Would Mandatory Opioid Registry Checks Solve Painkiller Abuse?

Mandatory Opioid ChecksThe Minnesota legislature has a proposed law to make checking the Minnesota Prescription Monitoring Program database (PMP) mandatory prior to prescribing any opioid medication. The purpose of the law is to help identify people abusing medications and to prevent the explosion of overdose-related deaths.

Unfortunately, this is another oversimplification of the opioid problem in our country. Abuse of opioids is a very real problem. The solution is much more complex then checking a database for the number of prescriptions being taken. Mandating this step will only have a very minor effect on the problem of opioid abuse.

Opioids Abuse And The Database

Opioid abuse is a very complex problem. There are many people who have very difficult to treat pain problems that are dependent on these medications, and they take them on a very reliable basis without abuse. Currently, most pain physicians, including my practice, have a variety of steps they take to reduce the potential for abuse. One of the easiest is to look at the PMP database. We sometimes find abnormalities of behavior there, but it is not that common. Most often we find the patient is using both an opioid and a drug for anxiety that can cause a significant interaction. Then we need to advise a patient on these issues.

Other steps taken include a comprehensive medical exam for appropriate problems to be treated and finding alternative treatment plans. Believe it or not, the worst problem is obtaining insurance company approval for more expensive options with better outcomes and less risks to the patient. Other steps taken include drug testing, checking state criminal databases and evaluating psychological stability before prescribing. For those wondering, our practice does check the PMP for everyone for each refill.

Mandatory Checks?

Mandatory checking of the PMP does not significantly help solve the opioid abuse problem. It is only a feel good step for politicians to say they are doing something. The problem runs much deeper. First off, a lot of people who are abusing opioids should probably never have been placed on the medication. The next step is that they should not be on them for any length of time – they may be okay for a very acute problem – but then they need to be stopped. Addiction is a medical condition. It is tough to treat and programs to help with addiction need funding and staff, and this needs to be promoted.

If the legislature wants to have a positive role in the addiction crisis, then they should be mandating insurance coverage for alternative treatments for pain besides opioids. Alternative treatments include everything from prolonged physical therapy, massage, chiropractic, and different medications, to comprehensive pain programs and implantable pain control devices. Obtaining insurance approval, especially from Medicaid or Medicare, is time consuming and often almost impossible. Physicians are extremely frustrated by the obstacles put up by insurance companies when better and cheaper alternatives are routinely denied in managing pain.

The last difficulty in understanding pain and the opioid crisis goes beyond the problems of addiction. Pain is extremely complex and one of the main tools to control symptoms is opioid medication. This is the same tool we have used for over 150 years. A third of the world population struggles with pain problems. Virtually no dedicated funding goes to research on pain compared to other medical problems. Our knowledge level in regards to pain as a disease is at the level where cancer was in about 1950. If the world wants to tackle the problem of opioid abuse, it really needs to fund research on all aspects of pain to solve the issues suffered by a third of the world population.

Are Stretch Studios The Next Big Fitness Wave?

stretching benefitsOne of the three key aspects of exercise is stretching. The other two are strengthening and conditioning. When one has pain, a component may be tight muscles. A recent article in the New York Times took a look at the new fad of stretching studios. There have been all kinds of health and fitness crazes, but this was something new.

There are many different types of exercise gyms, from the bare bones centers to the multimillion-dollar health clubs to the specialty studios for yoga. Now the new kid is the studio that works individually with a client to increase a person’s flexibility through muscle stretching. Athletes and those with a wide variety of injuries or conditions like neck and low back pain have muscle tightness. Muscle pain with lack of full range of motion often contributes significantly to pain.

Stretching Benefits

The advent of the “stretch” centers, the studios that concentrate on working with people on muscle stretching, is an outcome of our world of pain. Muscle pain is common in athletes due to strengthening without also concentrating on maintaining full muscle length and joint mobility. In the person with neck or low back pain, muscle tightness occurs due to the muscles contration in an effort to prevent someone from moving a painful area. In either cause, tight muscles and lack of joint range of motion are causes themselves for pain.

Stretching is an essential component of exercise. Being an ancient doctor, the reference book of my time was “Stretching” by Bob Anderson, and it was an easy to understand guide to stretching any region of the body. Now, the Internet or your phone’s apps can be an easy source of exercises to stretch any part of the body. Routines do not need to be complicated or take large amounts of time. Stretching for 5 to 10 minutes every day is extremely helpful to loosen up muscles. Sometimes, it takes multiple times a day that one has to stretch, especially if the problems are neck and low back pain. A stretch can be as simple as bending over to touch your toes or sitting on the floor and reaching for your toes.  A lot of people are stiff at the end of the day or first thing in the morning. Doing a stretching routine before going to bed and first thing in the morning can often help reduce tightness and pain especially at night and early in the day.

Advanced Stretching

The stretching studios are a bit higher level of stretching. A staff member works with a client to help them stretch a wide variety of muscles. They spend 45-60 minutes work on whole body flexibility. Getting all the muscles loosened up by stretching can be very relaxing. Supposedly the relaxation is similar to what is felt with a massage, but it would require more participation for the client.  

Physical therapy can also teach a person how to effectively stretch, especially a person who has had an injury. Working with a therapist is helpful to learn the correct techniques and to prevent further injury. Oftentimes a therapist will give a patient numerous exercises to perform, and doing the whole set could take 45 minutes. Once one understands the exercises, you can choose a few that cover the areas that need work so the whole routine can be done in hopefully 10 to 15 minutes at the most. The main message is tight muscles are often a source of pain, and learning and performing effective stretching routines daily can significantly improve function and diminish overall symptoms.

An Update On Daith Piercings

daith migraineI wrote my first article on Daith piercings about a year and a half ago. As many know, this has been advocated for the treatment of headaches. The questions I have been asked since that time have been numerous but the most common question is, “Will it work for me?” I obviously cannot tell if it work for anyone in particular. I have heard from many that it has helped them manage their migraine headaches. Most interesting to me was some of my regular patients have tried it successfully.

Daith Piercing Information

Daith piercings are a specific type of ear piercing. The ear cartilage midline toward the front of the ear is pierced. This type of ear piercing has been around for 3,000 years, but the name “Daith piercing” was probably started in the 1990’s. The placement of the piercing is at the entrance to the ear canal and has symbolic meaning as the “Guardian to the Gate.” This piercing can be quite painful, and since it is through bony cartilage, care must be given to keep the site clean and to prevent infection.

There are many types of headaches, and only certain types of headaches will respond to Daith piercings. Those most likely to improve are migraines that are sensitive to ear stimulation, and likely to be one sided in nature. Daily headaches may be caused be a variety of factors – most common are muscle tension and stress headaches. Muscle tension headaches are caused by neck muscles tightening up, often associated with the position one has while working on a computer. Stress type headaches are caused by psychological factors that make a person anxious.  The most common headache in my practice are those associated with neck problems; either from nerve and disc problems or from the joints in the neck causing pain. These types of headaches are best treated successfully by managing the underlying causes.

Managing Headaches

The headaches that have been managed by Daith piercings are those that are migraine headaches. If you have been diagnosed by a neurologist with definite migraine headache (not self diagnosed), Daith piercings may be a treatment option. Over the last 18 months of studying this subject, an interesting correlation occurred to me that this treatment was similar to acupuncture and vagal nerve stimulation. All these treatments seem to affect the vagal nerve via a branch near the ear, which sends signals back to the brain that may affect various neurotransmitters and hormones that lead to vascular headaches.

Unfortunately, the true scientific proof and medical evidence with regards to Daith piercings is not present. All the results when one researches the topic seem to be stories that it worked for them. There is some basis as noted above why it may work. For those who are interested, a few cautions should be remembered. First, this is specifically going to work best for migraine headaches. If you have frequent and sometimes severe headaches, and they are not easily managed, first see a medical doctor and possibly a neurologist and get a good diagnosis made, and try conventional treatment. The cause should be treated first and may be straight forward to manage. If the headaches are migraines, and they are not responding to management, Daith piercing may be reasonable. Physicians normally do not perform this procedure, so do not ask them to do it. Only get this done by someone who does body piercings and is familiar with this particular one. It is extremely important that meticulous care is performed before and afterwards to keep the area clean and free from infection. Since this is through ear cartilage, near the brain, an infection in the area can be very dangerous and should be treated aggressively by a doctor.

If you want to run a test before piercing, first try massaging the area of the ear when you have a headache and see if that makes a difference. Another possibility is to try acupuncture to see if that works. Most acupuncturists will report what they do is different than the piercing and this is not going to be equal to the piercing, but it may be safer and easier for a test. If you go ahead with a piercing, make sure you try to prevent an infection in the area of the piercing.

Why Pain Is Such A Complicated Process

Pain ProteinIn the February 4, 2017 issue of Science News Magazine, there is a fascinating article about pain. There is a protein in the body known as Na.1.7 that sits on pain sensing nerves. It has been known that when it is triggered, a signal is sent to the brain that the body should feel something painful. New experiments have shown how complicated things can be in the body, as tests on rodents have shown that Na.1.7 activity also triggers production of pain relieving molecules, meaning our bodies has an ability when sensing pain to also fight pain.  

To illustrate what this might mean, it is interesting looking at those people with a nonfunctional Na.1.7 protein. These are a rare group of people who do not feel pain. It may sound like a great problem, but these individuals have great difficulty preventing themselves from getting injured. When studying these people, researchers found higher than normal levels of the body’s natural opioid compounds. Then a researcher decided to give one of these patients naloxone, the compound used to block opioids, especially when someone has a narcotic overdose. The patient suddenly felt pain for the first time.

Understanding The Complexity Of Pain

This is why pain is so complicated; the protein Na.1.7 has both pain promoting and pain relieving properties in the body. This protein seems to sit at the balance point for controlling pain sensing and pain relieving functions in the body. If the cells have nonfunctioning Na.1.7 protein, then they increase their activity in producing the body’s own opioid compounds. So if we can block the activity of Na.1.7 or turn its activity down, the body can produce its own pain killing compounds.

The effect on the body of giving opioids over time is such that the body becomes tolerant to the medications. It will take more and more opioids to produce the same level of pain relief. What that is also implying is that giving a person opioids tends to make the body probable to produce more Na.1.7 and then the body produces less of its own natural opioids. The body then is sensing more pain and is less able to fight pain. Understanding this small piece of science now seems to explain why giving patients opioid medications for a long period of time is a bad solution to control pain. Simply, giving opioids increases our pain sensitivity and lowers our own ability to fight pain.

Next Steps

The next step for pain management is to do research on Na1.7 and find out how we can use this knowledge to develop treatments for pain. It is likely that it will be difficult to find the right way to influence the activity of cells and the production of this protein. If this can be done, maybe a medication can be given that just pushes down the Na.1.7 level slightly so we can feel less pain and the body can more effectively fight pain on its own. This is not something that will happen soon, but this is one of the new discoveries that may change pain control drastically in the future.

The Complexity Of Pain Management

complex spine careBack pain patients often state if they just lost some weight, maybe their low back would feel better. It would be nice if it were that easy, but it is often much more complex. Usually someone who has back pain has multiple causes of the pain, from simple lack of strength in the muscles, to nerve irritation, degeneration of the joints and discs in the spine and problems with body mechanics. Yes, weight can stress every structure in the back and make things harder and more painful, but oftentimes all the other things causing pain may be more important in order to control back problems.

Controlling Back Pain

Asking most doctors about how to lose weight is often not very helpful. About 75 percent of medical schools do not provide the recommended 25 hours of nutrition training, and many older physicians have had minimal to no training in nutrition. Complicating everything is the fact that older research was often sponsored by major manufactures of food and conclusions of the studies were not scientifically sound. Current research is showing that every person often responds differently to a diet, and what is helpful for one person will not always work for another. The more one reads, the more complex the human digestive system becomes and our understanding is really limited. Everything affects us, from our genetics, to what our mother’s ate during pregnancy, to the bacteria in our gut.  

Eating a healthy diet is probably the most sound advice, and then pay attention to the amount you eat as well as when you eat. Healthy eating means eating less processed substances like pre-made foods. Some people equate this to eating from the fringes of the grocery store, where the fresh fruit, vegetables, salads, lean meats, and diary if often kept. Limiting simple carbohydrates like bread, potatoes, pasta, sugar and white rice can help many people as well. Protein sources from poultry, fish, beans, nuts and diary, and not from red meat are recommended in many diets.  If you have gastrointestinal problems like inflammatory bowel disease or celiac disease with gluten intolerance, diets change play an even bigger role in solve the pain equation. In general, a plant-based diet is often the healthiest.

Managing Weight and Back Pain

Since low back pain is caused by many factors, it is rare that the most important issue is weight. The most common factor is usually the lack of exercise. Often a patient will go to physical therapy and learn what to do but after the formal sessions, they do nothing on their own. Those who are overweight are no different than most patients; they are not actively exercising and taking care of their health. Every patient must find their own internal motivating factor to take care of themselves and exercise. Staying healthy takes a lot of work. There is no quick fix and those who actually do the best take care of their physical and mental health. Those who do the best follow through with the three components of exercise – stretching, strengthening and aerobic conditioning. If you are doing the work of exercising appropriately and eating a healthy diet, it is likely that weight will not be an issue.

Those who do have back pain and who are significantly obese often can improve their back pain with weight loss. However, the improvement is relatively minor with the loss of weight. The patients who notice the most improvement in pain are those who adopt a healthier lifestyle. Despite being obese, they start consistently exercising, often finding a way to participate in a pool exercise program so they do not stress their joints. They also have changed their eating habits, and the combined efforts usually lead to a sustained weight loss of 1-2 pounds per week. Believe it or not, it becomes obvious who actually is exercising, as they start feeling better and have markedly less pain. Low back pain affects millions of people nationwide, the simplest solutions often are the best – exercise and a healthy diet.