Would Mandatory Opioid Registry Checks Solve Painkiller Abuse?

February 22, 2017 / Thomas Cohn, MD

The 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.

CRPS – The Pain Is Real

January 20, 2017January 25, 2017 / Thomas Cohn, MD

Recent findings suggest that individuals with complex regional pain syndrome deal with a great amount of pain during every day activities. According to some pain scale rankings, CRPS ranks higher on the pain scale than childbirth, cancer and even amputation.

For those of you unaware of what complex regional pain syndrome is, CRPS is categorized as a chronic condition that typically affects one limb, usually arising out of a trauma. CRPS involves a disruption in the way sensory signals are processed and deciphered along the central nervous system, leading to extreme pain even when no traumatic experience is happening. Actions like putting on your socks or brushing against a door frame can trigger inflammation and painful sensory signals.

Treating CRPS

According to the National Institutes of Health, CRPS typically affects women, and the average age of a CRPS sufferer is 40 years old. The issue with CRPS is that since it involves a communication breakdown in the central nervous system, it can be extremely hard to diagnose correctly. One report suggests that the average CRPS sufferer searched for answers for four years before receiving the appropriate diagnosis. Part of the problem is medical oversight, but this is due in large part to it being such a rare condition, and the fact that research dollars are being spent elsewhere.

So how do we work to treat and prevent this problematic condition? For starters, education is key. That’s the main reason we shared a large infographic about CRPS on the blog earlier this week. Both patients and healthcare providers need to be aware of the problem of CRPS. It can be treated and managed, but only with an accurate diagnosis. People should not have to wait four years to get to the bottom of their health problem.

Funding For CRPS

We also need to be spending more research dollars on understanding chronic conditions. Chronic pain affects roughly 30 percent of Americans, and the toll it takes on the healthcare system as a whole is billions of dollars, yet funding to better understand the condition and help those who suffer day in and day out continues to be lacking.

St. Paul CRPS Pain Doctor

If you’re dealing with chronic pain, and you’re struggling to get answers about your condition, set up a consultation with a Minnesota Pain Specialist. We won’t stop until we get to the bottom of your condition, because our goal is to help you live a pain-free life. Contact us today for more information.

Pain, The Brain, and the Emotional Link Between The Two

November 9, 2016 / Thomas Cohn, MD

The definition of pain is always worth remembering, especially when one spends their days trying to treat this vexing problem. For the record, by the International Association for the Study of Pain, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The take home message is that pain is always subjective. Pain is always considered unpleasant and therefore is also an emotional experience. The definition purposely avoids tying pain to a noxious stimuli and activity of sensory receptors for nocioception. Pain is always a psychological state.

As a specialist in medicine, learning is never done. Several weeks ago, I was again at a major national meeting. This time it was for the annual meeting for Physical Medicine and Rehabilitation, which brings together practitioners in this specialty from around the world. This is my specialty, and practitioners in this discipline have an extremely broad range of practice. One of the few common threads is we tend to treat people who have had some sort of “injury” to their body, and our goal is to restore function. Pain and the comprehensive management of the problems associated with it are always a major topic.

The Brain and The Emotional Pain Link

Pain is so complex because it is an event that occurs in the brain. If a patient is complaining of pain, one always is trying to determine what are the associated emotional components. When the symptoms have not resolved quickly with management, then the emotional components often become more important than the actual stimuli that are occurring. By the time a patient is seen by a pain specialist, the emotional components of pain are often some of the most important to treat to solve the overall problems. The hardest thing for most patients to understand is that pain is an emotional experience, and if pain is ongoing, many patients become anxious about the pain and depressed. Furthermore, if depression, anxiety, or personality issues are pre-existing conditions to pain, then treating the psychological problems often become a necessity to successfully treat pain.

In the brain, the regions that are responsible for interpretation of pain are actually in the same area as those for anxiety, stress, and sensations associated with depression. If there are a lot of signals for pain, they can secondarily stimulate stress, anxiety and depression regions. If there is significant anxiety and depression, pain often becomes intolerable. Pain and the associated emotional problems often appear inseparable. Further, many feel that if someone wants to treat the emotional aspects of pain, then it must not be real and its all in their own heads.

If the patient has ongoing issues with anxiety, stress and depression, the body interprets emotional pain as physical symptoms. Treating the peripheral issues often provides no relief of pain because there is still an emotional experience occurring. Both the patient and the physician become frustrated since the experience of pain is so complex with multiple levels of meaning. Further, addressing psychological issues that may have existed for years is often more daunting then treating a simple structural issue that caused noxious stimuli, but once the two start interacting, often they become inseparable.

Pain is an emotional experience. Treating both the emotional aspects of pain, the stress, anxiety and depression often is the only way to improve the function of a person. Having a patient recognize the importance of the emotional aspects of pain and start addressing these issues can be miraculous in successful pain management. Often the toughest discussions with a patient are how pain affects a person emotionally and the quality of their life. Recognizing stress, anxiety and depression is often equally important in effectively treating other body symptoms.

Proper Opioid and Painkiller Disposal

October 3, 2016October 3, 2016 / Thomas Cohn, MD

With the increasing problems with drug abuse plaguing our society, there often is a question with regards to disposal of unused medications. The old training used to be to crush it up and throw it down the toilet. However, this is not a very environmentally friendly method of disposal. Tests performed at water treatment facilities often test positive for compounds like Prozac, an antidepressant. Fish are currently showing up with human hormones from ingesting residuals from birth control pills to testosterone. Clearly there are better solutions.

Recently, several different solutions have been proposed. A common suggestion has been to crush the pills and mix them with used coffee grounds and then throw them in the trash. Most likely, this is not much better than flushing them down the toilet. If the trash is incinerated, that would destroy the medications safely, but most trash is still placed in landfills, and again may end up in the environment.

Another solution offered by some pharmacies involves a special bag provided by the pharmacy with a chemical agent that neutralizes the drugs when they are placed inside the bag, making them unusable. The drugs then can be thrown away in the trash, or in some places returned to the pharmacy for disposal. There is a push on the state level to make it legal for pharmacies to take back unused drugs and then they can send them to an incinerator to be fully destroyed. High temperature burning leaves no significant chemical residual that may be harmful.

Police Intervention

One of the best solutions currently available is returning them to drug take back boxes that many police departments use. My local police department has a disposal box that is in the lobby, and is can be used 24 hours a day, 7 days a week. The police will then make sure the medications are sent for safe disposal at an appropriate incinerator.

The most important thing to be aware of is that unused medications sitting around the home are a significant safety hazard. They can be abused, misused, or even accidentally taken, which can lead to overdose and death. Proper disposal is essential. Currently, the best solutions are to use police disposal boxes, neutralizing pouches, or to return them to a pharmacy. Avoid flushing them down the toilet when possible.

Sometime in the future, hopefully some genius will figure out how to safely recycle medications. This would not be an easy task. Each individual medication would need to be separated, and then chemically reprocessed and purified to the same standard as the original production. Whether this would be cost effective, no one currently knows. In the meantime, old and unused medications need to be safely disposed on a timely basis since these are dangerous and toxic compounds.

Fentanyl – The Newest Deadly Drug

September 26, 2016 / Thomas Cohn, MD

The death toll from opioid overdoses keeps rising across the country, and the new culprit turning up everywhere is fentanyl. Authorities are suggesting that Prince died of Percocet laced with fentanyl. More and more street drugs are being laced with fentanyl to increase the high. It started with heroin and now many of the street drugs are being laced with this compound. Sometimes it is normal fentanyl, but other times it is a “designer” type of fentanyl that are created to be even stronger and more potent than regular fentanyl.

Drugs on the street have obvious danger, and what is in them is usually unknown. Drug addicts seek out potent opioids for the high that they will get. Typically the high started with plain prescription opioids, often given for relatively minor injuries. For those who are prone to addiction, the legal prescription starts the path toward severe problems with abuse. Initially, it is doctor shopping and doing what ever is necessary to convince a physician to prescribe. Since pain was considered the fifth vital sign and was heavily promoted, obtaining medications for vague pains used to be easy. With increased awareness of opioid abuse, the tide has turned and it is now much more difficult to legally obtain the medications. Most doctors have become scared to prescribe, and those who do by necessity oftentimes check the state Pharmacy Board for reported fills of a prescription by the patient, and they drug test the patients on their own.

Addicts are now turning to the street to obtain their opioid fix since the legal prescriptions are harder to obtain. The most common cheap drug is heroin. However this drug has a definite bad reputation, and prescription drugs have been the preferred safer option for many addicts. Even heroin is now being laced with fentanyl to make the drug stronger. The street drugs are often marketed as the same as those obtained by prescription. Some are actually the drug, such as hydrocodone or oxycodone. Now however they often are being laced with fentanyl to improve the high generated from the drug. Fentanyl is 100 times stronger than oxycodone, hydrocodone or morphine. It’s dosed in micrograms normally for medical uses. Lacing another medication with fentanyl is very tricky since it is easy to add a trace too much. The consequence of too much fentanyl is a significant overdose. Too much fentanyl hits the respiratory centers of the brain hard, preventing breathing. Reversal agents must be given in multiple doses immediately if a patient has any chance of surviving an overdose.

New Fentanyl Problems

The latest drug to be added or laced to street drugs is carfentanil. It is 10,000 times more potent than morphine. Therefore just a trace of this drug mixed with another opioid would obviously give an extreme high, but also would likely kill a person if not treated almost immediately. This drug is now turning up in Ohio and along the East coast, and has been seen in Europe. It was initially used apparently as an elephant tranquilizer. To reverse this drug it often takes a half dozen or more shots of Narcan, the reversal agent for opioids. The rash of deaths linked to drug overdoses is often linked to this compound. Unfortunately it is also attracting addicts to areas where overdoses are occurring, since they know they might be able to find their ultimate high.

Unfortunately, as we become more aware of the latest problems with fentanyl, newer designer formulations are being made that are equally as strong or stronger. A brief search shows about a half dozen types of fentanyl possibly being made and all are deadly. These days, any street drug can be laced with a deadly compound, if you are an addict, death could be easily around the corner. Opioids are dangerous drugs, if addicted, seek appropriate medical treatment.

Chronic pain is a difficult problem. Clearly, opioids are dangerous drugs and are not the preferred treatment. There are multiple treatments available for pain. If your pain is not well managed, find a good pain specialist who will work with you to find alternative management options. Once pain becomes chronic it is extremely complex, and not able to be cured or fully treated. It often needs to be managed such that it is not the focus of life. It is not a perfect solution, but it can be made manageable.