Suggest Treatment For Chronic Pain Due To Arthritis

Brief Answer:
Surgery will be the last resort...

Detailed Answer:
Hi,

I understand your concern. Managing chronic pain has been intellectually and emotionally challenging. A thorough history and detailed evaluation is absolutely necessary before we can devise out a plan of action. That being said, many a times outcomes from treatment hasn't always been successful. I am not sure what treatments you been on and the effects of those treatment. But as it looks like you are currently satisfied with suboxone except for occasional breakthrough pains, I present some options that can be tried to handle breakthrough pains.

1. Use non steroidal antiinflammatory pain medications. Paracetamol, Ibuprofen and other prescription NSAIDS are available. These are sufficient to take care of mild intensity breakthrough pains.
2. On the other hand, if the breakthrough pain is severe (as it looks like), a short acting opioid such immediate release morphine or hydrocodone may be used. Some of these come combined with NSAID as Oxycodone or vicodin for added benefits.
3. Alternatively, fentanyl available as lozenges or patches have more rapid onset action. They can be used.

While we try one of those options, a better solution to treat chronic pain is to look at multidisciplinary approach. Tricyclic antidepressant, a few other SSRI antidepressant, anticonvulsant and antiarrhythmia drugs are widely used as adjuvants to opioid drugs. These are drugs that increases your pain threshold and help you cope up with those pain sensations. Off course they don't act immediately and you will need to be patient while on it.
Similarly physical therapy, counselling and nerve blocks can be used as per requirements.

All these agents mentioned above have complex interactions and adverse effects that are varied. You can discuss about it with your pain management doctor.

At last, I would not subject my patients to another surgery especially if the previous one failed; unless the surgeon is confident with his skills and expertise. Therefore surgery is my last resort.

I am not sure I will be of much use to put you into a research study. I had read about using NMDA antagonist as an advancement in managing breakthrough pains. You might have to research about those yourself.

I hope the discussed options help you.

Regards

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Brief Answer:
Set up specific and realistic functional goals...

Detailed Answer:
Investigation and evaluation to find cause / explanation is beyond scope of online forum as a good physical examination along with detailed history is the basis on which we investigate patients. Further sometimes we are unable to explain cause of pain even with detailed evaluation. Hence I would blame your MD for not giving proper explanation. In this circumstance, my first suggestion to you is to set up specific and realistic functional goals and work on it. These goals of yours will help the doctors manage you more efficiently.

I have enumerated possible means to tackle breakthrough pain. Besides those as I mentioned NMDA receptor antagonist agents is a latest advancement. Medical marijuana which is legalised in a few states is another option. Your local doctor will know about those.

I am unsure for how long you been on adjuvant drugs; but in my opinion adjuvants - tricyclic agents, anticonvulsants like lyrica are wonderful drugs. Therefore I will suggest you reconsider these. With regular follow ups and constant dose titration your doctors will be able to find the right proportion necessary. I understand these can cause a few side effects; however when we have no proper or rather treatable cause you will need to weigh the benefits (in achieving your realistic goal) vs the side effects. Some of these agents take 2-3 months before you find good results; therefore patience is going to be a key.

Lastly as you are looking for an institution where you can get facility, I name Mayoclinic as the choice. I have heard about this premier institute where there are professional who are experienced and also in the field of research. I do not have any connection to this centre or know any doctors who are associated with it. However I would try this place if I were in your shoes and if I have enough funds.

I am sorry if my suggestions is not upto your expectation. As I said earlier, physical examination is often the basis upon which I will be able to treat such patients.

Good luck and regards

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