronic pain when the pain continues after the original cause of pain has apparently resolved. Therefore, it is important to treat the pain as soon as possible so that it does not lead to any further complications. Additionally, patients should not “tough out” the pain because pain is easier to control when treated early on. For example, medications used to treat migraines should be taken as soon a headache starts or else the medication will not be as effective. All in all, pain is a very serious issue that can affect a patient’s quality of life and, therefore, early treatment of pain is important to control the pain and to prevent the pain from becoming a chronic, persisting pain.

What are the treatments for pain management?

Some non-drug treatments of pain include chiropractic care, psychological treatment, physical therapy, and regular exercise; sometimes surgery may be required.

As for drug therapy management, opioid analgesics and non-opioid analgesics are commonly used. Non-opioid analgesics are used to treat mild to moderate pain and they are easily bought over the counter at local pharmacies. A commonly used non-opioid analgesic is acetaminophen, widely known as Tylenol. Acetaminophen is used mostly for mild pains in backaches, headaches, and toothaches and is also commonly used for its fever-reducing effects. Other non-opioids analgesics includes NSAIDs (non-steroidal anti-inflammatory drug), which are also generally safe for short term but should be used with caution if needed long term. There are many different NSAIDs but some examples of commonly used NSAIDs are ibuprofen (Advil) and naproxen (Aleve). At low doses, NSAIDs help muscle aches, headaches, and fevers. At higher doses, NSAIDs help reduce joint inflammation. Before selecting an over the counter analgesic, be sure to discuss with a pharmacist or physician about what dosage strength is best for you.

For patients who don’t have enough pain relief with non-opioid analgesics, opioid analgesics are an option. Some examples of commonly used opioid analgesics include morphine, oxycodone, hydromorphone, and methadone. Opioid analgesics are much more effective for controlling moderate to severe pain; however, their use is limited primarily by their many side effects that include constipation, sedation, itchiness, and respiratory depression. Furthermore, long-term use of opioids can be associated with tolerance to their analgesic effects and physical dependence.

Some non-analgesic medications may also be used in treatment of certain chronic pain states, particularly neuropathic pain. Certain medications typically used to treat depression and seizures can also be used to treat neuropathic pain. Depending on the particular drug and condition, these adjuvant analgesics may provide significant pain relief in patients with neuropathic pain.

What can I do to prevent pain?

Some episodes of pain are inevitable but some can be avoided with exercise, a healthy diet, and by avoiding high risk activities. For example, try to stay away from heavy lifting to avoid lower back pain. If heavy lifting cannot be avoided, then make sure to use proper body mechanics, such as keeping your back straight and lifting with your legs. Make sure to do proper stretching and warm-ups before engaging in physical activities, such as playing sports. These are just a few things that you can do to prevent yourself from some common causes of pain. Be sure to talk to your doctor to see what else you can do to avoid certain types of pains and to see which options are best for you.

Where can I find more information on pain?

Pain can be a debilitating so be sure to discuss with your doctor or pharmacist about any concerns you may have. More information on pain can be found at the following websites.

·      International Association of Pain:

http://www.iasp-pain.org/am/template.cfm?Section=Home

·      American Pain Society: http://www.americanpainsociety.org/

·      American Chronic Pain Association: http://theacpa.org/

Written by:              

Joseph Truong

Doctor of Pharmacy Candidate

College of Pharmacy, University of Illinois at Chicago

UIC Pharmacy

September 2013

Alzheimer's Disease Awareness Month

September is Alzheimer’s Disease Awareness Month

What is Alzheimer’s disease?

Alzheimer’s disease is a disease that damages the brain’s nerve cells and results in a loss of some brain functions.  Some changes that occur because of the loss of brain functions include memory loss and changes in behavior, the ability to verbally communicate, and in thinking. Alzheimer’s disease is the leading cause of dementia and accounts for 50% to 60% of cases.  Dementia can be described as a decline in memory and brain function.  The decline in brain function is severe enough to interfere with activities of daily life.  At this time, there is no cure for Alzheimer’s disease.

How many people are affected by Alzheimer’s disease?

Over 5 million Americans are living with Alzheimer’s disease. Alzheimer’s disease is the sixth leading cause of death in the United States and the fifth leading cause of death in people aged 65 and older. About 12.5% of Americans over the age of 65 have Alzheimer’s, and it affects 42% of people 85 years old and older. Although there is no known cause of Alzheimer’s, it can be linked to genetic and environmental factors. Alzheimer’s usually presents after the age of 65. Early onset Alzheimer’s is classified as people aged 40 to 64 who develop the disease and also has a stronger genetic link than the Alzheimer’s cases after the age of 65. Early onset Alzheimer’s accounts for approximately 5% of the affected population.  

In 2011, total health care payments including long-term care and hospice were projected to be $183 billion for Alzheimer’s disease. Alzheimer’s disease not only affects the person with the disease, but also affects the patient’s family and caretaker. Family members often care for Alzheimer’s patients, which may become overwhelming and require these individuals to seek addition care themselves.

What are the common symptoms associated with Alzheimer’s disease?

Early Symptoms

·    Memory loss that disrupts daily life

Memory complaints are often the first problem family members notice in Alzheimer’s patients. It is the hallmark symptom associated with Alzheimer’s and is usually seen in the early stages of the disease. Early on, Alzheimer’s patients may forget well-known facts or events such as birthdays and phone numbers. Over time, memory worsens further and affects other functions of memory. Patients may then forget things they just learned and ask the same question over and over again.

·    Difficulty finding the right word

Alzheimer’s patients may also have problems with words early in the disease. Patients generally have difficulty finding the correct word and have a diminished vocabulary. They may forget words in the middle of a conversation, repeat parts of a conversation, or call things by the wrong name. Over time, speech worsens further and patients may develop problems understanding what is being said to them.

·    Misplacing things and forgetting familiar places

Misplacing things and not understanding what they see may also be seen early on in Alzheimer’s disease. Those affected by the disease may tend to put things in usual places and are unable to retrace their steps to find their misplaced object. This may lead them to blame others of stealing. Those with Alzheimer’s disease also have trouble finding their way around familiar places. As time goes, the patient may not be able to recognize objects and eventually not be able to recognize faces.

Later Symptoms

·    Problems doing everyday tasks

In the later stages of Alzheimer’s, patients may begin to have problems doing everyday tasks. It may be hard for patients to do chores, run errands, eat, get dressed, or even brush their teeth. This causes the patient to need every day help either from a family member or a caregiver.

·    Poor judgment and decision making

Another symptom that occurs later in the disease is the patient may develop poor judgment and decision making. An example of this is that they may pay less attention to their appearance and have poor hygiene. They may also make poor decisions with their money and give money to people they normally would not give it to.

·    Social withdrawal

Social withdrawal is also another common symptom that will appear in the later stage of the disease. Patients may withdraw from family gatherings, social events, and may stop doing things they used to enjoy doing. This could also be a sign of depression as well.

·    Changes in behavior

Lastly, in the later stage of Alzheimer’s, patients may have disturbances in their behavior. Patients may appear confused or depressed and may become agitated and aggressive. Some patients may wander or have hallucinations. Patients may also be delusional and believe something is true when it is not. An example of this is that an Alzheimer’s patient believing someone is coming to pick them up to go to the store when no one is actually coming.

What should I do if I experience some of these symptoms?

Having these symptoms does not necessarily mean you have Alzheimer’s disease. But if you or a family member experiences some of these symptoms consistently, you should consult your healthcare provider. They can rule out other causes of these symptoms or, if needed, begin treatment for Alzheimer’s disease early to treat the symptoms and delay the progression of the disease.

What are common risk factors for Alzheimer’s disease?

·      Age

Age is the greatest risk factor for developing Alzheimer’s disease. The odds of developing Alzheimer’s disease increases after 65 years of age. The risk doubles every 5 years after 65. After the age of 85, the lifetime risk of developing Alzheimer’s disease is even greater at about 50%.

·      Family history

A family history is also another risk factor of developing Alzheimer’s. If a parent, sibling, or child has the disease, you are more likely to get the disease. 

·      Depression

Depression has been linked to Alzheimer’s disease. Studies have shown that people with depression may be twice as likely to develop Alzheimer’s.

·      Environment and lifestyle

Environmental and lifestyle factors play a role in developing Alzheimer’s disease. People who have head injuries, heart problems, diabetes, or obesity or who smoke have an increased risk of Alzheimer’s.

What medications are used in the treatment of Alzheimer’s disease?

There is no cure for Alzheimer’s disease at this time, and treatment is focused on reducing the symptoms and slowing the progression of the disease. There are 4 medications that are normally used in the treatment of Alzheimer’s disease: donepezil, rivastigmine, galantamine, and memantine.

Donepezil, galantamine, and rivastigmine are a part of a class called cholinesterase inhibitors. They are usually used first in patients with mild to moderate Alzheimer’s disease. These drugs may help reduce symptoms and improve a patient’s ability to do daily activities. All 3 medications come in a tablet form while rivastigmine also comes as a patch. What is actually used depends on the patient. Factors such as patient preference, tolerability, and cost are all taken into account when deciding what treatment a patient will receive.

Memantine is in a different class of medications called NDMA antagonists and works differently from the other 3 medications. It has been shown to slow the progression of Alzheimer’s disease in the moderate to severe stages. Memantine is usually used in combination with one of the medications above.

What can I do to prevent Alzheimer’s disease?

Although there is no cure for Alzheimer’s disease, there are ways of reducing your risk of developing it. Increasing physical activity has been shown to reduce cognitive diseases that affect the brain. Some small studies have shown that people who are physically active had a lower risk of developing cognitive diseases later in life.

Other studies have shown that people who engage in intellectual activities and are more highly educated may be at lower risk of developing cognitive diseases. Lower levels of education may increase the risk of Alzheimer’s by about 30%.  It has also been shown that people who did activities that engaged their brain in exercises involving memory and reasoning were at lower risk for Alzheimer’s disease as well.

Lastly, lifestyle changes can also reduce the risk of developing Alzheimer’s. The Mediterranean Diet has been shown to decrease the risk of cognitive decline. The diet consists of fresh fruits, vegetables olive oil, dairy products, fish, poultry, and a limited amount of eggs and red meat. Other lifestyle changes such as social engagement may decrease the risk of Alzheimer’s disease.  Marital status, participation in social and political events, and contact with family members have been studied in its relation to Alzheimer’s and have been shown to decrease the risk of developing Alzheimer’s.

Where can I find more information on Alzheimer’s disease?

If you would like to find out more about Alzheimer’s disease, below are few helpful resources:

·      Alzheimer’s Foundation of America: www.alzfdn.org

·      Alzheimer’s Association: www.alz.org

·      Mayo Clinic: http://www.mayoclinic.com/health/alzheimers-disease/DS00161

Written by:    Tuan Vu

Doctor of Pharmacy Candidate

College of Pharmacy, University of Illinois at Chicago

UIC Pharmacy

September 2013

How to get Better Sleep

May is Better Sleep Month

Who has a sleep disorder?

Sleep disturbances are among the most common complaints brought to physicians. Around 70 million Americans have some form of sleep disorder, and 60% of these patients report that their sleep disorder is chronic. Women, seniors, night shift workers, and those with pre-existing diseases are more likely to have sleep disturbances than others. However, less than 5% of people with sleep disorder seek medical attention. It is important to address sleep disorder because it can lead to daytime drowsiness, decreased productivity, mood changes, and overall poor quality of life.

Why is sleep important?

A lack of sufficient sleep can lead to decreased physical and mental functioning during the day time. Sleepiness is a major cause of motor vehicle accidents and is also a leading cause of errors made in the workplace. It has been shown that being awake for 24 hours can be equivalent to a 140 lb person having 4 alcoholic drinks.

Poor quality sleep or insufficient sleep can also lead to increased risk of heart attack or infection, slower healing, changes in metabolism, and worsening of other health conditions.

How do I know if I have a sleep disorder?

There are 3 common types of sleep disorder: insomnia, obstructive sleep apnea, and circadian rhythm disturbances.

Insomnia is the most common of these 3 types of sleep disorder. Insomnia includes being unable to fall asleep, difficulty maintaining sleep, or not feeling refreshed after sleep. Those who have insomnia symptoms for over 1 month are considered to have chronic insomnia.

Insomnia can be caused by anxiety, stress, and other emotional factors. Insomnia can also be caused by other diseases, such as thyroid disorder, cancer pain, arthritis, gout, breathing discomfort in heart failure, severe heartburn, or asthma. Certain medications might also contribute to sleep disturbances. Below is a table of common medications that may cause insomnia.

MEDICATIONS THAT MAY CAUSE INSOMNIA
Over-the-Counter Medications	·       Cold medications containing pseudoephedrine ·       Pain medications containing caffeine (Excedrin Migraine, Midol Complete) ·       Some allergy medications ·       Stimulant laxatives (Senna, Bisacodyl) ·       Diet pills
Prescription Medications	·       Some antidepressants (fluoxetine, bupropion) ·       Stimulants ·       Anticonvulsants (phenytoin, lamotrigine) ·       Thyroid medications ·       Diuretics that may increase night-time urination (hydrocholorthiazide, furosemide) ·       Corticosteroids (prednisone, methylprednisolone)
Recreational Drugs	·       Tobacco products containing nicotine ·       Alcohol ·       Cocaine ·       Amphetamines or methamphetamines

Obstructive sleep apnea is another common disorder and is found in 15 million Americans. Obstructive sleep apnea is caused by interruptions in breathing, leading to too little oxygen during sleep. Thyroid disorder and acromegaly are diseases thought to be linked to sleep apnea. Obesity, male sex, and being middle-aged also puts you at risk for developing this disorder.

Sleep cycle (circadian rhythm) disturbances are another common form of sleep disorder. Sleep cycle disturbances can occur due to jet lag or shift-work changes. Jet lag is a sleep disturbance that happens after travel between different time zones and can last up to 14 days after travel  especially if time zone changes are greater than 8 hours  or when traveling eastward. Shift-work sleep disorder can be caused by rotating between morning and night work shifts.

It is also important to look at how long your sleep disturbance lasts. Sleep disturbances are said to be transient (or temporary) if the disturbance lasts 2 to 3 days and short-term if it is resolved within 3 weeks. Chronic sleep disorder may last for over 4 weeks.

Can I treat my sleep disorder?

There are a number of ways to address sleep disorder. Life-style modifications and over-the-counter medications can aid in improving sleep. However, those with obstructive sleep apnea and chronic insomnia should seek the help of a physician for prescription-only medication and for further counseling.

Lifestyle changes that may improve sleep:

·       Keep a regular schedule for when you sleep and wake.

·       Sleep only enough until you feel rested, and then get up.

·       Go to bed 30 minutes later than when you usually go to bed to induce sleepiness before lying down.

·       If you are unable to fall asleep within 15 to 20 minutes of lying down, leave the room and return only when you feel sleepy.

·       Avoid napping throughout the day.

·       Make sure that your sleep environment is comfortable and free of clutter and noise.

·       Place your clock so that it is not visible while you are sleeping.

·       Avoid watching television or using computers on the bed. Try to reserve the bed for sleep only.

·       Do not exercise within 2 hours before bedtime. However, light, regular exercise 4 to 5 hours before bed is recommended.

·       Avoid foods containing stimulants in the evening, including coffee, caffeinated tea, caffeinated sodas, dark chocolate, and alcohol.

 Medications for Insomnia

If lifestyle changes are not effective in improving sleep, a medications may be needed. These ages vary in safety and effectiveness. The choice of a medication depends on each person’s individual sleep profile.

MEDICATIONS TO TREAT INSOMNIA
Over-the-Counter Medications	Helps you fall asleep: -        Diphenhydramine and doxylamine are safe and effective to use on a short-term basis (less than 7 days). Helps you stay asleep for longer: There are no over-the-counter drugs are approved for this use.
Herbal Medications	Helps you fall asleep: -        Melatonin is a supplement that can be found at most pharmacies. It is a hormone naturally found in the body that regulates the sleep cycle. It is effective in certain individuals with disturbed sleep due to school schedules, work schedules, and jet lag. -        Valerian is another commonly used over-the-counter herbal. However, it has been found to decrease time to sleep onset by only 1 minute, so its effectiveness is limited. -        Alcohol is commonly self-prescribed for sleep. While it has been shown to decrease time to sleep onset, it also increases sleep disturbances throughout the night and may lead to dependence. Helps you stay asleep for longer: There are no supplements that are effective to extend the amount of time you stay asleep.
Prescription Medications	Helps you fall asleep AND stay asleep for longer: Benzodiazepines are a class of drugs prescribed for sleep. While they are effective, they also have the potential for addiction. -        Short-acting benzodiazepines (estazolam, flurazepam, temazepam, triazolam) can help you fall asleep faster. -        Long-acting benzodiazepines (flurazepam and quazepam) can help you fall asleep and stay asleep for longer. Nonbenzodiazepines (zaleplon, zolpidem, eszopiclone) are another commonly prescribed group of drugs.  They can help you fall asleep, wake up less often, and stay asleep for longer. A melatonin agonist (ramelteon) can decrease the time it takes to fall asleep and can also extend sleep duration. Some antidepressants (amitriptyline, trazodone, doxepin) can help you fall asleep faster and can also be used to relieve chronic pain which may interfere with sleep.

Where can I find more information?

There are many resources for additional information on sleep disorders.  Below are a few helpful websites.

·       Center for Disease Control: http://www.cdc.gov/features/sleep/

·       The Sleep Foundation: http://www.sleepfoundation.org/

·       Mayo Clinic: http://www.mayoclinic.com/health/insomnia/DS00187

 

Written by:

Bonnie Vu

Doctor of Pharmacy Candidate

College of Pharmacy, University of Illinois at Chicago

UIC Pharmacy

May 2013