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Frequently Asked Questions

Center for Pain Management invites you to check the list below to see whether your question may be answered here. Please feel free to use the contact form, email, call us or simply visit us.


Blood Thinners and Injections FAQs

May I have an injection if I am on a blood thinner?

Depending on the type of injection, the answer is… “It depends”.
If the needle is going to be placed inside the spinal canal the answer is no.
If the needle is outside of the spinal canal then it is probably safe to have an injection

What is the risk of having a spinal injection while on a blood thinner?
The risk is uncontrolled bleeding into the spine. This is called an “epidural hematoma” and can cause permanent paralysis if it occurs. The risk is substantially higher if you are on a blood thinner.
I’ve had injections before and they didn’t tell me to stop the blood thinner! Why now?
It is possible that the injection was done outside of the spine. Or it is possible that the person doing the injection wasn’t aware of the risk!
Isn’t there a risk of stopping my blood thinner? I’m on it for a reason!
Yes. There is a risk of stopping your blood thinner. Depending on the specific reason that you are on the blood thinner, that risk may be an acceptable risk or it may be an unacceptable risk.
What could happen to me if I stop my blood thinner temporarily?
Again, it depends on why you are on the blood thinner to begin with. But as a result of stopping your blood thinner you could experience a blood clot, stroke, heart attack or other bad outcome. You could die as a result of these things, although it is very unlikely that this would occur. NO PATIENT AT CENTER FOR PAIN MANAGEMENT HAS EVER DIED AS A RESULT OF STOPPING BLOOD THINNERS TEMPORARILY!
Who can decide whether I should stop my blood thinner or not?
The decision is ultimately yours however we will speak with your cardiologist, neurologist, surgeon, or primary care provider to help you make the decision that is right for you.
What are the specific instructions regarding stopping and re-starting blood thinners?

These guidelines are based upon recommendations from an international/multi-disciplinary/multi-specialty conference published in 2015 in Regional Anesthesia and Pain Medicine.


 Medication When to Stop When to Restart
Plavix (Clopidrogel) 7 days 12-24 hours after procedure
Effient (Prasugrel) 7 days 12-24 hours
Aggrenox (ASA/Dipyr) 7 days  2-24 hours
Coumadin 5 days 24 hours (INR greater 1.4)
Brilinta (Ticagrelor) 5 days 12-24 hours
Pradaxa (Dabigatran) 5 days 24 hours
Arixtra (Fondaparinux) 4 days 24 hours
Xarelto (Rivoraxaban) 3 days 24 hours
Eliquis (Apixaban) 3 days 24 hours
Pletal (Cilostazol) 2 days 24 hours
Dipyridamole 2 days 24 hours
Lovenox (Enoxaparin) 12 days 12 hours
What about Coumadin?

You need to stop Coumadin 5 days prior to the injection and resume evening of injection.
You also need to have a PT/INR checked on the day of, or the day prior to injection
Someone at CPM needs to see those results prior to the injection
It is only safe to do the injection if the INR is below 1.4
If the INR is 1.4 or above, we will need to wait another day and re-test the INR.

What about baby aspirin? May I continue taking my baby aspirin?

Yes, you can continue taking baby aspirin right up until and through the injection. It does not pose a risk.

OOPS! I only stopped my Plavix for 6 days. That’s good enough, right?

No! All of the times listed above are non-negotiable! They are there for your safety.

What about supplements and OTCs like Fish Oil, Ginko, Turmeric, Ginger, green tea, garlic, Omega-3, ginseng, etc?

There are case reports of these products causing thinning of the blood. Therefore we ask that you stop these supplements 7 days prior to your injection. This list is not all-inclusive. Please ask the staff if you have questions about any other supplements you take.

I am scheduled for another injection but I feel better and I don’t think I’ll need it. Should I still stop my blood thinner prior to my next visit?

If you are fairly certain that you are not going to need another injection, then the safest thing to do is STAY ON the blood thinner and discuss options with your provider at your next visit.

Post-Regenerative Procedure Instructions

Weeks 1 & 2 After Injections

Restrict yourself to light activity and the tasks of daily living. You will be sore, but it is better to move than to be completely sedentary. Use pain as your guide. In the early weeks of regenerative healing, your body’s natural inflammatory process will use cytokines, leukocytes, proteins and inflammation to create a “scaffold” for the cells to bind to. The cells are just starting to form and divide, so you want to be very cautious and avoid overloading, shearing, or compression on the joint that was injected. Avoid too many frequent stairs, if possible (for hip and knee injections), and limit lifting to 5-10 pounds on occasion.

No running or weight lifting the first two weeks! Minimize load, compressive forces, and torque on the joints and discs. Range-of-motion and gentle stretching exercises are appropriate. Light and easy walking can be very helpful to minimize soreness for spine patients. Manage muscle soreness and spasms with heat (hot shower, heating pad) and inflammation from procedure with ice.

No NSAIDs (ibuprofen, Aleve, anti-inflammatory medication)! You need your body’s inflammatory process to help with healing. Walking in the pool is a nice way to get some motion; it can unload your joints and be soothing. You can get in the pool once your injection sites are healed. Use a kick board, buoy, or noodle for support in the water. Kinesiology tape or additional medication may be needed to help you manage your pain. Analgesic creams or gel (Biofreeze, Traumeel) can help with pain.

It is not uncommon to have increased soreness in your tissues and joints from the procedure. Mild to moderate pain is acceptable for a few days, but severe pain is not. If your pain becomes severe, or you cannot manage your pain with the above recommendations, contact us. We can refer you for physical therapy or massage therapy to provide gentle exercise and manual release.

No chiropractic adjustments or traction in the first four weeks for spine patients. You want to minimize intradiscal pressure changes in the early stages of recovery. Cold laser, ultrasound, and electrical stimulation (TENS) are appropriate for pain management. You may wear a compressive brace for support during activity if it feels good, but don’t wear it when sedentary. Begin core stabilization exercises to minimize re-injury.

Weeks 3 & 4 After Injections

Avoid repetitive loading exercise, like stair steppers, running, or weight lifting. You may walk, use an exercise bike or elliptical machine or swim/walk in the pool. These exercises have minimal compressive loading stresses on joints workouts should be done with less than 50 percent of normal/pre-injection distance/weight/reps. You need to give the new stem cells time to implant themselves in areas of damaged tissue.

If it hurts, don’t do it! Maintain normal range of motion in injected areas with gentle exercise. Yoga, stretching, gentle Pilates, tai chi, and easy walking are okay. Continue to manage inflammation with ice and pain medications as directed if needed. If pain persists and doesn’t respond to other medications or treatments, you may start taking NSAIDs, but avoid them if you can. Contact Center for Pain Management if you are still having pain or difficulty with your healing.

Weeks 5 & 6 After Injections

You may initiate light running exercise on even and soft terrain, a treadmill, or a track. Wear lumbar or joint support. Please be careful with jarring or compressive exercise, and avoid shearing. Going up hills may feel fine, but coming down is difficult for an unstable joint. Continue with core stabilization and joint stabilization exercises. You may start to increase resistance with weight lifting, but please still be cautious. Your stem cells are building new tissue and need oxygen/blood flow through gentle exercise but can’t tolerate being stressed by too much exercise. You may continue with stationary bike, elliptical, stretching, yoga, Pilates, and swimming exercise. Avoid compressive exercise such as overhead press, calf raises with weights on shoulders, squat rack, supine leg press, prone hamstring curls, twisting, repetitive flexion/extension, dead lifts, clean and jerks, kettle bells over shoulder level, box jumping, etc. If you still are experiencing pain, reduce your activity level. Continue to use ice as needed.

Weeks 7 & 8 After Injections

As long as you’re not having pain, you can slowly progress to your normal workout, but not to the point of pain in the injected area. Set yourself up for success by maintaining some aerobic capacity without injuring the new juvenile stem cells. Avoid or shearing or over compressive exercises. Continue to increase core and joint strengthening for optimal stabilization. Continue to use ice for pain and inflammation as needed.

Months 3–6 After Injections

The stem cells are now at their peak of healing potential! Help them to help you by not overdoing it. Walking, biking, yoga, stretching, and light weights are appropriate. Be careful with distance running. Continue to use caution with compressive activity, twisting, planting and pivoting, overhead activity, and repetitive motion. Consider physical therapy if you need guidance on proper exercise to protect your joints and injection site(s) as you continue to heal.

Special Populations

Disc Patients

Avoid overhead work if possible for several months. This can put a lot of force on your new cells. You want to be careful and try to avoid compression with extension, repetitive flexion or twisting until your core is strong. Avoid compressive exercise such as overhead press, calf raises with weights on shoulders, squat rack, supine leg press, twisting, repetitive flexion/extension, dead lifts, clean and jerks, kettle bells over shoulder level, box jumping, etc. Highly recommended: core abdominal exercises; strengthen obliques, QLs, and gluteus medius, gentle spinal stabilization exercises; and stretching lower extremities and lower back for mobility. Pilates (mat and Reformer, chair), yoga and swimming are also appropriate. Get yourself strong before you challenge your spine. If you need a referral for formal physical therapy, please do not hesitate to ask.

Shoulder Patients

Avoid overhead work if possible for two to three months. Don’t play tennis with the injected side for six to eight weeks. Set yourself up for success. A rotator cuff stabilization program and postural stabilization exercises are appropriate. Avoid shoulder/military press above head; no kettle bells over shoulder level during healing phase.

Hip, Knee and Ankle Patients

Avoid compression activities such as running, jumping, squatting, supine leg press, or pivoting for two to three months to allow the cells to settle. Pain is your guideline. Walking, elliptical, swimming, yoga, and Pilates are ideal exercises early in the recovery stage. You may resume light running and short distance running, ideally on soft terrain in weeks 6–8. Gradually increase your distance in weeks 8–12. You may start easy hiking in week 8 as long as there is no pain or swelling. Consider some physical therapy to strengthen knees and hips, and to support the joints. Ideally, you should exercise to stabilize the entire lower extremity (hip, knee, and ankle).


No golf (except chipping and putting) for two months. Be very careful with rotational load on the spine. In the early stages of healing (weeks 1–8), you will want to work hard on increasing your core strength, especially abdominal obliques and QL muscles for spinal support with rotation. For months 2–3: minimal golf (no more than nine holes, once a week) and avoid over-rotation of neck and spine. Let the stem cells heal your discs/knee/shoulder/hip. During months 4–5, slowly work up to a few nine-hole games per week. After six months, take the next few months to slowly progress to 18 holes. Work on your swing to abbreviate over-rotation. Consider some lessons with a golf pro to change bad habits with your swing. Remember, almost everyone on the PGA senior tour has had lumbar surgery. Avoid surgery of your own with gentle, short swings. Strengthen abdominal obliques and spinal rotators to protect your spine during the forceful rotation activity of swinging a golf club. Every case is unique and side effects differ for each person. Some patients may experience more pain and inflammation than others; please contact

us if you have any questions or concerns. Certain joints and body areas can be more painful to inject, such as the spinal discs and the ankles. Expect varying degrees of pain in the first few days after the procedure, and treat with ice and/or heat and medication if necessary. If your severe pain lasts for more than a few days, contact us for advice. Treatments that can help with managing the pain and benefit the healing process include ultrasound, electrical stimulation, cold laser, gentle myofascial release, core and joint stabilization, stretching, trigger point dry needling, kinesiology tape, massage, ice and heat, and medication.

Post-Procedure Ancillary Care

Massage Therapy

You may have a massage the day before the procedure, but keep it gentle (Swedish). You may have another massage once the injection sites are healed (after five to seven days). Massage lotions/oils are not sterile, and you don’t want to risk an infection. In the early recovery stages, gentle massage appropriate (like Swedish and effleurage) is appropriate. You may progress to deeper-tissue myofascial release after week 2, but gradually increase the pressure with the manual release. If the tissue around the injection site feels warm to the touch, is swollen or shows signs of infection, do not get a massage. Call your doctor or the Premier Stem Cell Institute instead.

Physical Therapy

In the early stages of recovery after injection (weeks 1–4), you may start with gentle myofascial release, kinesiology taping, TDN, ultrasound and TENS, gentle stretching, ROM, isometrics, and mat-based core stabilization exercises. Stationary bike, elliptical, and swimming are acceptable early in the recovery phase. Avoid traction, heavy load or resistance, compression to the spine, and NSAIDs the first few weeks of recovery. Avoid any forceful rotation or manual manipulation. Remember that good healing during the first two months after injection will give you the best chance for success. The cells are fragile, and you need to be cautious that you don’t overload them or cause too much stress or shearing on them.

Chiropractic Care

You may seek chiropractic care for pain management in weeks 1–2, including manual release, ultrasound, electrical stimulation, and cold laser treatments. Absolutely no rotational adjustments should be performed. The discs may be weakened by the injection, and the injection site needs to heal.

In weeks 2–4 weeks, adjustments need to be low load, gentle, and non-forceful. A drop table or activator is OK. No spinal decompression or traction for four weeks. You don’t want to increase intradiscal pressures while the tissues are healing. Once you start decompression, force must be low load, just to increase the flow of fluid and nutrients into the disc. Ultrasound, electrical stimulation (TENS), cold laser, TDN or acupuncture, cupping, and gentle myofascial release are acceptable.


Acceptable any time before or after injection.

Personal Training

In the early stages of recovery (weeks 1–4), you may start with gentle stretching, ROM, isometrics, planks, and mat-based core stabilization exercises. Stationary bike, elliptical, and swimming are acceptable early in the recovery phase. Avoid heavy loads or resistance, compression to the spine and joints, and NSAIDs the first few weeks of recovery. In weeks 4–8, you can progress to more activity and gradually add more resistive load to workouts, up to 50%– 75% of pre-injection workouts. Avoid any forceful rotation, flexion, or extension moves. Remember that good healing during the first two months after injection will give you the best chance for success. The cells are fragile, and you need to be cautious that you don’t overload them or cause too much stress or shearing on them. Avoid compressive exercises, such as overhead press, calf raises with weights on shoulders, squat rack, supine leg press, loaded twisting, repetitive flexion/extension, dead lifts, clean and jerks, kettle bells over-shoulder level, box jumping, etc. Highly recommended: core abdominal exercises; strengthen abdominal obliques; QL, and gluteus medius; gentle spinal stabilization exercises; and stretching lower extremities and lower back for mobility. Pilates (mat, Reformer, chair), yoga, and swimming are very appropriate.


Many factors or variables can lead to cartilage or disc degeneration and arthritis. Some you can control and some you cannot. These include genetics and family history, aging, autoimmune disease, connective tissue disease, poor diet or malabsorption of nutrients, obesity, lack of exercise, decreased strength around the joints and spine, diabetes, rheumatoid arthritis and chronic inflammation, gout, hormone disorders, smoking, consuming alcohol, repetitive trauma, or a low-energy trauma that progresses over time. Chronic inflammation and micro-motion instability can produce ongoing pain and tissue breakdown.

Spinal discs and joint cartilage have a little or no blood inside of them, but still have live cells in the disc or joint space. They get their nutrition from diffusion and osmosis with motion, not through blood supply. Once the disc or cartilage tissue is damaged, cell nutrition is compromised, and the body cannot naturally heal the degeneration on its own. Degenerative discs are diagnosed with MRI and are often but not always painful. A painful degenerative disc is frequently 50% or more collapsed, and has cartilaginous endplate erosion. A healthy disc appears white or light grey, indicating fluid retention. A degenerated or desiccated disc will appear dark and have less volume or height. However, new regenerative cellular therapy uses your own mesenchymal stem cells to help your body repair these tissues and make your joints/spine healthier. It is imperative that you follow suggested guidelines during this repair phase to have the best outcome.

Arthritis and joint degeneration occur over time, and are often due to poor joint mechanics, poor body mechanics, bad posture, weakness, repetitive motion, high or compressive forces, and bad habits. Poor diet, weight gain, and other traumas can cause tissue and joint injury. Consider making lifestyle changes to eliminate factors that might put you at higher risk for joint/cartilage breakdown. You have pursued treatment with regenerative cellular therapy because you want to be healthy and get out of pain. Make the commitment to yourself and make the lifestyle changes that you can control, like diet and exercise, and get back to what you love doing!

Regenerative Medicine Rules

Rule 1: Set Yourself Up for Success

Your new stem cells are tender and delicate. They need special care if they are to grow and help heal your injured or degenerated joint or disc. When in doubt be kind to them! You are your body’s best advocate.

Rule 2: If It Hurts – Don’t Do It

Please use caution with activity. You will be sore from the procedure. Muscle spasms from the injection are not uncommon, and you should be prepared to have some pain or discomfort the first week. Use pain as your guideline and limit activity early in your recovery. Use heat for muscle spasms (deep ache, grabbing pain with transitions), and ice for inflammation (sharp, localized, burning, nerve pain). You may alternate hot and cold as needed. Get up and walk frequently.

Rule 3: The Anti-Inflammatory Effect

The first week after injection, some people enjoy the anti-inflammatory benefit of stem cells, resulting in a dramatic decrease in pain. But many people have increased pain from the procedure. You must not overdo it! Use caution with activity, no matter how good you feel. The old pain may return in a few days. Do not take anti-inflammatory medication. You need your body’s natural inflammatory process to start the healing process to create the matrix in your tissue/joint to gravitate the stem cells.


What is Dermapen?

Dermapen is a medically engineered device that utilizes 12 surgical grade micro- needles to deliver effective skin needling. Dermapen’s patented operation incorporates vertical oscillation technology (as compared to a more damaging “roller” technology) to trigger the skins natural healing response. Multiple treatments provide long lasting rejuvenation and correction for face and body skin.

How does the Dermapen work?

As the Dermapen glides over your skin, it creates micro-point punctures in the skin, the majority of which are simply pushing your pores open temporarily. This is perceived by the body as damage, which stimulates the release of growth factors that trigger the production of collagen and elastin. Your skin reacts to any injury by initiating the healing process. In cases where PRP (platelet rich plasma) is applied during the Dermapen treatment, the healing process is immediately augmented by the growth factors and cytokines released by the platelets. Dermapen stimulates the skin’s healing response, encouraging the production of growth factors, collagen, and elastin for a naturally rejuvenated, vitalized, and regenerated skin.

Your skin normally assumes that scars, stretch marks and wrinkles are repaired, but with the Dermapen micro-needling treatments, the skin is “tricked” into repairing itself. The process of micro-needling skin remodeling can go on for months after each Dermapen treatment. Results can be seen within a week or even a few days.

What are the indications for having a Dermapen treatment?

Skin needling is especially effective for aging concerns such as wrinkles, lines, folds and crow’s feet. General lack of skin radiance, and lack of skin firmness is also an indication for skin needling treatments. Because collagen is produced with Dermapen, scars and stretch marks can also improve from treatment — especially indented acne scars or chicken pox scars. Pigmentation issues can also be helped including hyperpigmentation (darkened areas of skin) and hypo-pigmentation (abnormally light areas of skin), although pre-treatment assessment and preparation is required in these cases.

How is the treatment administered?

Skin needling procedures are performed in a safe and precise manner with the use of the sterile Dermapen needle head. The procedure is normally completed within 30-60 minutes depending on the required treatment and anatomical site.

Before the procedure starts a topical anesthetic will be applied to your skin to ensure a comfortable experience. After the skin is numbed, the technician gently glides the Dermapen over the skin to stimulate the epidermis layer of the skin and create miniscule sub-cutaneous injuries. These microscopic wounds stimulate new collagen deposition which may last for up to a year, yet they close within less than an hour.

What topical treatments can be used along with the Dermapen?

The Dermapen will induce collagen synthesis on its own, but skin improvement is significantly enhanced by combining skin needling treatments with the topical application of Platelet Rich Plasma (PRP).

How quickly are results visible?

Visible results of skin rejuvenation are generally seen after just 6-8 weeks following procedure and improve further over time. A course of Dermapen sessions is usually recommended to achieve optimum results, however skin improvement is often times noticeable after just one treatment.

Is the Dermapen safe?

Skin needling does not involve injections and therefore allergic reactions and side- effects are unlikely to occur. It is minimally invasive, involves minimal downtime (about 24hrs), rapid healing and requires simple after-care.

What are the contraindications of skin needling treatments?

Contraindications and precautions include; keloid or raised scarring; history of eczema, psoriasis and other chronic conditions; history of actinic (solar) keratosis; history of Herpes Simplex infections; history of diabetes; presence of raised moles, warts or any raised lesions on targeted area. Absolute contraindications include; scleroderma, collagen vascular diseases or cardiac abnormalities; Rosacea and blood clotting problems; active bacterial or fungal infection; immuno-suppression; scars less than 6 months old; and facial fillers in the past 6 months.

Are there any side effects or risks associated with skin needling?

Side effects experienced with the Dermapen will usually subside within 24-48 hours. They include erythema (redness), stinging, itching, tightness of the skin.

Can the Dermapen help with skin wrinkles?

Dermapen excels when used as a treatment for fine lines and wrinkles. Best results are seen over a period of 4-6 treatments, which we call a “Dermapen Series.”

Can the Dermapen help with stretch marks?

In a word, YES. Before & after pictures of Dermapen treatments applied to one half a large area of stretch marks, with the other half left untreated show that the results can be dramatic.

Can the Dermapen remove or repair surgery scars?

Dermapen has proven to be effective on all manner of acne pitting and scarring, burn scars, injury scars –and yes —surgical scars as well.

Does a Dermapen treatment hurt or make you bleed?

Depending on the depth or aggressiveness of treatment, it is possible to experience pin- point bleeding during the treatment, but not typically afterwards. You may find temporary redness of the skin for an hour or so, or possibly or a day, depending upon the age of the skin, skin type, and treatment depth.

What will I will look like after the treatment?

After the procedure, the client’s skin will be red and flushed in appearance in a similar way to moderate sunburn. The client may also experience skin tightness and mild sensitivity to touch in the area being treated. This will diminish greatly a few hours following treatments and within the next 24 hours the skin will be completely healed. Typically, after 3 days there is very little evidence that the procedure has taken place.

Can Dermapen treatment be used during pregnancy?

Skin needling is not recommended for pregnant or lactating women due to a number of minor reasons. The needles produce micro-injuries which trigger the natural wound healing response. This wound healing and production of new collagen requires vitamins and nutrients which would otherwise be needed for the baby so is suggested to not be used during pregnancy. Another minor reason is simply increasing the chances of infection which is never a good idea when pregnant.

Can the Dermapen be done on Asian or African American skin?

Skin needling can be safely performed on all skin colors and types. The risk of post- inflammatory hyperpigmentation is low with Dermapen micro-needling, since the melanocytes remain intact during skin needling. Other invasive procedures such as laser resurfacing are not recommended for Asian or African American skin due to the potential risks of delayed wound healing, pigmentary changes and scarring. This is where micro-needling has an advantage as these potential risks are very unlikely due to the epidermis remaining intact.

What should I do after the Dermapen treatment session?

Follow-up care is typically very simple. For the first 2 days post-procedure you need to avoid direct ultraviolet exposure, intensive physical workouts or other cosmetic procedures. You will be provided with a list of postoperative instructions for home care which are best suited to your specific needs.

Reconsidering Opioids for Treatment of Chronic Pain

What’s an opioid?

“Opioids” are substances that act on the central nervous system to relieve pain. They also act on other areas of the body such as the gray matter in the brain, the endocrine system, and the GI tract. These are drugs like Vicodin©(Hydrocodone), Percocet©(Oxycodone), Morphine, etc.

What’s going on with the opioids? Why all of a sudden are they in the news so much?

In early 2016, the US Surgeon General, VH Murthy M.D., MBA wrote a letter to all US physicians asking for help in “turning the tide” on the opioid epidemic that our nation is facing.  See contents of the letter here: http://turnthetiderx.org .  In this letter, he noted that since 1999 there had been a 300% increase in opioid prescription sales without an overall change in the amount of pain that people were experiencing.  In this letter, he asked physicians to do 3 things:

  1. Educate ourselves to treat pain safely and effectively.
  2. Screen our patients for opioid use disorder and provide or connect them with evidence-based treatment.
  3. Talk about and treat addiction as a chronic illness, not a moral failing.

This letter was unprecedented in terms of its outreach and its potential impact on patient’s suffering with chronic pain.

As experts in the field of pain management, the providers at Center for Pain Management have always believed in using a “multimodal” approach when treating chronic pain.  In doing so, we have followed what has essentially been the “standard of care” since our graduation from academic fellowship programs in the 1990s.  Because we have always been in the business of trying to help patients live as healthy and active a lifestyle as possible, we have never relied solely on opioid therapy for management of chronic pain conditions.  We have always strived to engage our patients actively in their treatments, and in doing so have helped them to minimize their reliance on opioids by utilizing other treatment modalities such as physical therapy, chiropractic therapy, acupuncture, image-guided injection therapy, spinal cord stimulation therapy, radiofrequency ablation, and more recently, regenerative therapies with PRP and stem cells. This conservative approach has helped us to avoid “high-dose opioid therapy” for most of our patients.

OK, I like the conservative approach you take… So, what’s the problem with taking opioids?

The problem with opioids is that our bodies were not designed to have a constant supply of opioids in them.  While it is true that the body makes its own opioids (endogenous opioids) in times of stress or injury, these levels typically go down quite quickly as the body returns to normal.  While we did not think that there were any significant long-term risks to taking opioids back in the 1980s and 1990s (other than the well-known side effects and risks of constipation, itching, nausea, and slowing down of breathing) we are now finding out that there are indeed potential long-term risks associated with taking chronic opioids.

What are the risks of taking chronic opioids?

As noted above, we have known for a long time that the risks of constipation, itching, nausea, and slowing down of breathing exist for all patients taking opioids.  More recently, and perhaps more concerning recent studies have been published showing the following potential risks of taking chronic opioids:

  • Long-term opioid use increase depression risks (Annals of Family Medicine 2016; 14: 54–62)
  • 1 month of opioid use causes gray matter loss, new study confirms (Pain Medicine 2015, December 26)
  • “Although prescribing benzodiazepines, currently with opioid analgesics has been shown to raise the risk of fatal overdose, new research documents a risk that is 4 times that of opioids taken alone, even at low doses.”  (British Medical Journal 2015; 350: H2698)
  • Opioid analgesics subpar for chronic back pain (Marcia Frellick June 3, 2016)
  • “Opioid use in older drivers double the risk for single vehicle crash.”(Clinical Essentials from Age Aging August 10, 2016)
  • “Compared with nonuse, long-term opioid use was associated with increased use of medications for erectile dysfunction or testosterone replacement” (Annals of Internal Medicine February 17, 2015)
  • “Recent studies have found that doses of morphine over 50 mg double the risk of fractures in the elderly, with an annual fracture rate of 9.95% “ (Prim Care Companion CNS Disorder.  2012; 14 (3)
  • “For older adults taking long-acting opioids, the odds of contracting community acquired pneumonia was 3.43 times higher than non-users”(J Am Geriatr Soc.  2011 October; 59 (10): 1899–907)
  • CDC reports: “Opioid-related deaths at all-time high… With an increase of nearly 5000 deaths from 2014-2015.  Overdose deaths in the US rose 11% last year to 52,404.”  (Washington Post December 9, 2016)
Wow, that makes it sound like I’d never want to take another opioid again, doesn’t it?

Is certainly does.  The examples above are just a small sample of the literature that has come out in the past 2–3 years arguing against the use of opioids for treatment of chronic pain.  Now, more than ever, with the additional information that we have at hand, we need to carefully consider whether or not to use opioids at all when managing chronic pain.  While on the one hand we very much want patients to be able to function as well as possible in the setting of chronic pain, on the other hand, we do not want the very medications that we are using to try to treat pain make a patient’s overall health suffer.  The answer to the question, “Should we be using opioids at all to treat chronic pain?”  is a very complex one, that needs to be considered very carefully in each individual patient.

I have been on opioids for a number of years. Does that mean that I’m addicted and I can’t quit?

No, it does not.  Even if a person has been taking an opioid for many years, it does not mean that they are “addicted” to the medication.  Long-term use of opioids does, however typically lead to a “physical dependence” on them which is very different from addiction.  If a person who has been on chronic opioids decides to discontinue them, they should never do so abruptly because it will likely lead to a withdrawal syndrome which will be very uncomfortable and potentially harmful to a person’s health.  Typically, if the opioids are tapered off over a number of weeks to months, it can be done safely, without a significant amount of risk.

If I want to discontinue opioid therapy do I have to go into a treatment program?

No, it typically does not.  Most of the time this can be achieved slowly, under the close supervision of a medical professional without the need to go into a “detox” program.  As noted above, since we are typically not dealing with an “addiction” problem but more of a “physical dependence” problem the process is usually much less complicated.

So how do I treat my pain if I quit opioids?

That is a good question and one that will have a different answer for each individual person.  Thankfully, since there had been a number of advancements in the treatment of chronic pain over the past 10 years, there may be options that were not originally available.  The first step is asking “What else can be done?”

Are you going to stop prescribing opioids?

At this point in time, the providers at Center for Pain Management have no plans or desire to stop prescribing opioids for patients who need them, and who are taking them in a reliable fashion, with minimal side effects, and good overall effect on activity levels and quality-of-life.  However, in light of the national opioid crisis, as well as the emerging clinical data regarding the effects of chronic opioid therapy on the body, we are trying to reevaluate each and every patient’s specific care plan in order to determine:

  • Whether or not opioids are needed/justified.
  • When opioids are needed, what the lowest dose and safest form of opioid therapy are.
  • Whether a patient who is taking opioids believes that opioids are providing a reasonable balance between “risks vs. benefits” in terms of quality of life and overall health and well-being.
I’ve heard about “Opioid Rotation”. Is that an option for me?

In the past, we have used opioid rotation — switching from one opioid to another— as means of continuing the patient on opioid therapy without having to continually escalate the dosage of one particular medication.  While this strategy may still have some clinical utility in certain cases, by definition it ignores the point of the whole discussion about the appropriateness of opioids for treatment of chronic pain.  Essentially by adopting this strategy we are simply “kicking the can down the road” regarding the question of the appropriateness of long-term opioid therapy for treatment of chronic pain.

What do I need to do right now?

As part of your care plan, if you are receiving opioid therapy you’ll continue to be seen on a quarterly basis, as usual.  This FAQ sheet is not meant to alarm you.  We are hoping that as you read this FAQ sheet it will raise some questions in your mind about the “pros and cons” of chronic opioid therapy and how it relates to your long-term health.  At this very moment, a number of different pharmaceutical companies are working on new non-opioid medications for treatment of chronic pain.  The “silver lining” to this “opioid storm cloud” is that, along with the concerning news that we have about the potential negative effects of opioids in the human body, we are also discovering new ways that pain can be treated without the use of opioids.  Our hope is that we can continue to work hand-in-hand with our patients as these new therapies are being perfected and that we can offer these therapies as soon as they become available clinically.

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Wilmington, NC 28401