Opioids For Long-Term Pain Relief

March 12, 2018 / Thomas Cohn, MD

The latest copy of the Journal of the American Medical Association has a lead article on the use of opioids in the long-term management of low back pain. The article is a study of some 200 people who were managed either with opioid-type medications or without them. The conclusion was that there was no difference in level of function with the use of opioid medication.

There is a large problem with this study, since it does not distinguish between the wide variety of patients who have back pain. Back pain can be due to everything from spine problems to nerve damage and residual surgical issues. As it has been preached multiple times, opioids are only one tool in the treatment of back issues and there are often many different strategies to control pain.

Opioids and Back Pain

The reality of life is that many different things can cause pain, and treatment should be aimed at the cause of pain. Depending on what is causing the sensory complaints, management will vary based on the individual’s needs. A combination of strategies is often necessary to treat every different component contributing to a problem. Treatments may be simple, such as ongoing exercise, to complex, including injections and surgery. Sometimes simple strategies fail and the only medication that does help are opioids. Since these drugs have tremendous problems, they often are not a good solution especially for long-term use. Pain specialists often know a wide realm of treatment options and can help lead one to better choice or a combination of choices.

The biggest problem with the use of opioids is that they are cheap and they have been pushed in the United States as a great, inexpensive tool to manage any type of pain. It takes a lot of work to manage pain, and in this country many have opted out of the challenges. On top of the drug companies pushing these medications, often the insurance companies are equally complicit by not allowing treatments that may be more expensive. Everything from physical therapy, massage, chiropractors, acupuncture and even fitness centers with athletic trainers are often more beneficial than many medications and may well be cheaper. However, most insurance companies turn a blind eye towards alternative treatment strategies. Now that opioids are a problem, insurance companies still want to say no to alternatives to drugs, but are not willing to pay for the better alternatives.

Alternative Treatment Options

The important message from the study of opioids is that for most people there are better treatment strategies than these drugs for the management of pain in the long term. For short-term, these medications may be okay. For surgery and several days immediately afterward it may be reasonable to use them. After that time period, medications that are not addictive may be used with the strategy to return the body to normal functional patterns. The body needs to move and relearn normal movement and function. As the body moves and functions as it was originally designed, the body acts appropriately and does not generate pain sensory signals.

If you have a body that cannot move and function normally due to permanent changes, these may constantly send sensory signals that are interpreted as pain. Designing treatments that bring the body as close to normal motion and function as possible can reduce pain. This is difficult and requires significant effort; rarely is there a magic pill that performs this function. If one gets past the thought that life is pain free and then focuses on making life as close to ideal motion and function, then one can improve their quality of life.

The last take home message is that medicine needs to understand that some people honestly have tried everything available to treat their problems and nothing has worked. If they have worked with a legitimate pain expert, sometimes it is found that opioid medications are appropriate in the management of a problem long term. This should be considered a last option in most cases. Hopefully our culture will get a more realistic understanding of opioids in the management of pain and all those involved in treatment will support the use of reasonable alternative strategies. Initially it may not be cheaper, but a healthier society is likely the final outcome.

Staying Healthy and Fit as We Age

February 26, 2018 / Thomas Cohn, MD

Staying fit and being healthy as we get older usually requires work. There’s always the tale of someone who smoked a pack of cigarettes a day, drank a six pack every night, ate whatever they wanted, sat on the couch and lived to ninety years. A few people having amazing genetics and nothing affects them, but this is not the norm. Most people need to take an active approach to life including fitness, diet, rest, and stress. Health is about paying attention to our lives and reducing harm as well as maintaining our bodies and minds.

Your Body is Like A Car

My favorite analogy is that our bodies start out like new cars and generally are like that until we reach adulthood. A new car needs fuel and very little maintenance to keep it running well. If you do not wreck it, the car will run smoothly for our younger years. As the car ages, more and more routine maintenance is needed and as it gets older, major overhauls are sometimes necessary. When we are young, we feed the body and let it run and generally it will be healthy. As a young adult, we need to start doing some general health care such as monitoring our cholesterol and blood pressure, and start purposefully watching things like what we eat, our exercise, and make sure we sleep and reduce our stress. After we turn fifty, technically the body is in old age range, and maintaining our health is needed to keep us running smoothly.

In the 1800’s, the average life expectancy was between forty and fifty years of age. Death was due to injury, trauma, infections, heart problems, cancer and multiple other issues of the time. Since then we have learned how to stay alive such that the modern life expectancy has risen to about 80 years. The caveat however is the body has not evolved much in the last 150 years, so it takes much more work to keep an old body healthy.

How to Stay Fit

Staying fit and healthy does take some work and affects a variety of aspects of your life. If it were easy and simple, everyone would know the secrets and live long without problems. The reality is that it does take effort to be healthy, and everyone is throwing in advice on ways to live. The books, diets, pills, retreats, and machines available for a price to make you live longer and happier are countless. Understanding our history can possibly help us understand our needs into the future.

Exercise is one of the most basic concepts. In the past, we did not sit at desks all day. Rather, we were very active and often constantly moving. Since our sources of survival and income have changed, our amount of activity and movement has plummeted. As we age, exercise to maintain our bodies are essential. Daily stretching for 10 minutes or more is necessary to keep the flexibility of muscle and joints and the health of these tissues. Stretching markedly reduces stiffness and associated pain from muscles, ligaments and joints.

Strengthening is the next pillar needed to maintain the health of muscles as well as bones and other structures in the body. Light strengthening three times a week for 20-30 minutes is needed to maintain muscle and bone health as well as to reduce injury from unexpected events like falls. Lastly, the body needs aerobic conditioning to maintain health including for the heart, blood pressure, muscle endurance, weight control, and to reduce pain from increased endorphin levels and stress reduction. The overall recommendation from the American Heart Association is 30 minutes of exercise 5 times a week, from a simple walk to an intense workout.

Diet and Sleep

Our diet is the fuel that runs our bodies. If we put the wrong fuel in our cars, they won’t run, and it is the same with our bodies. It is becoming clearer that our nutrition plays a huge role in our health. As a doctor, unfortunately we learn very little in out training about diet and nutrition. Curiosity about the subject has slowly been very enlightening. Eating better does take more planning and understanding, especially about processed food, sugars, fats, carbohydrates, and other essential nutrients. Spending some time to read and understand healthy diets helps improve the ability to control the fuel entering your body. Even an old doctor can educate himself; using my drive time to work and back, I am spending time listening to courses on nutrition.

Sleep is one subject we know we need but understand very little about. The purpose of sleep, how much we need, and whether the measures we have are helpful and accurate is debatable. Children need more sleep than adults, and adults often need more than we get nightly. Somewhere over seven hours is recommended every night for adults. Sleep is used by the brain to restore functions, to clean up waste products and to rest the whole body. What constitutes as “quality sleep” is not very clear and those sleep trackers that monitor body motion at night are not accurate, according to most experts. Feeling well rested the next day is probably a reasonable sign of adequate rest.

Lastly, having good mental health is necessary to stay fit. Society tends to ignore our mental health needs. Good mental health is needed to stay physically healthy. The body is dependent on the brain for good function. Emotional health is the part that emanates from the brain that allows us to function well physically. When we are stressed, anxious, depressed, or suffering psychologically, we often cannot put in the energy to maintain physical well being. Once we improves our psychological state, we often can focus our energies to pay attention to the rest of our life. Whether it is meditation or medication that is necessary for good emotional health, without paying attention to our psychological selves, maintaining good physical health is difficult.

Staying healthy and fit as we age requires work on our physical and mental well being. There are multiple pillars that keep up our health and as we age we need to pay more attention to these important aspects of our lives. From sleep, rest, exercise, diet and mental health, they all provide strength and structure to keep going as we age.

Independent Medical Examinations After An Injury

January 29, 2018 / Thomas Cohn, MD

One 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.

Making Pain Patients and Doctors Feel Like Outlaws

January 15, 2018 / Thomas Cohn, MD

An opinion piece by Dr. Thomas Cohn

I spent Friday evening with my staff trying to get authorization for medications for one of my patients. The process started on Wednesday when we changed the opioid dosing to a more logical plan based on the needs of the patient. That is when the problem started with the insurance company. We obtained the first authorization for the long-acting medication, then the change for the short-acting medication was refused since the insurance company decided it was too high a dose for a month. We were given a peer review and scheduled a time for the review, but the insurance company physician did not call. We then were finally told on Friday at 3:00 p.m. that the doctor would talk to us and we called immediately.

This was a total sham, the doctor read the insurance company guidelines and said he had no ability to change what was written. Since I have done many reviews as both the reviewer and the one asking for review, the person reviewing can tell the insurance company the rationale for any decision for a patient if medically indicated. It did not seem like anyone at the insurance company cared about the patient.

Villianizing the Patient

For starters, a few patients have very significant medical conditions that may be appropriately treated with opioids. For cancer patients, there is no question that it is within reason to treat with these medications. Some patients also have severe medical conditions that are causing progressive deterioration of the body and likely will lead to death eventually, and opioids also are reasonable. Lastly, some patients have failed every other treatment or surgery and were left with such significant body dysfunction that opioids are the only thing that helps manage pain. These patients are extremely compliant, not abusing their medications, and are being treated by reputable providers, not pill mill doctors. Unfortunately, this patient fell into the class of having a nasty progressively deteriorating neurological condition that has been causing significant pain as well as difficulty with daily activities.

Trying to obtain understanding for the patient who needs medications is supposed to be relatively straightforward. There are guidelines on prescribing to reduce using medications inappropriately, especially in acute settings for starting an opioid regimen. For patients who have legitimate uses for these medications, they are supposed to be able to obtain them if the physician feels it is indicated. Again, this patient appears to have a very significant neurological disorder affecting the whole body, and it is causing significant pain that other treatments will not stop and other medications do not help.

As a pain physician, I was being asked by her other doctors to manage the pain medications. Being board certified in pain, one would think recommendations for medications would have good reasoning as well as being up-to-date with concerns of abuse. If another board certified pain physician saw the recommendations made, I am sure they would agree on the treatment. So when a peer review occurs and the physician says he can do nothing, it is clearly not a well-trained physician and they should not be reviewing such a complex case. The insurance company should fire such doctors from their review panels. Furthermore, it can put a patient in jeopardy since needed medications are not obtainable.

Insurance Problems

The insurance company also had a major fail in patient management. The doors close at 5:00 p.m. on Friday. All the phones start rolling over to automated voice call systems. There is no emergency contact person available to obtain authorizations. There is no contact person for any information so the patient can obtain the necessary treatment. Friday and the weekend comes, and you are out of luck.

The most infuriating aspect of the process is no one seemed to care at the insurance company, the pharmacy benefits company or the patient’s pharmacy. I was totally insulted by the Walgreen’s pharmacist who implied that they could not prescribe because physicians like me were causing the opioid abuse problem and patients like the one receiving the medications were obviously abusers. Statements like that are divisive and show clear ignorance and bias. Legitimate pain patients should not be made victims and neither should their physicians.

The opioid crisis is a problem related to addiction and only minimally related to pain management. In pain practices run by board certified physicians that are providing full service management strategies, opioid abuse is likely less than 5 percent of those patients using medications. When the need is legitimate, pain physicians should be given the ability to make the right recommendations and not need to waste time on approvals versus providing treatment. There are very few specialists in pain care, and providing appropriate medication management by these physicians should be encouraged.

Beyond just prescribing, the insurance companies need to step up and pay for the complex solutions like injections, behavioral health interventions, physical therapy, health clubs, dieticians and other integrative approaches to pain management. The patient and the physician trying to develop appropriate treatment plans should not be stymied but encouraged. The chronic pain patient and board certified pain physicians are not the cause of the opioid crisis. The opioid crisis is really a crisis that started from the lack of treatments for pain. Find the solutions for pain and the addiction crisis will start to crumble. Until we understand pain management, we may continue to have a opioid abuse crisis.

Kratom and Chronic Pain

January 10, 2018 / Thomas Cohn, MD

kratom Every once in a while the herbal supplement kratom makes the news. Last November the FDA decided to classify kratom as a schedule 1 drug like heroin or marijuana, but after some opportune lobbying, the decision was put on hold. It is a substance that has been around for hundreds of years, mainly in Southeast Asia, and what it is and what it does is still poorly understood. Recently, some have claimed that it has the potential to be helpful in managing pain and opioid withdrawal.

The Truth About Kratom

Kratom is an herbal substance derived from the leaves of a Southeast Asian tree of the Mitragyna species, which is an evergreen. The leaves are either chewed or used to make an extract. Traditionally, in Southeast Asian cultures it was used for wound healing, coughs, intestinal infections, and to relieve stress and enhance moods, especially for those in boring repetitive labors.

The effects of kratom are dose dependent. At a low dose it acts like a stimulant, and at moderate to high doses it can act like an opioid. Even at low doses it can cause problems like:

anxiety
agitation
nausea
loss of appetite

At high doses, especially on a frequent basis, serious side affects can occur similar to problems with opioids including hypertension, weight loss, constipation, and even seizures and psychosis. Sudden stopping of high dose kratom can mimic withdrawal from opioids. The full pharmacology has been studied only in animals.

Kratom was first reported as an opium substitute in Malaysia and Thailand in the early 1800’s. From the traditional use, it has now become an herbal substitute for opioids for either managing pain or for withdrawals. In most of the world its sale and use are either controlled or prohibited. In the United States, the DEA was going to list it as a Schedule 1 drug like heroin, but due to legislative pressure they decided to leave it alone. In November of 2017, the FDA noted concern about sales and marketing since it can have serious side effects. Further, there have been no quality scientific studies on the effectiveness of kratom for either pain or prevention of withdrawal.

Substances like kratom should be considered very carefully before use. Like any herbal substance, this is not a pure drug and its potency can vary. The difference between an herbal substance and a medication like ibuprofen or aspirin is the dose and chemistry is fairly well understood with predictable effects. A dose of a herbal substance like kratom may be variable and the effect can be as toxic as regular use of opioids.

There may be beneficial properties to kratom, and further actual scientific studies would be useful. Perhaps a pure extract someday may lead to a very helpful compound to treat pain. However, until further understanding is determined, kratom use may be fraught with the same issues of any other opioid-type compound.