The Benefits and Drawbacks Of Medical Marijuana

Minnesota Medical Marijuana BenefitsRecently, the National Academies of Sciences, Engineering, and Medicine did a comprehensive review of the information available on the use of marijuana. The study looked at research published since 1999, and they came up with a number of conclusions. One of the most important findings is the current lack of good scientific information on marijuana. There is a clear need for good scientific research to guide healthcare professionals on the risks and benefits associated with marijuana use. Currently, to study marijuana or any of its derivatives, the federal bureaucratic hoops one must go through makes it extremely difficult to perform. The information available and the quality of the research at this point are limited. The conclusions are based mostly upon case report studies with limited controls.

The Complexity of THC and Marijuana

In Minnesota, medical marijuana is available to treat several specific conditions, and this year chronic pain was added to the list of approved conditions. The recent study also supports the idea that marijuana may be helpful to treat some people with chronic pain. For some it seems the non-THC (THC is the component that is responsible for the “high”) may help for pain. Since there are multiple causes of pain, it definitely is not indicated for everyone. Further, no studies have been done to determine what types of pain may be helped by components of marijuana, and it is not clear which of the 80 or more different compounds in marijuana are helpful. It is also known to be helpful for nausea from chemotherapy, and spasticity in multiple sclerosis. Marijuana may help in appetite with HIV, and there is limited evidence for help with bowel disorders, epilepsy, and Parkinson’s disease.

Potential Drawbacks

There are multiple potential harms that may be caused by marijuana. There is strong evidence that its use can lead to schizophrenia and psychosis, especially among young and frequent users. It may also lead to depressive disorders. The claim that it can make you a better driver is simply false, as statistics have shown that it leads to inattentive driving, a main contributor to traffic accidents. In pregnancy, use can lead to low birth weight in infants. Smoking pot can also cause and worsen any respiratory condition. There is weak evidence that smoking marijuana can increase the risk of heart attacks. One can also develop an addiction to marijuana. Conclusions cannot be drawn with regards to school achievement, unemployment, or social function and marijuana use.

Understanding It All

The overall scientific conclusion so far is that marijuana may have some reasonable medical uses. However, the scientific research on the compound is extremely limited at the moment. In the United States, it has been classified as a compound with no medical value and harmful to society. What needs to happen is that national legislation is needed to reclassify marijuana as a controlled substance, then good medical research can be done to determine what compounds in this plant are helpful or harmful. Once good research is done, then the use of compounds can occur with everyone understanding appropriate risks and benefits like with any other drug now available.

Why Doctors Should Be Listening To Their Patients, Not Relying On Scans

doctor listeningThe world is a fast-paced environment. No one has time for anything anymore. In medicine, there is constant pressure to see more patients and do more electronic paperwork, and productivity is a key guidepost to life. However, slowing down and spending a few minutes listening to the world around you and to patients may actually be more rewarding, and solve more problems.

Listening To Your Patients

Being an older physician, technology was just beginning to influence medicine when I began training. CT scans were just starting to become available at the beginning of my training, and MRI scans were not available until I was in practice for a few years. The hallmark of a good physician was their ability to make a diagnosis based on a patient’s history, a physical exam, and some basic testing. The patient encounter was the critical event, as was at getting the story.

Most of the time, if one listens to the complaint of a patient closely, the diagnosis of the problem becomes much more clear. The physical exam is also critical; this is especially important since high technology studies like MRI scans often find problems that are not the cause of a patient’s symptoms. Going old school and using the technology as an assistant and not depending on it often leads to a better treatment plan for a patient.

Treatment and Listening

There are many different styles of physician practice. Being in the field of pain management, one can use multiple approaches to the same problem. One common approach for low back pain is that everyone needs to have every structure in the low back injected with steroid. Another style is that the only treatment that is needed is a course of extreme physical therapy. The approach that seems to be the most effective is take a good history, do an exam of the patient and then decide what is wrong and needed. Most of the time, it will yield a more precise course of action.

Multiple times I have found that an MRI may show multiple significant looking issues, but the history and exam show no correlated problems that would warrant treatment. The body can adapt to multiple things seen on a scan and not have any problems. Treating a scan versus treating a person can be the absolute wrong thing. Furthermore, most problems can be treated in a number of ways, and the choice is often dependent on the approach the patient wants once they understand the options available.

Listening and examining a patient may be considered old fashioned. As a new physician it is often hard to understand the subtle things a patient is trying to convey. Sending a patient for tests and treating the tests is far easier. As an older physician, a lot of the stories become very classic, as is the exam. For example, spinal stenosis in the elderly has a unique story of pain when walking a few feet and being just fine when sitting or lying down. The story tells more in a few words then the MRI and then the treatment is absolutely defined by what the patient desires. Being old fashioned and listening is not glamorous, but it often is a more effective way to get the job done right.

Why Difficulty Sleeping Is Like Living With Chronic Pain

28201632 – woman suffering from stress or a headache grimacing in pain as she holds the back of her neck with her other hand to her temple, with copyspace

Chronic and acute pain often interferes with sleep. Since a third of our lives are spent sleeping or trying to sleep, having an issue getting good sleep can be a major issue. There are many problems that interfere with sleep, and many pain patients have difficulty sleeping. Sleep is similar to pain, in that it is a complex process, and many things can affect our sleep. Sometimes the solution to better sleep is simple, but more often the problem and solutions are complex.  

Why Recent Guidelines on Sleep Fall Short

The latest issue of JAMA came in the mail today and had two articles related to sleep. The first was on chronic insomnia and the new guidelines for its management. The second article was on restless leg syndrome (RLS). The “guidelines” were put out by the American College of Physicians (ACP) and written by primary care physicians and health care administrators. To be valuable, guidelines really need to be written by experts in the field of the guideline, and sleep specialists can be credentialed in Neurology and Internal Medicine with a specialty of Respiratory Medicine. These experts were not the ones to write these guidelines. If a patient wants only entry level advice on sleep, these may be okay, but for those suffering from chronic sleep issues, consulting an expert would serve most patients significantly better. It is shame that leading national organizations like the ACP and JAMA publish minimally useful information.  

Since I have been in practice for a number of years, learning some some of the basic treatment options to improve sleep is not difficult. If a patient is having difficulty sleeping, always start with a good history and physical exam. The history often tells significant information with regards to the nature of the sleep problem. Treating sleep is usually more complex than guessing the right medications. The most important first step is good habits prior to going to sleep. The easy things involve reducing caffeine intake, especially in the afternoons and do not drink it at night. Alcohol also does not help with sleep; it often will wake one up in the middle of the night. Technology is also a horrible actor; the blue light of cellphones and computers as well as television will stimulate people and prevent sleep. Lastly, do not exercise vigorously in the evenings; this also wakes up most people.

Solving Sleep Problems

If a person has addressed the simple sleep issues and they are still having sleep problems, then finding a solution will often require some expert intervention. Since there are many problems that affect sleep, obtaining a medical sleep consult by a specialist is worthwhile. Problems like sleep apnea are often an issue. Finding medical problems that need management can reduce interference with sleep. If nothing is found to be a problem by an expert, then solutions to what seems to be reducing sleep can be initiated. Many people cannot relax enough to go to sleep, and psychological based treatments like mindfulness or cognitive behavioral therapy are indicated. Few patients may need some sort of medications, but these need to be closely monitored for side effects.

Most experts have not found that a particular type of bed or pillow makes any significant difference. If I am asked about whether a person should buy a new bed, it is probably only necessary if the current one is totally broken. Pillows are really a matter of personal preference, but they need to keep the neck in a neutral spine position. Usually spending lots of money on beds and pillows is not a good solution for improved sleep.

The patient with chronic pain is often no different from any other patient with sleep difficulties. Correct the simple things with regards to sleep hygiene first. If a person continues to have sleep problems, they should see a sleep specialist who can often help find the most appropriate intervention. Expensive beds and pillows are not usually a good investment. If you need a new bed, buy either a bed with a memory foam type top, or an air adjustable bed so the firmness can be adjusted depending on how you feel. Beds with adjustable frames that raise the head are sometimes good for those with breathing problems at night. Most importantly, good sleep hygiene is the first issue to solve, and if the problems persist, ask to see a sleep expert.

New Low Back Pain Guidelines From The ACP

 

Low back pain treatmentIn the last week, the American College of Physicians (ACP) published new guidelines for the care of low back pain. The guidelines are their recommendations based on the available research on the subject. The most important thing to remember is this information is designed for physicians to assist with the management of particular problems.

However, the recommendations are only as good as the knowledge and ability of those who put together the data. These guidelines provide some reasonable information, but they do not contain significant information from board certified pain practitioners who are treating the problem every day. The reason why we need to highlight this issue is because the guidelines attack back pain as if it has one single cause, which we know is not always the case.

Where The Guidelines Fall Short

For the pain practitioner and as it should be for every doctor, pain is one symptom, and the low back region covers a large number of structures that can cause problems. A diagnosis is based on a history of symptoms, a physical exam, and then the application of medical knowledge to determine the causes related to the problem.

The new guidelines move away from coming up with a specific diagnosis of the pain problem. They also recommend any number of treatments that have a limited scientific basis, like acupuncture and spine manipulation, and they did not address medications very well. Muscle relaxants are recommended as well as duloxetine (Cymbalta), while many more common medications like Celebrex were not studied. The guidelines also recommend many psychological therapies and exercises that are not readily available or not covered by insurance.

Treating Back Pain

Guidelines are meant to serve as a road map to help practitioners establish appropriate treatment for patients. The new ACP guidelines lack instruction on establishing appropriate diagnoses and true evidence-based treatment alternatives. The guidelines appear to be the answer to what is the cheapest way to get a complex problem patient out of an office. They recommend everything but appropriate diagnostic testing, referrals to experts in pain, or advice on all the non-opioid options available and when to use them. These guidelines made headlines in the national news, but they surely are not truly newsworthy.

Acute, subacute, and chronic low back pain all have different meanings and can be quite well treated with a variety of interventions. It is true that most acute back pain is short lived, but primary care physicians should learn much more about all the causes and treatments available.  For the patient, telling them “No matter what you do, it usually gets better in a month,” as these guidelines suggest, is poor quality care. No patient wants to be sidelined for a month, and they want to have a definitive diagnosis and treatment plan. These guidelines fall short of offering the best care for each patient with back pain.

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.