Penny-A-Pill Plan Proposed To Prevent Opioid Abuse

penny a pillMinnesota Governor Mark Dayton has proposed a “penny-a-pill” program in which drug companies would have to pay the state an extra penny for every pill prescribed in the state. The money raised from this tax would go towards an opioid stewardship program that provides opioid prevention, treatment and recovery services.

Gov. Dayton said the program may be able to generate $20 million a year.

“You can call it whatever you want,” Dayton said. “It means that they’re going to pay for the product they’re producing, which is causing this epidemic.”

According to data, there were 395 opioid overdose deaths in Minnesota in 2016. That number represents an 18 percent increase from the previous year, and 194 of the 395 deaths were linked to prescription opioids. The CDC also notes that there are 47 opioid scripts written for every 100 Minnesotans.

One Of Many Changes

The penny-a-pill program is just one of a number of changes aimed at reducing the number of opioid overdoses and deaths here in Minnesota. Two months ago, the state announced new guidelines that affect how area physicians write prescriptions for painkillers. The new guidelines suggest that physicians should:

  • Prescribe the lowest effective dose and duration of opioids when used for acute pain.
  • Monitor the patients closely, including prescribing opioids in multiples of seven days.
  • Avoid initiating chronic opioid therapy, make it so long term prescriptions would include face-to-face visits with the provider at least every three months.

Additionally, Minnesota wants to renew the focus on educating physicians, patients and their families on the potential dangers of opioids, as well as how to spot the signs of a problem.

“One opioid prescription can start the downward spiral in the right person,” said Dr. Rahul Koranne, Chief Medical Officer for the Minnesota Hospital Association.

Minnesota is actually one of the better states in the US when it comes to regulating prescription opiods. The state prescribes the fifth fewest opioids in the nation, which speaks volumes considering there are 47 scripts written per 100 Minnesotans.

Do you think the penny-a-pill program is a good idea? Leave your thoughts in the comments section below.

Can You Just Cut Those Painful Nerves?

nerve pain

A common question from patients with pain is whether someone can just cut the nerves that are causing pain or otherwise destroy them. There are a few cases where this is done, but it is limited since most nerves in the body carry motor and sensory functions and cutting them would leave a person weak wherever that nerve controls a muscle.

The loss of muscles would also produce pain or sometimes the nerve then short-circuits and becomes even more painful. This is common in amputations where the nerves that are cut cause odd pains and phantom sensations. However, there are some special situations where we can damage the ends of sensory nerves in isolation to treat certain types of pain.

Nerve Control and Pain

The most common times where nerve endings are purposefully destroyed are for facet joint pain. On each side of the spine at every level there is a joint between the bones known as the facet joint. In the cervical and lumbar levels they are very mobile, but they also support a significant amount of weight from our head and bodies. These joints are almost identical to your finger joints in size and function but they have significantly more weight going through them. Pain from these joints in the neck have well defined patterns for head, neck and upper back pain. This is also the typical pain seen in a whiplash type injury.

In the low back, the pain is usually just along the spine or into the buttock area. The thoracic region rarely produces joint pain due to the ribcage providing support and restricting motion. When facet pain is unresponsive to other conservative treatments like medications and physical therapy, blocking the medial branch nerve to the joint with anesthetic will determine if the joint is the cause of the symptoms. If it is successful, we can use a special needle and machine to create a microwave signal at the tip of a needle and cut the very end of the nerve away from the joint to relieve pain for about a year. Since this is the terminal end of the nerve and not its cell body, the nerve ending will regrow and re-innervate the joint.  

In the rest of the body there are very few safe places that only a sensory nerve travels separately from a motor nerve. For example, the knee joint is another place where doctors are trying to sever the sensory nerves. The technique is similar to the one used for the facet joints but the locations of the appropriate nerves are somewhat variable and a much larger lesion is needed to be successful, and it often only works for six months. There are other techniques for knee pain including the use of specialized hyaluronidase (rooster cone); a compound that stimulates joints to produce their own fluid. Another possible better treatment in the future will be the use of stem cell injections, since this may allow the joint to regrow more normal joint tissue. At this time it is not covered by insurance, is somewhat costly ($5,000/treatment) and is successful about 50% of the time.

Cutting Sensory Nerves

There are very limited other places and times when sensory nerves are attempted to be cut. Sometimes for rib pain or pelvic pain that does not respond to any other simpler management, the nerves can be frozen using a special machine. Localizing the nerves that cause this pain may be very difficult, and the success is around 50 percent. Pain relief again is about six months. In a few special circumstances, nerves are cut as part of surgery, like during amputation or certain reconstructive surgeries, especially after trauma. The problem with cutting nerves in amputations is phantom pain, where pain is felt by the brain in an area where a person no longer has an extremity.

Pain is a complex process that occurs in the body. Simply cutting a nerve to rid the body of pain usually causes more problems with pain and additional possibility of loss of muscle function. Nerves sometimes can be cut for certain types of spine joint pain, but there are very few other places in the body where a similar technique can be used successfully. If pain is a significant problem, asking a pain physician about the variety of options available for a particular issue may be the best plan.

FDA Declares Kratom An Opioid

kratom fdaWe’ve blogged about Kratom in the past, but now the FDA is chiming in on the subject. According to the FDA, Kratom is more than a plant, it is an opioid.

“As the scientific data and adverse event reports have clearly revealed, compounds in kratom make it so it isn’t just a plant — it’s an opioid,” said FDA commissioner Scott Gottlieb. “And it’s an opioid that’s associated with novel risks.”

Kratom, which has been credited with giving users feelings of euphoria, strength and pain relief, has now been linked with 44 deaths. Aside from its obvious dangers, the FDA decided to classify the plant as an opioid because the drug taps into some of the same brain receptors as opioids.

The Dangers of Kratom

Like a number of drugs in their infancy, the dangers of kratom stem from the fact that we haven’t had much time to scientifically study the substance. Despite never gaining approval from the FDA, kratom was advertised as a concentration booster and workout enhancer in largely unregulated supplements. Because of its properties, it also made its way into the pain management community as a potential option for individuals with chronic pain. And ironically, it’s also been touted as a treatment option for opioid addiction.

“Patients addicted to opioids are using kratom without dependable instructions for use and more importantly, without consultation with a licensed health care provider about the product’s dangers, potential side effects or interactions with other drugs,” Gottlieb said in a previous statement.

Now that we’ve had more time to study the substance, researchers are realizing just how dangerous unregulated kratom use can be. After studying the chemical structures of the 25 most prevalent compounds in kratom, researchers discovered that they all shared similarities with opioids like derivatives of morphine. Moreover, two of the five most prevalent compounds in kratom latch onto the brain’s opioid receptors, just like other opioid painkillers do.

“The new data provides even stronger evidence of kratom compounds’ opioid properties,” Gottlieb said.

Some states have already taken steps to ban the substance, and it wouldn’t be surprising if Minnesota followed suit in short order. Kratom is already banned in Alabama, Arkansas, Indiana, Tennessee and Wisconsin.

At the end of the day, we have to remember that there is no miracle pill that can cure us of our pain or treat our opioid addiction. Trust that doctors have your best interests at heart, and that clinically tested and proven methods are best.

The Unforeseen Opioid Issue

overdose pain pillsThis week, another issue of opioid use to control pain came to light in the news. In a suburb of Minneapolis, a patient was in a nursing home type facility. Along with whatever issues brought them to the facility, apparently they had pain and were receiving opioid medications. At the nighttime dose, a staff nurse, probably in a hurry, gave a huge dose of the medication instead of the proper dose without noticing the mistake. By morning the patient was dead from an overdose. All opioids can cause breathing problems especially in those who are sick, and too much medication can easily be deadly.

The overdose of anyone by a person administering medications is unfortunate and should never happen. Two lessons are clearly evident. First, always double check to make sure you are taking the right medication and dose, and second, be aware that these medications are dangerous. When prescribing opioids, medical personnel should always be careful on how much medication is being prescribed and try to avoid giving excessive dosages.

If there are no alternatives, then be careful. Evaluate for medications that may interact with the opioids, such as sleep medications that may suppress breathing or anxiety medications. Check the person’s history for other medical conditions that affect breathing, like lung disease and sleep apnea, since opioids may disrupts breathing patterns. Make sure the person is mentally capable of taking the medication correctly, and that they are not suicidal, depressed, or  dealing with dementia, because this too can also lead to an opioid overdose.

Narcan’s Role In Preventing Overdose Deaths

Besides the above and a bit of common sense, preventing opioid overdose deaths is important. Many providers are adding a prescription of Narcan nasal spray when writing scrips for opioid medications. This is a medication that can block the effects of opioids and reverse its medical effects completely in the body. Narcan can block the respiratory or breathing problems from an opioid, but it will also reverse any pain relief. It is easy to deliver, it is shot as spray up the nose and will quickly reverse only the opioid-induced problems. However, for the new synthetic opioids like fentanyl or carfentanyl that are being abused with heroin, multiple doses may be needed in treatment.

Now, anyone receiving any significant amount of opioid for pain should receive Narcan nasal spray. The person who is normally taking the opioid may not need the Narcan unless they accidentally take to much medication. Otherwise, if someone else in the home of the opioid user takes the medication on purpose or by accident, the Narcan can be used to reverse the opioid and prevent death. As always noted, opioids are not ideal pain medications and can be easily deadly. Having and using Narcan in cases of emergency can prevent an untimely death.

Independent Medical Examinations After An Injury

ime doctorOne of my least favorite tasks is seeing what an Independent Medical Exam (IME) has said about any of my patients. IMEs are evaluations performed on a patient usually at the request of an insurance company or sometimes an attorney. Theoretically, these are to be used to determine the true nature of the medical problems and to provide recommendations for ongoing management of a patient. Usually they are performed in cases where there may be legal issues involved; mostly commonly the insurer is either workman’s compensation or auto insurer. These exams are performed by physicians who are often not actively in practice, and may not even have expertise in the area of treatment. Therefore the quality and purpose of such an exam is often questionable.

The Inherent Problems With Some IMEs

In my distant past, I also performed independent medical exams, most commonly for insurance carriers in workman’s compensation cases. The most common reason why insurers sent patients to my office is that they wanted to know what was really wrong with their clients and what may be the anticipated cost for future treatment. A good evaluation by a Physical Medicine and pain expert can at least tell them what is actually wrong with their client, and what are likely going to be necessary future treatments.

Instead of denying any injury ever occurred, several of the insurers took the proactive step to determine what was going to be the best way forward. Since they knew that I was going to tell the truth about the patient’s medical condition, it was valuable and a positive experience for both the patient and the insurance company. The last one I performed was a year ago and I had to ask if they knew the results may not be in the insurance company’s favor and if they would be okay with whatever I determined. Surprisingly, they really just wanted to know what was wrong with their client.

Most independent medical examinations I see are ordered by an insurance carrier and they only will hire physicians that they know will find any way deny that a medical problem exists. Often the physician will minimize an injury, and then report it as not feasible that the patient’s complaint can be present. The history taken is usually very short, and a physical exam is limited. The physician then develops “alternative facts” and delivers the “fake news” back to the insurer. Honesty and an understanding of pain, as well as most conditions that cause pain, is absent. The overall purpose is to minimize liability by the insurance carrier in a future legal setting. These exams are used to limit any ongoing medical care for a patient. The frustrating factor for the patient is that if these were done in a true independent manor and actually were done by professionals with real skill and understanding of the medical problems, then they could actually be useful.

Preparing For Your IME

The take home message for a patient who needs to undergo such an exam is that they need to be knowledgeable about the process. The patient should consider recording the exam for their own record, whether it is having a witness, taking notes or actually filming or recording the event such that one can counter incorrect information in any report. It is important for the patient to be fully cooperative and not combative and really participate in any exam such that any abnormalities will be evident. Lastly, insist that the report be made available to you or your legal representative so inaccuracies can be addressed later.

Rarely are independent medical examinations done to develop a full understanding by all parties involved in settling medical-legal issues. For a patient, the results of these exams should be taken with skepticism at best. For lawyers and insurance companies, honest and good exams would likely be more helpful. To develop future plans for a patient, currently the best source of information is usually the treating physicians. If the insurance company really wants to know what is wrong with a patient with a musculoskeletal problem, recruit the use of an experienced, board certified Physical Medicine physician. A good expert who can explain a range of management options is the needed expert to help settle questions in patient management.