BRAIN WAVES

Brain Injury Alliance of Arizona Blog

Opioids for Pain Management: The Other Side

The opinions expressed in this article are those of Dr. Bill Levinger about his journey and should not be taken as medical advice. You should always consult with a medical professional before starting any new or additional pain management regimen.

With all this well-deserved attention about the dangers of opioids, there is another side to the story that should not be discounted. Opioids can also be beneficial for many patients as long as they are carefully prescribed and monitored.

Opioids for Pain Management: The Other Side

The opinions expressed in this article are those of Dr. Bill Levinger about his journey and should not be taken as medical advice. You should always consult with a medical professional before starting any new or additional pain management regimen.

Daily headlines blare out the dangers of opioid misuse— how it can lead to addiction, while masking underlying emotional problems, and even lead to overdose. In 2018, the National Institutes of Health (NIH) reported that 128 people die from opioid overdose every day in the United States. Between 21 and 29 percent of patients misuse prescribed opioids, with many transitioning to heroin.  

With all this well-deserved attention about the dangers of opioids, there is another side to the story that should not be discounted. Opioids can also be beneficial for many patients as long as they are carefully prescribed and monitored.

What’s more, when managed in addition with increased daily activity and range of movements, recovery time from injuries, such as ones stemming from brain trauma, can be expediated.

With all this well-deserved attention about the dangers of opioids, there is another side to the story that should not be discounted. Opioids can also be beneficial for many patients as long as they are carefully prescribed and monitored.

Dr. Bill Levinger, a graduate of the University of Pennsylvania School of Medicine, understands these benefits not only from his 30 years in pain management, but from personal experience as well.

While interning at a family practice residency in Idaho almost 40 years ago, Dr. Levinger went rock climbing with a friend. Both were experienced climbers, but not experts. They didn’t set up properly on a 60-foot cliff and both hurdled toward the ground. His friend died on impact. Dr. Levinger fell 20 feet onto the only patch of grass in the vicinity. That softer landing spared him his life.

He was raced to the hospital in restraints while on a backboard. In the ER, he threatened to bite people unless they would let him up to take care of his climbing partner. For an entire month, he couldn’t tell what day it was, nor differentiate between dreams and reality.

In a concerted attempt to cover his deficit, he would ask visitors about events that were prominent in the news – the Tylenol murders and the NFL strike. However, he asked every visitor the same questions so often, his brother told him that repetition actually proved he had a brain injury. Trying desperately to appear normal, Dr. Levinger shut down and stopped rambling about current events.

As it turned out, he had experienced what’s known as a coup contrecoup injury with a right parietal contusion, meaning his brain basically sloshed around in his skull from one side to the other and he had bruising on his brain.

Several days later, he was released from the hospital in order to attend his climbing partner’s funeral. He still has no memory of the hour or so prior to the accident, nor the four days he spent recovering in the hospital.

Most damning in terms of his medical care is that he has absolutely no recollection of anyone ever asking him what day it was or performing any tests regarding his mental or neurological status. While he thinks the doctors most likely did do these things, the fact that he has no memory of their visits or any type of follow-up is troubling. “Once you are out of the hospital, people assume you are okay,” Dr. Levinger says.

Despite the fact that he wasn’t okay, he was sent back to work 11 days after the accident, still not able to function. He remembers not recognizing himself in the mirror but recalls believing he must be fine. “Otherwise,” he’d reasoned at the time, “they wouldn’t have released me to work.”

In his mind, his recovery was obviously just a bit slow; if he could manage to hang on a few more days, everything should work itself out. With a clean shirt, tie, and plan to keep quiet, he thought he could hide his confusion until all was well.

This turned out to be easier said than done. Daily routines, such as shaving, suddenly seemed more complicated than he had remembered. During the week he was home from the hospital, he had been able to sleep 16 hours a day, an amount of rest that allowed him to function for a full hour at a time. Going down to sleeping only 8 hours, he wasn’t able to maintain enough concentration to understand new lab techniques that required concentration and dexterity or integrate visual and spatial learning.

In short, his brain was badly damaged.

Finally, he had the wherewithal to ask for more time to recuperate. Since his Program Director was untrained in this area, he did not refer Dr. Levinger back to the neurosurgeon for evaluation or for psychometric testing, nor perform any kind of physical or mental status exam of his own.

Even today, head injuries are often still misdiagnosed, and doctors tend to believe that if an MRI or CT scan of the brain comes back normal, the patient’s brain is in good shape.

Neuropsychometric testing, however, is a detailed way to assess many aspects of brain function. When Dr. Levinger received this testing three months after his accident, the true extent of his injuries was finally revealed.

After being released from work, Dr. Levinger returned home to recuperate with his family. Normally an avid reader, he found he could only concentrate for five to 15 minutes at a time, and had trouble distinguishing between the content and his own dreams.

Determined to break through this fog, he took on Shogun, a 1,000-page bestseller about feudal Japan in the 1600s. By using internal testing, he was able to remember dates and events. When there was a discrepancy, he would mentally flag it, then re-read sections to ensure he hadn’t inserted something from his own imagination.

For instance, there was a reference to Japan being “discovered” by the West in 1542. In his mind, he thought of the children’s rhyme about Columbus discovering America “in 1592.” That stuck with him. Since he knew the “discovery” of Japan was after Columbus sailed the ocean blue, this was obviously an error and he must still be having a fantastic dream.

As part of his internal testing and intense need to keep all of his deficits hidden, he told no one about what he was doing. Several days later, his brain cleared enough to know he had been wrong; America, of course, was discovered in 1492, and now he knew that his experience of reading the book was real.

Eventually, a friend referred Dr. Levinger to see a neurosurgeon at Brown University. The one-and-a-half hours spent with the Chief of Neurosurgery “was absolutely life-saving,” he says. “He also told me I couldn’t get back to work for at least three to four months.” In reality, it took ten months before Dr. Levinger had the stamina and concentration to return.

Another one of the symptoms of Dr. Levinger’s injury was an inability to smell. Never giving up hope, he finally regained some of his olfactory senses over a period of six years.

Continuing along the path to recovery, the Massachusetts native completed his internship in internal medicine at Wyman Park Health Systems, a hospital associated with Johns Hopkins.

After serving his National Health Service obligation on the Paiute Shoshone reservation in Schurz, Nevada, he stayed in the Silver State, working at a 10-bed clinic. Afterwards, while establishing his own family, he went to work at a family practice with a focus on pain management. It was there that his partner introduced him to trigger point injections, a technique used to soothe muscle pain in the arms, legs, back, and neck.

Several years later, he completed his residency and board certification in anesthesiology at the University of Virginia. Then it was back to the West, specializing in pain management at urgent care centers in Idaho, Oregon, and Washington state, where he was on the Board for a brain injury advocacy group. Their philosophy of “do no harm” has become his mantra in his multi-layered approach to chronic pain.

“There are six keys to successful treatment,” says Dr. Levinger. “All are important to alleviating pain.”

  1. Sleep. With a good night’s sleep, it is easier to have the energy to manage pain and overcome the sense of loss and grief that accompany an injury.
  2. Depression. Treating depression directly is essential to maintaining a normal lifestyle and having the emotional resources for better coping skills.
  3. Over-the-counter pain medications. Tylenol and Advil are often very effective, but chronic or excessive use can cause problems. Many OTC medications that promote sleep simply don’t work. A low-dose tricyclic anti-depressant will usually help with sleep. In fact, some of the older and cheaper ones have a modulating effect on pain transmission. By starting at a low dose and increasing gradually, they can usually enhance sleep without side effects.

    Another medication that can be extremely useful for atypical pain (most often a burning or sharp shooting sensation) is Lyrica, aka pregabalin. Neurontin, or gabapentin, acts the same and is cheaper, but “in my experience, not as effective and with additional side effects,” Dr. Levinger cautions.

  4. Improving the quality of daily life. This includes counseling, with behavioral therapies for pain management, physical therapy, acupuncture, massage, and yoga. Fear often plays a large role in pain, and pain and injury can be very isolating. “Many of my patients were more afraid of what the pain meant than of the pain itself,” states Dr. Levinger. “If I could perform a nerve block that temporarily took away their pain and prove to their satisfaction that it was not dangerous or going to get worse, and most importantly was not cancer, then many people were able to minimize the effects of the pain.”
  5. Interventional technologies. There are multiple advanced pain management techniques available at a pain clinic, including nerve blocks and other strategies for chronic pain.
  6. Narcotics. When the above strategies are incorporated into the treatment plan, long-acting narcotics can be a very effective method of treatment, with short-acting narcotics also available when needed to adjust for increased activity. The initiation of narcotics for the treatment of chronic pain is most often initially managed by a pain clinic.

Part of Dr. Levinger’s success revolves around the theory that measuring activity levels is more important that pain levels. “Many patients fear what the pain signifies, not the pain itself. Once I’m able to remove the pain, their fear is removed as well,” he shares. “Then I can explain the reason for the pain.”

While everybody is different and treatment plans need to be customized, this approach has certainly been effective for a wide range of patients:

“Ross” was blown up by a 500 lb. bomb in Vietnam. One of only three survivors, he was thrown 30 feet and broke several bones. For years, he had been taking a high daily dosage of Tramadol, but it wasn’t fully alleviating the pain. Dr. Levinger switched him to a long-lasting, less expensive, and more effective morphine. It changed his life in a very brief time, and he was able to leave his dark room and return to work.

The assistant manager of inventory for a large big-box store, “Diane” fell off a stocking ladder and landed on her head. At first, two MRI’s indicated no damage, but she was suffering. What’s worse, she was being accused of malingering. However, she knew her brain wasn’t functioning well, as she was increasingly frustrated with simple mental tasks and had to create internal systems and structures to hide her issues.

This lasted for two years. Even though she was smart, she couldn’t handle the job any longer and sought help. Fortunately, Dr. Levinger was able to assess the issues and developed a plan that combined the right medication and physical therapy to help “Diane” return to a more normal life.

“Mike” was a carpenter…until a wall fell on his back and head. Since he had been given psychometric testing that indicated his IQ was 100, he was told he was normal and should return to work, but not as a carpenter. However, Dr. Levinger saw that he had been an “A” student and completed community college, indicating a much higher IQ pre-injury.

Mike’s assessment included a series of tests for memory, concentration, and spatial reasoning. After the injury, results indicated his spatial reasoning was low; therefore, he was obviously unable to return to work as a carpenter. Due to this information and testing, he was able to receive disability compensation and job retraining.

Dr. Levinger explains it’s more than just focusing on the pain. “Everybody’s different, so you need to pay attention to the whole person.”

He also emphasizes the importance of being able to look at a problem from multiple perspectives through a compassionate lens. “My primary job was as an anesthesiologist; however, my life experiences and general background have allowed me to be more patient and focus on a stepwise solution to problems,” he says. “Sometimes, all that’s needed to reduce pain is a different pair of shoes or an ergonomic chair. And sometimes, using the right medication for the right diagnosis can make all the difference in the world.”

Dr. Bill Levinger lives in Sedona, Arizona and can be contacted through BIAAZ. His wife Tracy works for a corporate travel management company. Together, they have a blended family with six adult children.

ABOUT BRAIN INJURY ALLIANCE OF ARIZONA

The Brain Injury Alliance of Arizona (BIAAZ) is the only statewide nonprofit organization dedicated to improving the lives of adults and children with all types of brain injuries through prevention, advocacy, awareness and education. BIAAZ also houses the Arizona Brain Health Resource Center, a collection of educational information and neuro-specific resources for brain injury survivors, caregivers, family members and professionals.

What began in 1983 as a grassroots effort has grown into a strong statewide presence, providing valuable life-long resources and community support for individuals with all types of brain trauma at no charge.

The Brain Injury Alliance of Arizona:

  • Works with Congressional Brain Injury Task Force
  • Houses Arizona Brain Health Resource Center
  • Hosts Statewide Opioid Use Disorder & Cognitive Impairment Workgroup
  • Has Statewide Opioid Use Disorder & Cognitive Impairment Response team with peer support, training, and family wraparound services
  • Facilitates Brain Health Advisory Council
  • Manages statewide Neuro Info-Line: 888-500-9165

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