For the first time ever, the New York State Assembly’s one-house budget proposal included more expansive plans to approve the use of  medical marijuana.  In a recent poll 88% of New Yorkers felt that medical marijuana should be legalized, and both republican and democrat senators are listening.

In order to make a decision on whether a drug should be available, we look to the science (peer-reviewed research) to help us decide whether the benefits of the drug are worth the risks.  Some studies show marijuana is effective for pain relief (especially the neuropathic pain which accompanies disorders like Multiple Sclerosis[1]) and for improving sleep for those with painful disorders.[2]  Other studies also found that smoking marijuana helped to increase pain tolerance, with a greater effect observed for those who were not novice users.[3]

In a study in which individuals smoked marijuana cigarettes containing different amounts of THC (one of the active components that is responsible for many of Marijuana’s effects), they found that too small a dose did not provide any analgesic benefit, and too large a dose actually increased pain.  In this study, cigarettes containing 4% THC experienced the most pain relief.  This suggests that there is an optimal dosage of marijuana to relieve pain.4

Despite the apparent benefits, there are short and long-term adverse effects.  Marijuana can cause anxiety and panic, and, at very high doses, psychotic symptoms.  Patients using marijuana should not drive while taking it.  Long-term users can show signs of dependence and subtle cognitive impairment.[4]

Marijuana may be useful in a variety of painful conditions, but most studies currently available are not large enough to draw useful conclusions.  Legalization will allow larger scale studies to be done so that we can be more confident about both the positive and negative effects.  Like any other potent drug, it needs to be carefully regulated and only used when appropriate.

Anti-seizure, or anti-epileptic, medications have commonly been used to treat pain, especially nerve-related pain. Examples include pregabalin (Lyrica), gabapentin (Neurontin), topiramate (Topamax), and carbamazepine (Tegretol/Carbatrol). The exact mechanism in which these medications work is not completely clear. Anti-seizure medications help decrease hyperactivity of the nerves that cause seizures; therefore, it is thought that these medications can have a similar effect with decreasing the activity of the nerves that cause pain.

As with all medications, there are side effects – most common side effects are dizziness, drowsiness, nausea, vomiting,  blurred or double vision, and weight gain. Therefore, if you are not having reasonable pain relief with one of these medications, it shouldn’t be continued. It is generally a good idea to stop these medications slowly, since abruptly stopping in someone who is seizure prone could cause a seizure.

Do you have or used to have high cholesterol? Statins are a class of drug used to lower the amount of cholesterol produced by the liver.  You might recognize some of the more common brands like Lipitor (Atorvastatin Calcium) or Crestor (Rosuvastatin Calcium).  They are commonly used for patients with high cholesterol, diabetes, or those with a family history of heart attacks.  Recent data shows that approximately 5% of patients maintained on statins experience muscle pain and weakness.  Muscle pain is one of the top reasons patients choose to stop taking statins[1].  If you are taking a statin and are experiencing muscle pain or weakness, you may want to talk with your doctor about adjusting your dose or finding an alternative treatment.

You can experience muscle pain for many reasons. We discussed trigger points in an earlier blog (see www.normanmarcuspaininstitute.com/what-are-trigger-points/ to recap your memories).  A common medical problem, abnormal activity of the thyroid gland, can cause muscle pain.

Hypothyroidism is a condition in which your thyroid gland doesn’t make enough hormone.  (Hyperthyroidism, which is not as common, is when the thyroid gland produces too much hormone and that can also produce muscle pain.)  When you don’t have enough thyroid hormone, many systems in your body are affected and you may notice the following signs and symptoms:

-brittle nails

-hair loss

-fatigue (feeling tired)

-dry skin

-memory problems

-having trouble thinking clearly

-weight gain

Muscle symptoms associated with hypothyroidism are often described as a cramping, stiffness or weakness.

Hypothyroidism is generally treated with hormone replacement therapy, which means you’re taking synthetic (man-made) hormones to replace the ones that the body isn’t producing.  In one study, almost 20% of patients complained of joint and/or muscle pain, of which 50% had relief in symptoms after starting thyroid replacement therapy[1].

So if you have been diagnosed with hypothyroidism or have symptoms of hypothyroidism and also complain of muscle pain, it’s very possible that the two are related. Ask your doctor to check it out.

Nerves connect muscles to the spinal cord.  When something stimulates your muscles, for example, if someone were to press on your arm, the muscle sends a message via the nerves first into the spinal cord, and then up to the brain.  Once the brain receives the message (in this case, that there is pressure on your arm), then your body is able to perceive sensation.  This all happens in a split second, so that your brain receives the message immediately after the stimulus appears.  When the sensation is strong enough it no longer feels like pressure or a simple touch; it is experienced, rather, as pain.    Once the brain processes the message, then you become aware of pain in your muscle.

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We have always encouraged a step-care model for treating our patients in pain. Start with the least expensive, least invasive procedures before trying the more expensive, complicated, and invasive procedures.  So when you first experience pain, your primary care physician, or PCP, would be your first stop.

The Institute of Medicine (IOM) made the following key recommendations[1]:

1. Use non-steroidal anti-inflammatory medications (NSAIDs) and acetaminophen (Tylenol) as first line pain medication.
2. Referral from primary care physicians (PCPs) to specialists for back pain was not recommended. Referral  to physical therapists was recommended.
3. Use of imaging, such as MRI, CT scan, or x-ray, were not recommended.

This may be easier said than done.

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A study in Clinical Orthopaedics & Related Research [468(10):2678-89], reports that over time the function of the shoulder deteriorates in a significant number of patients who underwent rotator cuff repair, despite continued pain relief in many of the same patients.  The study found that even if greater function was achieved in the months directly following surgery, both strength and range of motion decreased to less than preoperative values even though pain was alleviated.

I treated a 60 year old man with a diagnosis of rotator cuff tear. Because of severe shoulder pain and restriction of movement in his shoulder, he was unable to brush his teeth, hold utensils to eat, or comb his hair. He was scheduled for surgery to repair his rotator cuff. He was found on examination to have six muscles in his shoulder girdle that were causing his pain.

These muscles were injected over the course of 3 weeks and following each injection a physical therapy protocol was used that restored his range of motion. His pain was eliminated. His surgery was cancelled. He remained pain free for the two years that he was followed.

In view of the findings reported in the paper and my results with this patient and others diagnosed with shoulder pain from rotator cuff tear or impingement syndrome, it is important to evaluate muscles as a source of pain and function impairment prior to performing surgical repair.

A recent study of office workers who complained of weekly headaches examined the effect of a simple resistance exercise program for the neck and shoulders, and found an approximately 50% reduction in headache frequency.

Headaches are the most commonly reported pain problem. If brief exercise can have such a dramatic effect on headache frequency, it should be considered as a standard intervention for all office workers who appear to have muscle tension type headaches. One possible reason brief exercise is so effective is that it may help relax tense muscles which can become stiff from repetitive strain, for example bending your head and neck over a desk for hours at a time.  Simply performing an action to address headaches on a daily basis may also make you more aware of the circumstances surrounding a headache episode. Since headaches are frequently brought on with emotional stress, being more aware of and addressing stress can reduce headache frequency.

Even though self-awareness can help, knowing what you are thinking and feeling is not as easy to achieve as one might imagine. Many of my patients report becoming aware of unsettling feelings and sometimes divulge situations that have been troubling to them while doing their prescribed exercises. There are many thoughts and feelings that are upsetting for us to acknowledge. It may be difficult to admit that you are angry or resentful towards someone you love or someone on whom you depend for your livelihood. We may be uncomfortable or ashamed to admit to feelings of fear or envy. Repressing or denying thoughts and feelings can lead to increases in muscle tension with resultant headaches, and to symptoms of anxiety.

If it’s all about repressed feelings why don’t all the headaches or anxiety symptoms disappear when we become more conscious? H.L. Menken said that “there is always a simple solution for a complex problem, and it is usually wrong.” Exercise addresses a different reason for your neck pain than struggling with uncomfortable emotions. When it comes to persistent pain problems, a multi-faceted approach which addresses multiple sources of discomfort may provide the most relief.