Here are the 12 Recommendations the CDC Should Have Made

May 19, 2016 / Thomas Cohn, MD

Opioids and the management of pain have been in the spotlight recently, and rightfully so. Many physicians felt like the recent CDC guidelines for doctors in regards to how they prescribe opioids for chronic pain fell short of addressing the real problem, mainly because CDC Director Tom Frieden placed the blame for the opioid addiction crisis on doctors, calling the problem “doctor driven.” Instead of a sweeping generalization saying that doctors are the problem, physicians feel that the new guidelines don’t address other complex challenges, like medical insurance coverage, legislative policies and clinical realities.

Dr. Lynn R. Webster, former president of the American Academy of Pain Medicine, opted to pen an op-ed that included 12 recommendations the CDC should have made instead of their current guidelines. Rooted in stronger evidence than many of the CDC guidelines, Webster believes these 12 recommendations would better address the problem of opioid addiction, and we tend to agree. You can see Dr. Webster’s entire piece by clicking here, or you can see the 12 recommendations below.

The following are 12 additional recommendations with a stronger evidence base than most of the CDC guidelines, and that would be far more likely to reverse the harm from opioids while not creating more suffering for people in pain. In Utah, a multipronged, state-funded program that included provider education (Pain Med 2011;12:S73-S76) with elements from the eight principles mentioned below was followed by a 28% reduction in the number of unintentional, opioid-related drug overdose deaths from 2007 to 2010, as reported by the Utah Department of Health:

1. Apply the “Eight Principles for Safer Opioid Prescribing” endorsed by the AAPM.

2. Use abuse-deterrent formulations when an extended-release opioid is indicated.

3. Remove the cap on the number of opioid-addicted people who can be treated for addiction with medications such as buprenorphine.

4. Allow nurse practitioners to prescribe medication agonist therapy for opioid addiction.

5. Recommend affordable, perhaps free, access to buprenorphine and methadone therapy in line with public policy that recognizes addiction as a disease.

6. Push U.S. and state legislatures to issue mandates to payors demanding a minimum level of benefits for patients in pain to increase coverage for evidence-based alternatives to opioids.

7. Remove methadone as a preferred opioid for pain from state formularies.

8. Ask that payors require prescribers to demonstrate methadone-specific knowledge before being allowed to prescribe methadone for chronic pain.

9. Encourage the U.S. Congress to increase funding to find safer and more-effective alternatives to opioids for the treatment of acute and chronic pain.

10. Recommend legislation for partial prescription filling for Schedule II controlled substances to reduce the quantity of unused prescription drugs.

11. Implement the National Pain Strategy as a top priority.

12. Consider prescribing naloxone with all extended-release opioid prescriptions.

Pacing Yourself With Chronic Pain

April 18, 2016 / Thomas Cohn, MD

If one has chronic pain issues, sometimes life requires compromise. Our bodies change as we age. Just like a car, when we are young, not much maintenance needs to be done. As we get older, the parts become worn and it takes more work to keep us running. We can no longer just add fuel and go, we have to do routine maintenance and do special work to keep the body moving. Going full speed ahead may not be the wisest move, and slowing down might be helpful.

3 Aspects of Health and Wellness

In order to keep going, one of the most important aspects of care is to exercise. There are three components to a good program; stretching, strengthening and aerobic conditioning. Like a three legged stool, all of these components are necessary to prevent one from collapsing. When one is young, doing only one aspect may be okay, but if you have chronic pain, without all three it may not work.

Stretching – Muscle tightness and “spasms” often cause pain, so stretching of these areas significantly reduces muscle tightness and pain. Stretching often needs to be done several times a day, once should be fairly extensive, but short 30-60 seconds of isolated stretches may be extremely helpful throughout the day.

Strengthening – Strengthening is essential to maintain the body’s power and ability to perform activity. To be able perform an activity, one needs to have the muscle strength. Performing strengthening of the muscles by using exercises that push the body against gravity, or using machines, weights or bands are simple ways. Simple exercise routines can be found easily in apps for your smart phone or by searching the internet especially for the neck and low back region.

Aerobic Conditioning – The last leg of the stool is aerobic conditioning. Aerobic exercise ranges from walking, to pool exercises, to workouts on treadmills, ellipticals, or bicycles. Conditioning should be for about 30 minutes and be 4-5 times a week.

If one has chronic pain, the intensity and speed that one went at life prior to injury often needs to be decreased. Going all out at any activity often will cause more problems. Despite doing the appropriate exercise, once injured the body is often not perfect thereafter. Expecting to be able to do everything the same as what one did 20 years ago is unrealistic. Spring cleanup or housework that was once done in a single day may now require splitting up the routine over several days and paced out. It may take just a bit longer, but the job will still get done. It often does not matter what route one takes, as long as one gets to the same endpoint.

Once a new car leaves the dealer, it is always deteriorating unless it is never used. Once we reach adulthood, the body is always slowly growing older. It will never be quite the same as it once was in the past. Maintenance is always needed. Pacing ourselves through life will give us longevity. Getting to the endpoint is what is important. Speeding will garnish a ticket; more pain and will not make the journey especially enjoyable.

Mentoring and Support Crucial For Teens With Chronic Pain

March 24, 2016 / Thomas Cohn, MD

New research out of Canada suggests that doctors should ensure that teens who are battling chronic pain and illness should have a support system in place to address their mental health, as it can help manage physical symptoms.

The study was small, but the findings speak to a larger issue that oftentimes gets overlooked when it comes to helping adolescents with chronic pain. For their study, researchers conducted an eight-week study with 28 kids between the ages of 12 and 17 who had been diagnosed with various chronic pain conditions. The group was split in two, with one group participating in the iPeer2Peer program.

Those in the treatment program were partnered up with an adult between the age of 18 and 25 who had also been diagnosed with a chronic condition. The mentors needed to undergo a 20-hour training session prior to being paired up with a mentee. The pairs talked via Skype twice a week for at least 20 minutes a session for the first two weeks, then at least once a week for the remaining six weeks. Researchers noted than sessions routinely ran about twice as long as the minimum 20-minute scheduled session. Mentors shared advice, offered emotional support and addressed any concerns or questions the mentee had.

Mentoring Chronic Pain

At the conclusion of the eight weeks, researchers uncovered:

Mentees reported significantly higher self-management skills and more satisfaction with their ability to cope with pain after completing the program.

Mentees in the program said they were satisfied with the program and would recommend the treatment to a friend.

Mentors responded that they enjoyed the sessions as well.

Researchers believe that showing teenagers that they don’t have to fight their battles alone can be a significant step in helping them cope with their chronic condition.

“Young people with chronic pain can become socially isolated and many have never met another person with chronic pain,” said lead study author Sara Ahola Kohut, a pediatric health psychologist at The Hospital for Sick Children in Toronto. “By having trained mentors, young people who are only a couple years older than the teens, teach coping strategies, we believed the pain coping skills might be easier to learn and practice.”

Kohut concluded that anywhere from 11 to 38 percent of children and adolescents deal with chronic conditions at that stage of their life, so we need to start addressing the issue. This program may be the answer.

“The program is easily accessible, teenagers liked it, and it helped improve the teenagers’ ability to cope with pain.”

Guidelines For Prescribing Opioids For Chronic Pain

March 17, 2016February 7, 2023 / Thomas Cohn, MD

The Centers for Disease Control and Prevention recently announced some new guidelines for physicians in regards to prescribing opioids for chronic pain control. The official statement is a little wordy, but the CDC also published an infographic to explain the new guidelines. I plan on publishing my thoughts on the new recommendations, but for now, here’s a look at the recommendations as well as a statement from the American Academy of Pain Medicine.

AAPM Statement

“We know that doctors – primary care and pain medicine specialists – are integral in treating pain wisely and carefully monitoring for signs of substance abuse. Abuse and diversion of prescription opioids must be addressed. Opioids are not the usual first choice for treating chronic non-cancer pain, but they are an important option—as part of a comprehensive multidisciplinary approach— that must remain available to physicians and appropriately selected patients,” said Dan Carr, MD, President of the American Academy of Pain Medicine and Professor of Public Health and Community Medicine at Tufts University.

“We need to address both chronic pain and its treatment as public health challenges. This view is endorsed by the National Academy of Medicine and outlined in the draft National Pain Strategy from the NIH. Public health problems are typically complex; well-meaning, but narrowly targeted, interventions often provoke unanticipated consequences. We share concerns voiced by patient and professional groups, and other Federal agencies, that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence. It is incumbent upon us all to monitor the deployment of the guideline to ensure that it does not inadvertently encourage under-treatment, marginalization, and stigmatization of the many patients with chronic pain that are using opioids appropriately.”

Tarantula Venom May Help Provide Chronic Pain Relief

February 29, 2016 / Thomas Cohn, MD

We spoke briefly in the past about how researchers are looking at spiders as a potential source of relief for patients battling chronic pain, and new research suggests that a tarantula may hold some answers.

According to researchers in Australia, the Peruvian Green Velvet Tarantula, native to South America, may help advance our knowledge of chronic pain reception and expression. A bite from the spider isn’t deadly enough to kill, and in fact, it may have some benefits. Researchers say the venom actually helps to inhibit pain receptors in the body.

“Our group is specifically interested in understanding the mode of action of this toxin to gain information that can guide us in the design and optimization of novel pain therapeutics,” said Sónia Troeira Henriques, senior research officer at the University of Queensland’s Institute for Molecular Bioscience.

The peptide toxin, referred to simply as ProTx-II, works to block pain signals by binding to the membranes of nerve cells.

“Our results show that the cell membrane plays an important role in the ability of ProTx-II to inhibit the pain receptor,” said Henriques. “In particular, the neuronal cell membranes attract the peptide to the neurons, increase its concentration close to the pain receptors, and lock the peptide in the right orientation to maximize its interaction with the target.”

Venom and Chronic Pain

Based on the new findings, researchers are hoping to mimic the effects of the venom in drug form. They see at as a new avenue in the pursuit of pain management.

“Our work creates an opportunity to explore the importance of the cell membrane in the activity of peptide toxins that target other voltage-gated ion channels involved in important disorders,” said Henriques.

The Australian team isn’t the only one studying the role of venom in chronic pain management. Researchers out of Germany are exploring the benefits of snail venom in pain control, citing an added benefit that the venom decomposes quickly and thus is less likely to lead to dependency and abuse. That research is farther along, as a drug has already been created using the snail venom. The drug is called Prialt, and it is being used as a spinal pain injection to treat pain from failed surgery, cancer and AIDS.