“Pain is only relevant if it still hurts.” Ed Sheeran
I was reading an article, not long ago, regarding the epidemic of pain killers in women in the USA leading to this administrations recent policy changes in an attempt to curtail this problem. It got me thinking about pain as an initial presentation in neurological diseases such as in Parkinson’s disease. Like many other neurological illnesses, PD has a big pain component which varies from person to person. It is believe that 40-80 % of people who have PD have pain.
The pain can occur at any stage of disease and can take many shades within the same individual at any given time. Pain in my experience is more frequent and more pronounced in younger patients as well as a common initial presentation of illness. However, because pain is subjective it is too often misunderstood and misdiagnosed by many physicians.
In my own practice it seemed that women with young onset PD had a higher rate of pain at presentation. Subsequently, because of misdiagnosis they were often the ones to be placed on opioids for chronic intractable pain. Because of the likelihood for women to be placed on opioids due to lack of concrete diagnosis we as physicians and patients alike must take a proactive approach to getting not just diagnosed earlier but starting treatment early.
Once opioid treatment is begun there is a potential increased risk of mortality for women compared to men. But also worsening of PD symptoms particularly cognition and gi symptoms causing a downward spiral. This is because women across the board not excluding PD have more chronic pain then men. I for one have chronic pain as one of the major impacting symptoms of my Parkinson’s disease which disrupts my day to day activities more than any other single symptom.
In my two decades of treating Parkinson’s – I found that very rarely was there a need to use opioids (like hydrocodone, fentanyl, morphine, codeine,
etc.). However, if there ever was a time to use such methods as
in the case of an acute herniating disc common ibn PD patients. The prescription and intake of these pain medications should have a set finite amount of time. They are not meant to be taken long term where addiction is most likely to occur. The key is treating pain acutely at its source with morphine if necessary to prevent the brain from becoming sensitized remodel to require constant doses of high opioids to produce a desirable effect. Having personally experienced multiple types of pain from dystonia, to central and radicular pain as well as musculoskeletal pain, I can attest without a doubt that dopamine agents will treat and reverse the majority of pain syndromes without the need of opioids. The only time I ever required the use of an opioid like drug was during the acute phase of my herniated disc as well as post op ( again for a limited time only). Having surgery resolved the pain immediately as it does in case of an acute nerve entrapment. However for my central –non localized, intractable boring pain. Azilect was a life saver. In my experience the majority of cases of
pain in those living with PD, treating the motor PD symptoms adequately
typically relieves their typical shoulder or hip pain, musculoskeletal pain in
limbs as well as back and neck pain. Dystonic pain in neck responds well to Botox injections along with levodopa medication adjustment. Even so called entrapment nerves syndromes like carpal tunnel (hand
swelling and first 3 fingers going numb or tingling) or ulnar nerve
entrapment (numbness and tingling in 4th and 5th digit) will often correct by us of massage therapy, anti-inflammatory drugs. But more importantly upping dose of levodopa to relieve dystonia and rigidity of muscles does far more to alleviate the problem. Same types of problems can occur in lower extremities causing a tarsal tunnel much less infrequent though.
The increased muscle stiffness can be so profound as to actually dislocate joints. Patients with PD often times have a shoulder dislocation even hip dislocation at times. So if you start having joint pain talk to your doctor ASAP a simple increase in dose or frequency of medications can resolve the issue as I has me many occasions. Thus, before you pursue any other treatment ensure that your PD medications are at their optimal level.
In cases, where dyskinesia’s have caused the pain by distorting curvature and musculature of axial muscles and even caused discs to herniate, the first order of business is treat the problem –STOP the dyskinesia’s either through medication or surgically (DBS ) or combination. Then you can begin to treat the pain by performing neck/back surgery if necessary and using prophylactic medications such as anticonvulsants-(e.g. Keppra, Topamax); anti -depressants in the tricyclic family such as Elavil, and Remeron or antidepressants in ssri and snri family- e.g. Cymbalta, Effexor. The use of centrally acting muscle relaxants like baclofen and dantrolene are also quite helpful. The use of topical anesthetics (e.g. Lidoderm patches) and topical anti-inflammatories also can be of benefit like using .
Thus, in my opinion as a former PD specialist, opioid addiction in our Parkinson’s community should not be something we need to contend with improving our life expectancy particularly for us women. If we follow the mantra that the majority of pain syndromes CAN and should be treated first and foremost by increasing and adjusting PD medications as a first step.
Make sure you speak with your physician if you are
having any of these issues.
Kam Katherine. (September
2017) “Opioid addiction: the gender Gap” medical editor- Neha Pathak,
WeBMD magazine. 69-71.
all right reserved By maria L. De LeonMD