Tips On How To Treat Chronic Pain Without Medication

For too long western medicine has portrayed medications as the pinnacle remedy in treating diseases and conditions. Medications are more than likely present in every pain management case that we see. Unfortunately, many pain medications have unwanted side effects not to mention the high probability of pain medications being addicting. As pain management physicians, we encourage patients struggling with pain to consider all of their alternatives before resigning themselves to long-term drug use; nonetheless, please consult your doctor first as to what alternatives are best for you.

Diet & Exercise

If you are familiar with any of our past blogs, you will note just how important diet and exercise can be in influencing chronic pain. With that being said, with the support of your physician, we encourage you to take a look at your overall level of activity and the types of food you frequently eat and see what changes can be made to reduce symptoms of chronic pain without having to rely on pain-relief medications. For example, an anti-inflammatory diet involves eating a lot of low-starch vegetables, fish, some fruit, limited amounts of dairy & whole grains, moderate amounts of red meat, and almost no flour or sugar. This sort of diet may seem foreign based of the typical foods you eat; yet small and simple changes over time can offer immense benefits. For more information on this topic, please see our blog post, “Tips On How Your Diet Can Reduce Chronic Inflammation”. Again, making changes to your diet can be a challenge, but it is well worth it. One clinical trial concluded that some patients started to have substantial pain relief and overall feel better in as little as two weeks. Participants also reported lower blood pressure, lipids, cholesterol, and blood sugar levels. Concerning exercise, numerous studies have found that even minimal amounts of physical activity has been shown to reduce pain symptoms. Pick a couple of your favorite activities: walking, cycling, swimming; anything that you feel comfortable doing may have a tremendous benefit on reducing your dependence on medication. Yet before you go signing up for the next yoga, talk to your doctor and get their approval beforehand.

Manipulative Techniques

Research has shown that manipulation therapy and physical therapy may be effective methods in relieving pain throughout the body (back, neck, shoulder, knees, chest, etc.). During a manipulation therapy session, the physician delivers uses their hands to manipulate patients’ bodies into proper alignment as a way to ease the pain. During a physical therapy session, a healthcare provider will guide the patient through various exercises and stretches meant to alleviate pain. Another well-researched alternative to medication for treating pain is acupuncture. Acupuncture is the practice of strategically placing thin needles on the epidermis throughout the body to stimulate nerves and relieve pain. A meta-analysis completed in 2012 found acupuncture to be useful for the treatment of chronic pain. They found significant differences between true and sham acupuncture indicating that acupuncture is more than a placebo. However, we must note that these differences were relatively modest, suggesting that factors in addition to the specific effects of acupuncture may be important contributors to its overall therapeutic effects.

It is possible to overcome disabling pain and resume an active life without medications. If you think you might benefit from these steps, talk to your talk about implementing one of these alternatives to your pain management regimen. Besides the alternatives we mentioned, what alternatives have you found to be effective? Please let us know!

Tags: chronic pain, diet, exercise, medications, meta-analysis, acupuncture


  1. Andresen TCB, Cristian CR. Efficacy of osteopathy and other manual treatment approaches for malocclusion – A systematic review of evidence. Int J Osteopath Med. 2013;16(2):99–113.
  2. Estruch R, Ros E, Salas-Salvadó J, et al.; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–1290
  3. Itoh K, Katsumi Y, Kitakoji H. Trigger point acupuncture treatment of chronic low back pain in elderly patients–a blinded RCT. Acupunct Med. 2004 Dec;22(4):170–177
  4. Mensink RP, Zock PL, Kester ADM, Katan MB. Effects of dietary fatty acids and carbohydrate on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 con- trolled trials. Am J Clin Nutr 2003;77:1146–55.
  5. Ng MM, Leung MC, Poon DM. The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: a randomized controlled trial with follow-up evaluation. J Altern Complement Med. 2003 Oct;9(5):641–649.
  6. Posadzki P, Ernst E. Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials. Clin Rheumatol. 2011;30(2):285–91.

Vickers AJ1, Cronin AM, Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012 Oct 22;172(19).

5 Proven & Effective Tips To Reduce Your Head Pain

Let’s face it; we all get headaches. A headache can be a burden to our daily lives, whether it’s a clinically diagnosed primary headache such as a cluster, tension, or migraine headache, a secondary headache, or innocuous head pain that generally goes away in due time. Fortunately, there are many treatments that can ease head pain without a trip to the doctor or drugstore and we’d like to share five of our favorite tips. Nonetheless, if you believe you are experiencing a headache as a result of a disease/condition (i.e. secondary headache) or feel that you may be having one of the three primary headaches, please consult your doctor as soon as possible. He or she will be able to treat your headache in the most effective way. Also, though these tips are more for non-life threatening headaches, please talk to your doctor before implementing any of these tips.

Take Medication in Moderation

Walk into any pharmacy and you will be bombarded with a number of medications offering pain relief. Picking the right one will vary from person to person and each one has its risks. But to get the most benefit from an over-the-counter (OTC) medication that is right for you with the least risk, follow these guidelines:

  • Avoid OTC’s that contain caffeine or multiple ingredients for these may cause ‘rebound’ headaches.
  • Choose liquid over pills. Your body will be able to absorb the active ingredient much more readily.
  • Be prophylactic and take a painkiller as soon as you feel pain. Start with the recommended, even a smaller, dose and see how you respond.
  • Take an OTC only when you are experiencing pain. Taking a drug for too long or too often may actually make your condition worse, not better.

Make Friends With Darkness

For some people bright, flickering, and ambient light have been shown to exacerbate symptoms of a migraine. If you are someone who is sensitive to light, cover your windows with special blackout curtains during the day. Wear sunglasses both indoors and out. You might also add anti-glare screens to your computer and use daylight-spectrum fluorescent bulbs in your light fixtures. Last but certainly not least, try to limit the amount of time you spend on your phone, especially closer to your bedtime.

Liberate the Tension From Your Head

People who were ponytails can vouch for us when we say a tight ponytail may lead to a headache. If your ponytail is too tight, it could cause a headache. So, if you’re prone to getting “external compression headaches”, avoid wearing items such as tight hats, headbands, glasses, sunglasses, and (you guessed it) hair ties to reduce your chances of getting a headache. In fact, one study found that over 50% of participants who loosened their hair experienced their head pain reduce with some noting their headache disappeared all together.

Spit Out Your Gum

Chewing gum can hurt not just your jaw, but your head as well. The same is true for chewing your fingernails, lips, the inside of your cheeks, or objects such as pens. Do your best to limit crunchy and sticky foods making sure you take small bites. If you suffer from a condition known as bruxism (night grinding), talk to your healthcare provider about getting a mouth guard or participating in therapy. Research has shown than individuals who participate in cognitive behavioral therapy were able to reduce clenching their jaw, leading to a reduction in headaches.

Icy Hot: Not Just A Catchy Name

We’re sorry if our title misled you. We are not talking about the pain cream ICYHOT®, but we are referring to alternating between hot and cold packs to ameliorate symptoms of a headache. If you are having a headache, specifically a migraine, compress a cold pack on your forehead for approximately 15-minutes followed by a 15-minute break. Try to repeat this cycle up to three times. If you experience tension headaches, place a heating pad on your neck or the back of your head. If you have a sinus headache, hold a warm cloth to the area that hurts. Allowing warm water to run down your head and back as in a warm shower may also be effective in reducing the headache. What other tips and tricks have helped you reduce head pain? Lets us know!

Tags: headache, primary headache, secondary headache, over-the-counter, migraine, bruxism, pain management


  1. Bader G, Lavigne GJ. Sleep bruxism; an overview of an oromandibular sleep movement disorder. Sleep Medicine Reviews 2000;4:27-43.
  2. Blau, J. N. (2004), Ponytail Headache: A Pure Extracranial Headache. Headache: The Journal of Head and Face Pain, 44: 411–413. doi:10.1111/j.1526-4610.2004.04092.x
  3. Offenbächer M., Stucki G. Physical therapy in the treatment of fibromyalgia. Scandinavian Journal Of Rheumatology Vol. 29 , Iss. 113,2000
  4. Sheftell, F. Role And Impact Of Over-The-Counter Medications In the Management of Headache. of Neurologic Clinics. W. B. Saunders Company. Elsevier Inc. 1997
  5. Thompson BA, Blount BW, Krumholz TS. Treatment approaches to bruxism. Am Fam Physician 1994;49:1617-22.

3 Essential Questions to Answer Before Taking An OTC Pain-Relief Medication

How much do you want to bet that there is at least one type of over-the-counter (OTC) pain-relief medication in your house? With such a huge number of available OTC medications on the market, we would bet the odds are in our favor. Drugs such as ibuprofen, aspirin, acetaminophen, and naproxen are some familiar medication names and all fall into the spectrum of OTC pain relievers. But have you done your due diligence and made sure you’re not putting yourself at risk before deciding to take these drugs, or do you know which OTC medication is best for your current condition? Unfortunately, the answer for many people is, “no”; but it’s not their fault! Yes, these are medications that do not require a doctor’s prescription, but they can pose a risk for some, where proper education is needed.

Warnings as well as research done by the U.S. Food and Drug Administration (FDA) have often called over-the-counter pain-relief medications’ safety into question. For example, the FDA disseminated a warning that non-steroidal anti-inflammatory drugs (NSAID’s) may raise the risk of heart attack and stroke. Unless you’re an avid FDA news savant, studied pharmacology, or spent years in medical school; the general public is just not equipped with the knowledge to determine if they can safely take these medications. But you’re in luck! We would like to go over three essential questions you should be able to answer before you head to the nearest Walgreens for some Tylenol®; however, please talk to your doctor before taking an OTC pain-reliever. He or she knows you best and will help guide you in the appropriate direction in reaching pain-relief.

Why have you turned to a pain-relief medication?

The cliché, “more bang for your buck” is appropriate here. Anyone taking a medication wants to take the lowest dose possible with the minimum risk of side effects while having the most therapeutic effect possible. Let’s say you are dealing with osteoarthritis. Research has found that acetaminophen has been shown to be favorably effective at relieving osteoarthritis symptoms. Studies have also found that acetaminophen is effective at treating headaches while avoiding side effects regarding cardiovascular or digestive diseases. We must note that this is assuming acetaminophen is the only medication you are taking (we’ll go into further detail later). On the other hand, NSAID’s may pack a punch against dysmenorrhea (painful menstrual cramps) and muscle aches for some patients.

Do you currently suffer from other conditions?

Before considering what medication to take, have in mind if you also have conditions other than the chief complaint. For example, NSAID’s like Aleve® & Advil® can be hard on the digestive system where long-term use of these medications cannot only upset your stomach but may pose a risk for severe stomach ulcers. If you suffer from digestive diseases, consult a doctor before taking Advil® or Aleve®. The same goes for those who have kidney disease, because NSAID’s can decrease blood flow to the kidneys.

Recently, the FDA released a warning about NSAID’s identifying those who have had a recent bypass surgery or heart attack, specifically. If you fit into these categories, it is all the more reason to consult your doctor before taking a pain medication. For instance, acetaminophen might be a better choice for you. To drive home how OTC pain-relief drugs can exacerbate multiple conditions, if you suffer from liver disease, avoiding acetaminophen (e.g. Tylenol®) is in your best interest because of the potential negative symptoms acetaminophen can have on the liver. These are just a few examples among many. If you’re in good health, such concerns may not apply to you. But any chronic condition will play a part in drug safety.

Are there other medications you are currently taking?

Polypharmacy, or rather taking more than one medication concurrently, contributes significantly as to if you should be taking an OTC pain-relief medication or not. Most drugs undergo metabolism by the same enzymes in the liver. These interactions between drugs, also known as drug-drug interactions (DDI’s), can influence the overall effect of a given medication. Some drugs may synergize the response of other drugs while some drugs can inhibit the reaction of others. For example, if you are taking a blood thinner such as warfarin, adding NSAID’s for pain-relief significantly increases your risk of hemorrhaging (bleeding), while acetaminophen in higher doses may have a mild interaction with warfarin, it may be a better choice if your doctor advises it.

What we would like you to take away from this article is that if you are suffering from a chronic condition such as rheumatoid arthritis or degenerative disc disease, it is entirely ok to ask for your doctors’ and pharmacists’ advice. The package inserts that come with prescription medications can be a lot to process and so can the labels on over-the-counter drugs. A little expert advice on drug interactions can help you get the pain-relief you need while avoiding unwanted side effects. Once you and your healthcare team have decided on an over-the-counter medication that works best for you, remember to take it with caution considering the minor side effects that are mentioned on the package. Even then, take it only when needed and take the least amount that controls your symptoms. Which over-the-counter drugs have worked for you? Let us know!

Tags: painkiller, pain reliever, NSAID’s, adverse side effects, pain management


  1. FDA Consumer Health Information. COX-2 Selective (includes Bextra, Celebrex, and Vioxx) and Non-Selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). April 2005.
  2. FDA Consumer Health Information. FDA Strengthens Warning of Heart Attack and Stroke Risk for Non-Steroidal Anti-Inflammatory Drugs. July 2015.
  3. Lenzer J. FDA advisers warn: COX 2 inhibitors increase risk of heart attack and stroke. BMJ 2005;330:440.
  4. Moling O, Cairon E, Rimenti G, Rizza F, Pristera R, Mian P. Severe hepatotoxicity after therapeutic doses of acetaminophen. Clin Ther 2006;28:755–760.
  5. Rampal P, Moore N, Van Ganse E, Le Parc JM, Wall R, Schneid H, Verriere F. Gastrointestinal tolerability of ibuprofen compared with paracetamol and aspirin at over-the-counter doses. J Int Med Res 2002;30:301–308.

Making The Pain Scale Work For You

Physical pain is one of the few incidents that are experienced virtually by all living creatures. Nonetheless, unlike animals we as human have the existential ability to apprise and be consciously aware of what we are feeling. Although pain, whether acute or chronic, can be very difficult to describe especially when trying to convey the feeling to a physician. This is why numerous subjective pain scales have been developed in the hopes that doctors may better understand a patient’s current level of pain. As mentioned, there are a variety of pain scales such as the Pain Quality Assessment Scale (PQAS), the Visual Analog Scale (VAS), the Numeric Rating Scale (NRS), and the Wong-Baker FACES® Pain Rating Scale (WBFPRS); to name a few. But for our conversation, let’s view pain scales as either a Verbal Rating Scale (VRS) or a Nonverbal Rating Scale (NVRS). Research has shown that patients prefer the VRS; unfortunately, it lacks sensitivity and the data it produces can be easily misunderstood. This misunderstanding is largely due to the fact that everyone tolerates pain differently, where someone’s “5” could be an “8” for another person based on a 1 to 10-pain rating scale. Thus, patients and doctors alike can find it difficult to arrive at an appropriate prognosis when someone’s pain is not easily defined or relatable.

Diabetic Neuropathy Vignette

Treating patients based solely off a pain scale would not only be difficult, it would also be a disservice to the patient. Let’s use two patients both with diabetic neuropathy as an example. Dr. Smith has two diabetic neuropathy patients; patient #1’s pain is a “10” and patient #2’s pain is a “7”. Given only this subjective information, Dr. Smith places patient #1 on a higher dose of Lyrica® for pain-relief while Dr. Smith puts patient #2 on a lower than average dose. Three weeks later for each patient’s follow-up appointment, patient #1, unfortunately, presents with similar diabetic foot pain and labored breathing, confusion, and difficulty in bowel movements. Patient #2 presents with similar (if not slightly worse) foot pain subsequent to being prescribed Lyrica®. Ostensibly something is wrong. Not only did both patients receive slim-to-no pain-relief because of a dose that did not fit their level of foot pain, but also unwanted side effects resulted that could have been avoided. Being provided with a subjective explanation of pain does not allow a physician to tailor a precise prognosis. So what’s the best way to convey as to how you’re truly feeling?

Sharing is Caring

It is clear that pain scales need accompanying objective context. For example, the National Institutes of Health (NIH) do use a numeric pain scale, but also ask questions that bring a more reasonable, albeit imperfect, assessment. Below we have provided some example questions that your doctor may ask. Note, although your doctor may not ask you these exact questions, still be sure to talk about these points of reference; for the more your healthcare practitioner knows about your current pain, the better chance you have of a pain-free (or reduced pain) outcome.

  1. Elaborate on what was the worst pain you have ever experienced. Maybe it was when you broke your arm or during childbirth. Whatever, the case, make it known that it is your worst pain ever felt. This can be used as a metric for what your “10” feels like and can be compared to the pain you are currently experiencing.
  2. Elaborate on your mental state. Let your doctor know if you are feeling anxious, depressed, irritated, hopelessness, etc. By identifying your feelings and emotions, it will give your doctor a better picture on how pain is affecting you overall.
  3. Show your doctor exactly where the pain is located. Instead of giving an overall-general pain level, try to pinpoint where on your body the pain is located. If the pain is radiating away from the focal point, be sure to tell your doctor the varying intensity you may be experiencing.
  4. Tell your doctor what makes the pain go away or what makes it worse. Are you taking any over-the-counter (OTC) medications once a day, or every few hours? Are you having to turn to stronger medications (e.g. opioids) for pain-relief? Does your pain get worse when doing normal daily activities, or is your pain only worsened by strenuous activity?
  5. Elaborate as to how frequent your pain is occurring. If you are struggling with chronic pain, let your doctor know the frequency and length of a pain episode. Be sure to describe a chronic pain episode that parallels how you are feeling when talking to your doctor. That way your doctor will get a “feel” as to how you are feeling on a regular basis.

Any subjective diagnostic tool that a doctor may use is always going to have its drawbacks; and yes, a pain scale is subjective. Use the five examples we mentioned as objective evidence that you can provide your doctor; but solely see our examples as a guide for communicating your current pain level. You of course can come up with your own points of reference to convey to your doctor how you are feeling. Look at your pain management regimen as a team between you and your doctor. Communication is key in any team and the more you and your doctor understand one another, the more effective you will be in reaching the goal you both are striving for, complete pain-relief. What’s the best way you have found to communicate your level of pain with your doctor? Please let us know!

Tags: pain scale, acute pain, chronic pain, diabetic neuropathy


  1. de C Williams AC, Davies HT, Chadury Y. Simple pain rating scales hide complex idiosyncratic meanings. Pain. 2000 Apr;85(3):457–463.
  2. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986 Oct;27(1):117–126.
  3. Lang EV, Tan G, Amihai I, Jensen MP. Analyzing acute procedural pain in clinical trials. Pain. 2014 Jul;155(7):1365–1373.
  4. Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nurs. 1997 Apr;20(2):88–93.
  5. Robinson-Papp J. Barriers to Chronic Pain Measurement: A Qualitative Study of Patient Perspectives. Pain Med. 2015 Jul;16(7):1256-64

New Year’s Kisses & Pain Medication Don’t Go Well With Alcohol

You did it! You survived Christmas! We hope you had an excellent time getting together with friends and family as well as having a lovely time at all your Christmas parties. We also hope our blog post, “’Tis the Season! How Alcohol Can Interact with Your Pain Medications” brought you some solace in understanding how alcohol may not be your best drink of choice if taking a pain medication. Given that New Year’s Eve is today where tonight is a night that is all too familiar for partying with alcohol, we would like to go a little deeper into how alcohol is processed in the body as well as provide three major classes of pain medications and their specific interaction with alcohol. Overall, we hope that this furthers your understanding of the medications you may be taking and how alcohol can leave you with dire side effects.

Alcohol Ingestion, Absorption, & Distribution in the Body

When alcohol is ingested through the mouth, a small amount is immediately broken down in the stomach. Most of the remaining alcohol is then absorbed into the bloodstream from the gastrointestinal tract where alcohol circulating in the blood is transported to the liver, where several enzymes break it down. The activities of these enzymes may vary from person to person, contributing to the observed variations in alcohol elimination rates among individuals. While in the liver, alcohol is metabolized by specific enzymes into acetaldehyde. Acetaldehyde is a toxic substance that may contribute to many of alcohol’s adverse effects (several medications can inhibit these reactions thereby inducing a flushing reaction in all people who consume alcohol after taking those drugs). The acetaldehyde is then transported out of the liver and into the blood system where it is distributed throughout the body. The takeaway message here is: the stronger your New Year’s Eve cocktail, the higher the concentration of alcohol will remain in your circulatory system.

Specific Medication-Alcohol Interactions

Interactions between alcohol and medication can occur in a variety of situations that differ based on the timing of alcohol, drug consumption, gender, weight, and age. Many classes of prescription and non-prescription pain medications can interact with alcohol. The drug classes we would like to discuss are opioids, benzodiazepines, and over-the-counter (OTC) anti-inflammatory agents.

  1. Opioids. Opioids are agents with opium-like effects (e.g. sedation, pain relief, and euphoria) that are used as pain medications. Alcohol enhances opioids’ sedating effects and may cause extreme drowsiness. Consuming large amounts of alcohol and opioids are potentially lethal because they can reduce the cough reflex and breathing functions; as a result, you are putting yourself at risk of getting foods, fluids, or other objects stuck in your airways. Certain opioid pain medications (e.g. codeine, propoxyphene, and oxycodone) are manufactured as combination products containing acetaminophen. These combinations can be particularly harmful when combined with alcohol because they provide “hidden” doses of acetaminophen (see below).
  2. Benzodiazepines. This class is categorized as sedative-hypnotic agents and act through the same brain molecules, as does alcohol. Studies have shown that concurrent consumption of moderate amounts of alcohol while taking a benzodiazepine can cause synergistic sedative effects, leading to substantial central nervous system impairment. It is worth noting that benzodiazepines can impair memory, as can alcohol. Consequently, the combination of these medications with alcohol may exacerbate this memory-impairing effect.
  3. Non-Steroidal Anti-Inflammatory Drugs (NSAID’s). Many people frequently use NSAID’s (aspirin, acetaminophen, ibuprofen, naproxen, indomethacin, and diclofenac) for headaches, minor aches & pains, arthritis, and other disorders of the muscles and bones. Nonetheless, NSAID’s have been associated with an increased risk of ulcers and gastrointestinal bleeding. Alcohol may exacerbate these risks by enhancing the ability of these medications to damage the lining of the stomach. Aspirin, indomethacin, and ibuprofen may cause prolonged bleeding by inhibiting the function of certain blood cells involved in blood clot formation, which is enhanced by concurrent alcohol use. Furthermore, people should be aware that over-the-counter combination cough, cold, and flu medications might contain aspirin, acetaminophen, or ibuprofen, all of which might contribute to serious health consequences when combined with alcohol. Also, alcohol consumption may result in the accumulation of toxic substances (i.e. acetaldehyde). Therefore, patients also using opioid-acetaminophen combination products should be cautioned about restricting the total amount of acetaminophen they ingest daily.

We understand there is quite a bit of medical terminology in each medication-alcohol interactions. In no way is anyone expected to remember all of that information; but what we would like you to remember is that alcohol consumed alongside pain medications can have disadvantageous effects on your physical, mental, and emotional state. By seeking the help of a pain management physician you have made a commitment to live a quality life free of pain, and we salute you! Undertaking activities that deviate from your goal for complete pain relief hurts not only you but also your friends and family. If you’re currently taking any of the medication we mentioned above, alcohol does not have to be in your New Years’ plans to have an excellent time. There are so many alternatives that you could opt for, which not only keep you social but also keep you on the right track for your pain therapeutic regimen. So from us here at Pain Consultants of Arizona, we all wish you and your family a happy New Year! What is an alternative that you turn to rather than alcohol at a party? Let us know and see you in 2017!

Tags: alcohol, pain management, medications, new years, opioids, nsaids, anti-inflammatory


  1. Berkow R, ed. Drugs and the liver. In: The Merck Manual. 16th ed. Rahway, NJ: Merck & Co., Inc;1992:781.
  2. Emanuele, N.V., al. Consequences of alcohol use in diabetics. Alcohol Health & Research World 22(3):211–219, 1998.
  3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118–145. e10.
  4. Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125(1–2):8–18
  5. Kuffner EK, Dart RC, Bogdan GM, Hill RE, Casper E, Darton L. Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients. A randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001;161:2247-2252.
  6. Levitt, M.D., al. Use of a two- compartment model to assess the pharmacokinetics of human ethanol metabolism. Alcoholism: Clinical and Experimental Research 22:1680– 1688, 1998
  7. Manyike PT, Kharasch ED, Kalhorn TF, et al. Contribution of CYP2E1 and CYP3A to acetaminophen reactive metabolite formation. Clin Pharmacol Ther 2000;67:275-282.
  8. Nemeroff CB, DeVane CL, Pollock BG. Newer antidepressants and the cytochrome P450 system. Am J Psychiatry. 1996;153(3):311–320.
  9. Niemela, O., al. Early alcoholic liver injury: Formation of protein adducts with acetaldehyde and lipid peroxidation products, and expression of CYP2E1 and CYP3A. Alcoholism: Clinical and Experimental Research 22:2118–2124, 1998.

‘Tis the Season! How Alcohol Can Interact With Your Pain Medications


It’s that time of year again where we spend time with families, coworkers, and friends all throughout this Christmas Season. We will assume that you will be attending at least one Holiday function where more than likely alcohol will be present. So, in light of the Holiday spirits (no pun intended), we would like to discuss why alcohol might not be your best beverage of choice if you are currently taking any medications. Alcohol is a big part of many types of holiday celebrations, but unfortunately, alcohol can interact in less than stellar ways with pain medications. Interactions between alcohol and a medication can occur in a variety of situations that differ based on the timing of alcohol, medication consumption, gender, weight, and age. Many classes of prescription and non-prescription pain medications can interact with alcohol. For example, opioids, muscle relaxants, narcotics, benzodiazepines, over-the-counter (OTC) anti-inflammatory agents, and antidepressants all interact with alcohol in a specific manner than can wreak havoc on your body. Alcohol can cause extended release formulations of pain medications to release all at once, and some short-acting formulations to release more quickly than normal, a phenomenon called “dose dumping.” Dose dumping can lead to rapidly increased levels of the medications in the system, resulting in overdose and possibly death. So let’s jump right into discussing alcohol & pain medication interactions.

Acetaminophen: A Real Life Example of a Drug-Alcohol Interaction

Let’s use drugs containing acetaminophen as an example. Certain opioid pain medications (e.g. codeine, propoxyphene, and oxycodone) are manufactured as combination products containing acetaminophen. These combinations can be particularly harmful when combined with alcohol because they provide “hidden” doses of acetaminophen that can cause drowsiness, sedation, and decreased motor skills. Acetaminophen also increases gastric emptying, leading to faster alcohol absorption in the small intestine; may also inhibit important gastric hormones. Alcohol enhances acetaminophen metabolism into a toxic product, potentially causing liver damage.


You might be thinking, “ Well, I do take a medication but this is only for people who drink a lot of alcohol”. Unfortunately, this is not the case. In fact, most of the data on alcohol-medication interactions was done on those who drank moderate levels of alcohol. Thus please be aware that any level of alcohol may interact with your medications. As alternatives to alcohol try virgin cocktails, non-alcoholic beer, sparkling non-alcoholic cider, sparkling water, and eggnog without the alcohol. All are festive, and allow you to blend in with the crowd. Nonetheless, if you do drink, please make sure to have a ride. Alcohol-medication interactions can exacerbate medication’s adverse side effects (drowsiness, dizziness, euphoria, etc.). We hope this in-depth explanation of the effects of alcohol will help you in making the decision about drinking. Have a blast at all your holiday parties this year and try to play it safe if you are taking any sort of medicines. From all of us here at Pain Consultants of Arizona, we wish you and your family a Merry Christmas!

Tags: alcohol, pain management, medications, Christmas, opioids


  1. Berkow R, ed. Drugs and the liver. In: The Merck Manual. 16th ed. Rahway, NJ: Merck & Co., Inc;1992:781.
  2. Emanuele, N.V., al. Consequences of alcohol use in diabetics. Alcohol Health & Research World 22(3):211–219, 1998.
  3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118–145. e10.
  4. Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125(1–2):8–18
  5. Kuffner EK, Dart RC, Bogdan GM, Hill RE, Casper E, Darton L. Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients. A randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001;161:2247-2252.
  6. Levitt, M.D., al. Use of a two- compartment model to assess the pharmacokinetics of human ethanol metabolism. Alcoholism: Clinical and Experimental Research 22:1680– 1688, 1998
  7. Manyike PT, Kharasch ED, Kalhorn TF, et al. Contribution of CYP2E1 and CYP3A to acetaminophen reactive metabolite formation. Clin Pharmacol Ther 2000;67:275-282.
  8. Nemeroff CB, DeVane CL, Pollock BG. Newer antidepressants and the cytochrome P450 system. Am J Psychiatry. 1996;153(3):311–320.
  9. Niemela, O., al. Early alcoholic liver injury: Formation of protein adducts with acetaldehyde and lipid peroxidation products, and expression of CYP2E1 and CYP3A. Alcoholism: Clinical and Experimental Research 22:2118–2124, 1998.

Why Would I Need To Take A Drug Test For Pain Management?

It’s never a favorable feeling when you feel disconnected from your healthcare management. Unfortunately, there still exists a gap between the treatment/procedures a given patient receives and the patient education and engagement of those treatments. One example that we would bring more insight to is why your pain management doctor may ask for you to provide a urine-drug test. It has been estimated that 20% patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings. From 2007–2012, the rate of opioid prescribing has steadily increased among specialists more likely to manage acute and chronic pain. If you are currently taking an opioid or certain non-opioid pain medications, your doctor may at some point request you provide a urine drug test. So let’s quickly detail what the urine-drug test is and then provide some reasons why it is important to your pain management treatment.

What Is A Urine-Drug Test?

You would be correct in assuming this procedure tests drug levels in the body through a urine sample. But let’s get a little more technical as to the mechanics of a urine-drug test. Once a urine sample is collected, it is sent to a certified laboratory where the sample is analyzed using laboratory methods known as immunoassay and chromatographic methods (e.g., liquid chromatography with mass spectrometry detection) to yield high detection sensitivity and drug specificity. The test will also determine the concentration of a given medication; the higher the dose of a medication, the higher the concentration will appear on the test. The results are then shipped back to your physician where they will overview the results with you as well as determine what the next step should be in your pain management treatment.

Why Is A Urine-Drug Test Being Done?

There are three main reasons why a urine-drug test is completed for a clinical setting. In general, the test will provide objective evidence and documentation that you are properly taking your medication, and not taking any substance that you are not prescribed. It’s a tool that physicians use to keep you safe, other patients safe, and themselves safe.

  1. Allows your physician to determine the right dose for your medication. When a medication is ingested and absorbed into the blood system, it will travel to the liver where specific metabolic enzymes will convert the medication into its metabolites. These metabolites are what are tested in a urine-drug test. Our DNA dictates as to how [active] our liver enzymes are at metabolizing a drug. Some people are slow metabolizers, meaning it takes longer to form a metabolite; some people are fast metabolizers, meaning a metabolite is formed much more rapid when compared to a normal metabolizer. Let’s use dilauded as an example. Two people are both given a 1mg dose of dilauded. One patient is a slow metabolizer where a lower concentration of dilauded’s metabolites will appear in a urine-drug test when compared to a patient who is normal. Because of a lower concentration of the metabolites, this patient is not receiving the full analgesic-effect of this dose. Thus the physician may determine to either increase the dose or alternate to a different medication.
  2. Determines If You Are Correctly Taking A Drug & Being Honest About It. Misuse of drugs can be accidental or intentional – unfortunately, it can also be fatal. A urine-drug test will report whether you are taking a medication at the prescribed dose and at the proper time. Your physician may decide to remove this medication from your drug therapy or change the dose depending on why the drug was not originally being taken properly.
  3. Determines If You Are Taking Any Illicit or Other Non-Prescribed Drugs. One chronic pain study found that many patients fail to report their drug use, especially illicit drugs. Abusing an illicit or non-prescribed drug can also be fatal, depending on the drugs involved. If potentially fatal drugs are being taken, your physician will do what they can to minimize the risk, and there is no way of telling by looking at a person what the risk for that person is. Because the potential consequences of medication abuse are so serious, i.e. death, your doctor may be required to test a patient who is prescribed an opioid.

We would like to point out that due to the advancements of technology, your doctor may choose to do a saliva, buccal cheek swab, or hair follicle test rather than a urine- test. Although these are different methods, the test still provides the same results so do not be too concerned with the method of testing your doctor may chose to do. Drug testing for opioid or other pain drugs is an important tool that healthcare providers can use to assess drug therapy treatment compliance and opioid misuse; however, no diagnostic test is perfect. It is sometimes possible to “game” the system, and avoid being detected for a while, although who are you really helping with that strategy? If you have trouble managing your medications or your pain, or you are using illegal or non-prescribed drugs, talk to your provider and get help! You don’t have to go it alone.

Tags: urine-drug test, medication, opioids, pain management, healthcare, technology


  1. Centers for Disease Control and Prevention. Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012. MMWR 2014; 63(26):563-568.
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  5. Frenk SM, Porter KS, and Paulozzi LJ. Prescription Opioid Analgesic Use Among Adults: United States, 1999 – 2012., National Center for Health Statistics Data Brief, February 2015.
  6. Romano G, Barbera N, Lombardo I. Hair testing for drugs of abuse: evaluation of external cocaine contamination and risk of false positives. Forensic Sci Int. 2001;123(2-3):119–129.

4 Reasons Nutrition Is Vital When Living with Osteoarthritis


Did you know a study done in 2005 reported that approximately 26.9 million American adults suffer from osteoarthritis where this conservative number of people suffering from this degenerative arthritic joint disease has only exponentially increased over the years? But why is that? Studies have shown that arthritis is twice as high in obese people as in those with a healthy weight since the extra weight puts pressure on your joints. Thus is it due to the rise in obesity? Maybe partly due to people retiring at a much later age putting more stress on their joints and bones? In this post we will not speculate as to “what” is causing an increase in osteoarthritis, but rather “how” osteoarthritis symptoms can be reduced and in some cases, prevented. If you suffer from osteoarthritis, then you are well aware that it is a disease where a loss of cartilage in the joints can bring severe inflammation and excruciating pain. Thus we would like to provide you with some handy nutrition and exercise tips (and why they are important) to help you manage this condition to live an enjoyable and healthy life. Nutrition is important to osteoarthritis patients for even small nutritional changes may reduce pain associated with osteoarthritis. However, it is in your best interest to consult your healthcare provider first before implementing any of these tips.

Nutrition Can Keep Your Bones & Cartilage Strong

Eating a sensible diet, focused on musculoskeletal rigidity, may aid in keeping your bones and cartilage durable. For example, studies have shown that foods high in antioxidants as well as in glucosamine may help reduce, if not repair, tissue damage caused by osteoarthritis. For adding antioxidants to your diet, try to add fruits and vegetables; for example, blueberries and leafy greens. For glucosamine, try to incorporate shellfish such as crab, lobster, or shrimp.

Nutrition Can Control Inflammation

Controlling your diet can help to control general inflammation in the body. Certain foods such as sugary foods, fried foods, and refined foods have been shown to increase inflammation in the body. Do your best to reduce if not avoid foods of this nature. On the contrary, numerous studies have also documented many foods that have anti-inflammatory effects. Foods high in omega-3 fatty acids (e.g. salmon & tuna), as well as spices such as ginger and turmeric, may help in reducing inflammation. It is important to note that [fat] is not a bad thing to have in your diet. To contrary belief, healthy fats can actually aid in weight loss. Just be sure the foods you choice are of the healthy-type of fat; for example, the fish we just mentioned, avocados, nut butters, almonds, and olive oil to name a few.

Nutrition Can Aid In Weight Loss

Having an appropriate weight for your body may reduce stress on your bones and joints, especially the weight-bearing joints as in your pelvis or knees. Removing excess weight from your body not only removes added stress on these joints but may also reduce pain. To lose weight, you must expend more calories (through exercise or hypo-caloric diet) than you are consuming. Thus for weight loss or weight-maintenance (if you are at an appropriate weight), eating a diet high in nutrient-dense foods will provide the right amount of calories without over consuming. Furthermore, studies have shown that people who continue to eat processed foods, fried foods, sugar and red meat are more likely to develop rheumatoid arthritis over people eating a diet of fresh fruits, vegetables, fish, and white meats.

Nutrition Can Get You Moving

Physical activity may help to maintain joint mobility where nutrition plays a vital role in how active we are. For example, the more fatty and fried foods that we eat, the more sluggish and worn-down we feel. On the contrary, eating nutrient-dense foods provides the minerals and vitamins to not only give us the ability to exercise but may also promote the motivation to exercise. This motivation in itself is significant for research has shown that 40% of women and 56% of men with osteoarthritis exercise less than 10 minutes a week, given the misconception that exercise wears down joints. In fact, physical activity may also reduce the risk of developing osteoarthritis in the first place. Frequently recommended activities are ones that put minimal stress on the body’s joints; for example, swimming and bicycling. Try to avoid intense activities that may injure or strain the joint cartilage. Exercise is beneficial when performed at a level that does not stress the joints.

We must stress how important it is to consult your doctor before implementing any of the above nutritional tips. Your healthcare provider can help you pick and choose which foods will work best for you and reducing the symptoms of osteoarthritis. We hope this quick overview of how nutrition can reverse the effects of osteoarthritis. What nutritional changes have helped reduce your symptoms of osteoarthritis? Let us know!

 Tags: osteoarthritis, nutrition, exercise, activity, inflammation, anti-inflammation, knee pain, pelvic pain, joints, obesity, diet


  1. Arita M, Bianchini F, Aliberti J, Sher A, Chiang N, Hong S, Yang R, Petasis NA, Serhan CN. Stereochemical assignment, antiinflammatory properties, and receptor for the omega-3 lipid mediator resolvin E1. J Exp Med. 2005;201:713–722. doi: 10.1084/jem.20042031.
  2. German B, Schiffrin EJ, Reniero R, Mollet B, Pfeifer A, Neeser JR. The development of functional foods: lessons from the gut. Trends Biotechnol. 1999;17:492–499. doi: 10.1016/S0167-7799(99)01380-3.
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  6. Yelin E. The economics of osteoarthritis. In: Brandt KD, Doherty M, Lohmander LS, editor. Osteoarthritis. Oxford: Oxford University Press; 2003. pp. 17–21.


5 Points To Know When Dealing With Peripheral Neuropathy


Living with peripheral neuropathy can be full of ups and downs from day to day, especially if you have been recently diagnosed. Managing this painful condition is frustrating at best, and can feel overwhelming at times. Patients often experience changing symptoms and debilitating pain. Learning more about potential treatment options should be a first step for anyone confronted with this condition, since treatments can go a long way to improving quality of life for those who are suffering.

Physiology & Pathology

Understanding a little more about the physiology of peripheral neuropathy, let’s start at defining the nerves involved in this debilitating condition. Peripheral nerves are the longest nerves in the body, extending all the way from the hands to the feet. When damaged, common symptoms are pain, numbness or tingling in the hands and feet. Unfortunately, these symptoms are far more severe and far-reaching than this. Some have reported experiencing such symptoms as stabbing pains and incapacitating weakness.

Better Insight For A Better Outcome

Today, 20 million people in the United States are affected by this condition, yet many are not aware of how it affects our loved ones, leaving the patient and their family helpless as to how to improve their overall quality of life. Below are five common conceptions that those with or know someone with peripheral neuropathy should be aware of for better understanding this condition.

 1. Diet Can Exacerbate Symptoms

Your diet may either help or hurt your nerves. To improve symptoms, avoid foods with excess sugar, artificial sweeteners, and refined grains. These foods may irritate the nerves causing nerve pain. In fact, studies have shown that a diet consisting of low-fat and whole foods supplemented with exercise may have a positive impact on neuropathy in reducing pain symptoms.

 2. Symptoms Are More Complex Than Just Tingling

While pain and tingling are common and the easiest symptoms to recognize they are not the only ones. There are three types of peripheral nerves: sensory, autonomic and motor. Each can show different symptoms. Sensory nerve damage causes the frequent pain, tingling and numbness. Motor nerve damage may cause difficulty walking or picking up items, and moving the arms. Autonomic nerve damage affects more of your involuntary functions, like breathing, sweating, blood pressure and more.

 3. Diabetes Is the #1 Cause of Neuropathy

Diabetes is the leading cause of neuropathy today. Over 70% of diabetes patients develop symptoms. To avoid diabetes manage your blood sugar carefully. This can be a great way to prevent or even reverse the effect of diabetic neuropathy.

4. There Are Other Causes Besides Diabetes

While diabetes is the leading cause of peripheral neuropathy, other causes may include: alcoholism, traumatic injury, chemotherapy, as well as a vitamin B12 deficiency. It is well documented that it may be very difficult for the medical community to identify the exact cause of each patient’s peripheral neuropathy. For cases where the cause cannot be defined, doctors will diagnosis the patients with “idiopathic neuropathy”.

5. Certain Medications Can Damage Nerves

For those suffering from diabetes, drugs such as metformin have been shown to encourage damage to the nerves. This association has been linked in a recent study to vitamin B12 deficiency, which may result in neuropathy.

Peripheral neuropathy is a very serious condition that should be managed as soon as even the simplest symptoms arise. Talking to your doctor and following their specific treatment plan, as well as being equipped with better insight into this condition, may better equip you in combatting the symptoms associated with peripheral neuropathy allowing you to still live a healthy and high quality of life. What other things have you heard about peripheral neuropathy? Let us know!

Tags: peripheral neuropathy, diet, medications, diabetes, b12 deficiency, pain, tingling



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8 Ways For Effective Sleep Hygiene When Dealing With Chronic Pain


We dare you to find a person that has never had a restless night of sleep. We think you can agree with us that finding such a lucky person would be quite a daunting task. With that being said, we have all had the occasional night where we just can’t fall asleep. A night or two, although annoying, hardly causes us to become alarmed. Nonetheless, for those suffering from a chronic illness, a couple of nights without sleep can wreak havoc on pain symptoms as well as their overall quality of life. Unfortunately, it is simply not just a couple of nights that individuals with chronic pain have to deal with. Not getting a good night’s rest generally leads to exacerbated pain symptoms where hyperalgesia (intensified pain) may keep someone from falling asleep at night. Said another way, pain worsens sleep patterns and sleep disturbances worsen pain. It is worth noting that chronic pain patients are all too familiar with sleep disorders where more than 66% of patients experience problems. Such a rancorous cycle could lead to a chronic inability to fall asleep, which could result in insomnia or other sleep disorders.

What Exactly Is Insomnia?

Insomnia is a general clinical term that refers to the difficulty in initiating or maintaining sleep that occurs for at least three nights a week for up to 3 months in a given year. It may present as an independent problem (primary insomnia) or as part of a coexisting medical or psychiatric condition (secondary insomnia). Insomnia is known to cause clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning; thus it is important to talk to your doctor as soon as possible if you find yourself meeting this criteria. Fortunately, in many cases insomnia can be reversible and can greatly reduce someone’s sleep-deprived pain symptoms. We will not go into too much detail but there are a number of treatments that can truncate symptoms of insomnia. However, it is very important to consult your physician to determine if the actual cause of your inability to sleep is from insomnia or from another sleep disorder that has yet to be ruled out. For example, sleep disorders caused by medication side effects, psychiatric disorder, or sleep apnea should all be considered as to why are not able to sleep.

Chronic Pain & Insomnia: A Catch-22

One form of treatment that we would like to discuss is the use of medications. Certain pain medications can in fact improve sleep and generally are prescribed for patients who have both a sleep disorder and a specific pain disorder. On the other hand, opioid pain medications can disrupt sleep and prevent patients from entering deep sleep after as little as one dose. Opioid pain medications can also cause sleep-related breathing disturbances. This is why it is crucial to consult with your doctor as to what the underlying cause is for your inability to sleep where a more precise treatment plan can be created.

Creating A Healthy Sleep Environment

Below are 8 ways that have been found to be effective in creating proper sleep hygiene where the first 6 are relatively easy to implement. We go into further detail about the last two in the hopes of furthering your understanding of these practices. As with any of these tips, please consult your doctor before implementing any of these.

  1. Use your bedroom only for sleeping. Avoid using your bedroom as an office, a place to eat, or a place to socialize.
  2. Only go to bed when you are sleepy.
  3. Watch caffeine and alcohol intake, especially after noon.
  4. Try to do physical activity earlier in the day.
  5. Try to wake up at the same time every day regardless of when you go to sleep the night before.
  6. Avoid naps during the day
  7. Cognitive Behavioral Therapy

As we mentioned above, medications are a very critical vehicle for alleviating symptoms of insomnia and pain. Nonetheless there does exist a therapy treatment that is just as effective as medications in the long-term and does jot have the side effects that may accompany medications. Cognitive behavioral therapy (CBT) is a form of treatment that has been shown to be highly effective in treating insomnia. CBT is comprised of a number of strategies that seeks to improve overall sleep quality as well as changing thought and behavior patterns that are assumed to interfere with sleep. CBT accomplishes this by helping patients control or eliminate negative thoughts and worries that keep them awake. Through CBT work there is an increased awareness of thoughts related to sleep and once controlled, they tend to decrease and it is easier for the patient to fall asleep. Numerous studies have shown that cognitive behavioral interventions are as effective as pharmacological treatments in the short term and more effective in the long term.

  1. Relaxation Therapy

Another strategy is relaxation training, which is used to reduce or eliminate muscle tension and distract one from racing thoughts. Relaxation therapy is useful for both sleep onset and sleep maintenance insomnia. Techniques include progressive muscle relaxation, guided imagery, biofeedback, and autogenic training; to name a few. Regardless of the type of relaxation strategy used, the treatment involves professional guidance and the teaching of these skills over a number of sessions.

Do your best to adopt one or any of these stress-management strategies to reduce the anxiety or other emotional disturbances associated with your lifestyle. Doing so will be your best bet in keeping sleep-deprived pain symptoms at bay. Again, we must stress to please make sure that you receive treatment for any medical, psychiatric, or other conditions that may interfere with your sleep. What tips have helped you create healthy sleep hygiene? Let us know!

Tags: alcohol, caffeine, CBT, chronic pain, insomnia, pain management, sleep, sleep hygiene


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