New Pain Medication Issues: The Zohydro Case

March 31, 2014December 11, 2015 / Thomas Cohn, MD

Zohydro A new pain medication has debuted and has set off major controversy. The new medication is called Zohydro, and it is a long-acting form of hydrocodone. This is the same medication as Vicodin or Norco, without the acetaminophen. Vicodin and Norco are the most abused short acting opioid/narcotic medication. Despite knowing this, the FDA recently reversed its stance and approved the high potency long-acting drug. Zohyrdro will certainly help some people who deal with chronic pain, but it will also undoubtedly be abused by others. This begs the question, will Zohydro cause more harm than good?

The answer to question is up in the air, but it certainly looks like it will cause significant harm. It will cause problems, especially since some physicians will ignore the risks and prescribe the drug because it will do a great job relieving pain. This new drug can be easily abused, and has no abuse-deterrent properties. Many potent opioids have abuse-deterrent properties like smaller doses and pills that are designed so the user can’t alter the contents to snort or inject the substance, but Zohydro has no such properties. It will be abused.

Physician Care

Pain physicians, at their annual meeting last week, came to the understanding that opioids are important, but the most potent medications need to be abuse-deterrent. Opioids have a tendency to be abused, and therefore pain physicians have an obligation to help reduce abuse. This new medication adds very little to our treatment regimen, but it opens up more opportunities for abuse.

There are many abuse-deterrent formulations that can be used to treat pain. As far as pain physicians are concerned, there are just to many medications available that are being abused. In reality, it is unlikely we really need this medication.

Pain physicians would like to see more pain medications designed with abuse-deterrent properties. These are medications that have properties which do not stimulate a “high”. These tend to be slower acting, or have specific properties that do not stimulate the brain areas that give a rush. The future in pain care is developing more medications that treat pain but do not lead to abuse. Opioid/narcotic abuse is rampant in the United States, and physicians can play a key role in reducing this problem. Aggressively prescribing Zohydro is not one of those ways.

Hand Pain & Carpal Tunnel Syndrome

March 24, 2014December 11, 2015 / Thomas Cohn, MD

Hand pain can be caused by a number of different ailments. There are a huge number of structures in the hand that allow it to have its functional ability. The bones, joints, muscles, ligaments, tendons, and nerves all may be sources of pain. Trauma can easily damage any of these specific structures. However, one of the most common syndromes to affect the hands is carpal tunnel syndrome.

Pressure on the median nerve in the wrist may cause pain, numbness, tingling and weakness in the hand. The median nerve and several tendons of the hand travel through a narrow space in the wrist called the carpal tunnel. The median nerve provides sensation and motor function to the thumb and first two fingers. Difficulty with pain, tingling and weakness in these fingers is often from median nerve injury in the carpal tunnel region.

Causes

The cause of carpal tunnel syndrome is pressure on the median nerve in that confined space. Swelling in the region of the wrist can cause pressure. Medical conditions such as diabetes, hypothyroid, and rheumatoid arthritis may also be causes. Obesity, hypertension, and pregnancy with fluid retention can also bring about symptoms. Even more commonly, repetitive motions of the hands and wrists, such as typing or the use of a keyboard or mouse, can cause the injury.

The diagnosis can be made by a physician exam with several tests that may reproduce pressure on the nerve and symptoms in the distribution of the median nerve. Confirmation of the diagnosis is made with electrodiagnostic testing of the median nerve and comparing it to other nerves in the hand. If the study is abnormal, the diagnosis is confirmed.

Treatment Options

Treatment of carpal tunnel syndrome depends on the severity of symptoms. Mild symptoms and changes to the median nerve are treated by reducing the repetitive activities and causes. Rest and splints are great at alleviating mild CTS cases. Moderate cases may be helped by anti-inflammatory medications and steroids with hand physical therapy. Severe cases, where significant damage has occurred to the median nerve, usually require surgery to resolve damage or prevent further damage.

Genetic Testing and Pain

March 19, 2014December 11, 2015 / Thomas Cohn, MD

Genetic testing is a new area of pain management in which enzymes are studied to help better define what medications may be helpful in treatment. Many physicians assume that if a drug is not working, the patient is probably not taking the medication correctly, or somehow is abusing the drug.

As technology and science has improved, so has our understanding of how various drugs are processed in the body, including many drugs used for pain. We now know what enzymes control the metabolization of drugs into a person’s system, and not all people have the same enzymes in their bodies.

A case in point is my own family. I likely have a missing CYP2D6 enzyme and have passed it on to at least two of my children. Several years ago, one of my sons had knee surgery for a torn muscle. Post-operatively he was given Vicodin. After the surgical anesthesia wore off, in the middle of the night, he was screaming in pain despite taking his medication. We ended up in the ER and changed his medication to Oxycodone. This resolved the problem and he was off the medication within several days. My daughter had a similar issue after surgery, and we again found that Oxycodone worked best to help control the pain. In the past, after surgery, I’ve noticed that Vicodin has done virtually nothing for me, but I just dealt with it. In retrospect, this is not a coincidence, but a genetic variation that now can be tested.

Enzyme Trials

Today, most medication is prescribed on a trial basis and we just see if it works. If it does not, we just look for another treatment. In cancer treatment, genetic testing has become essential; We are learning that medication effectiveness for various tumors can be determined at least partly by various genetic markers. The lessons that we are learning from cancer are now being applied to other areas of medicine. The enzymes responsible for the metabolization and processing of various drugs is starting to be understood. The interactions of various drugs with each other are also being better understood as this chemistry is being determined.

Genetic testing is done for several reasons. There are many drugs that interact; If you are on multiple medications for any number of reasons, testing may help clarify possible interactions and allow for more informed decisions to be made if medications need to be adjusted. The most important reason may be if a person is having trouble with medication effectiveness of treatment. Genetic testing may reveal interactions or enzymes that prevent a medication working properly. If the treatment you are receiving is working, there probably is no reason to undergo genetic testing.

Science and technology are moving forward quickly. The changes in the future may guide us to better tailored treatments for the individual. At this time we are just scratching the surface of understanding these higher levels of information. The future appears bright, but patience is necessary since new treatments take time to safely make it to the market.

The Overdose Issue: Narcotics and Benzodiazepines

March 17, 2014June 24, 2014 / Thomas Cohn, MD

The recent death of actor Philip Seymour Hoffman has brought to the forefront the issue of narcotic overdose. Many of the famous actors who have died of medication overdose have done so with a whole cocktail of drugs found in their system. Many have overdosed on a combination of multiple prescription medications, street drugs and alcohol. The mixture of drugs is especially lethal, since the effect of the mixture makes many drugs more toxic. A very common mixture found in overdose cases is the combination of opioid/narcotic and benzodiazepine. The source of these medications is most often the primary care provider.

Opioids and Benzodiazepines

Opioids have a very legitimate use for the management of pain. The prescription of these medications for acute pain on a very short-term basis by primary care providers is definitely appropriate. Once pain becomes chronic, pain management becomes much more complex, and the prescription of opioid medications should be in consultation with a trained pain physician. Since there are many advanced treatments for pain, the inclusion of a pain physician will reduce the over-prescribing of opioids. Furthermore, pain physicians will be able to better monitor appropriate medication use and determine early when the medications are not advisable.

Benzodiazepines are medications used for anxiety. Short-term use of these medications for anxiety is reasonable if prescribed by a pain physician. Anxiety and depression are closely related, and if the patient is depressed, treating the condition with an anxiety medication will not help resolve the feeling of depression. Ongoing anxiety is usually a sign that the patient is depressed, and a physician should prescribe a depression medication and not a benzodiazepine.

Pain and Depression

In the brain, the centers for pain and depression are next to each other and they interact with one another. Significant pain will cause stimulation in the area that controls your mood, thus, a patient with chronic pain will often be depressed. A primary care provider will often treat individual symptoms through a combination of opioids and benzodiazepines, which is safe as long as they are taken in the recommended amount. A patient may not realize the danger of these medications and may overdose if they take too much in a short period of time or in combination with other drugs.

The other main issue is that these medications are, for the most part, widely prescribed. These medications are available in the public, and they are being traded and sold, which opens them up for abuse. A person with an addiction has easy access to these medications either legally or on the street. Better management of patients who actually need these medications will greatly reduce the amount of medication on the street. Better education of all medical providers on pain management will also help. Experts trained in recognizing pain and depression symptoms can help decrease the amount of excessive or unnecessary pills that flood the market.

The more we know, the more we can do to help keep people safe.

Women Feel More Pain Than Men

March 12, 2014June 24, 2014 / Thomas Cohn, MD

Pain physicians often see more women than men in practice. Some pain-related diseases have a definitively higher frequency of occurrence in women compared to men. Fibromyalgia, for instance, is at least three times more common in women. Many rheumatologic conditions and headache problems are also more common in women. As science has become more sophisticated, we are beginning to obtain some of the reasons that pain is more frequent in women.

Estrogen and Testosterone

At this time, one of the leading hypotheses is that estrogen in women and testosterone in men impact nerve sensitivity. Research is indicating that estrogen increases the sensitivity of nerves. Women have more estrogen and thus are more sensitive to painful conditions. The connection is especially evident in fibromyalgia, where there appears to be a global increase in pain sensitivity throughout the body.

Testosterone is the opposite of estrogen, and men have much higher levels of it than women. Testosterone appears to be protective and decreases overall pain sensitivity. Young men often appear to endure more severe painful activities. It is common to watch men power through injuries during athletic competition as testosterone attempts to lessen the pain.

As men and women age, estrogen levels and testosterone levels begin to drop, and the difference in levels is less pronounced. As a specialist, I see a more even distribution between men and women with pain as patient age increases.

Hormone Help

The answer of hormone replacement for men or supplements in women is much more complex. As we are studying hormone replacement in both women and men, it appears the side effects and dangers of supplements may be significantly more dangerous. Rates of cancer and other complications tend to increase with hormone adjustments. At this time, it is probably not a great idea to treat most pain with hormone adjustments.

Science is giving us some unique insights into pain. Unfortunately, it is often just making our understanding of pain more complex. In the future, it may lead to better pain treatments, however now we just know that hormones do influence our pain perceptions in some manner.