New Low Back Pain Guidelines From The ACP

February 27, 2017 / Thomas Cohn, MD

In 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?

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.

Why Pain Is Such A Complicated Process

February 8, 2017February 8, 2017 / Thomas Cohn, MD

In 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.

How Body Fat Affects Chronic Pain

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

There are many measures of health. Many physicians are mainly looking at BMI – body mass index – and that is number calculated based on height and weight. It has many shortcomings, especially because it does not take into account that lean muscle mass weighs more than fat, giving a high BMI which is considered bad.

Understanding Fat Types

Body fat is one of the most talked about subjects. There are different types of fat in the body, and different places fat tends to occur. Two types of fat are in the body, brown fat and white fat. The brown fat is highly vascularized, is found in the neck and shoulder regions in adults, and tends to burn energy as well as help in body temperature regulation. There is also indication that this type of fat helps control the body’s triglycerides and cholesterol, and may reduce atherosclerosis. The most common fat in the body is the white fat, this is the stuff in the belly and is the majority of the “flab” we have. The fat in the abdomen and around the internal organs as well as in the liver all lead to increased risk for disease and illness.

Being healthy means getting regular physical activity. It does not need to be done in prolonged blocks at a gym; it just needs to add up over a day. Sitting on the couch, not moving or sitting at a desk all day long does not get the muscles moving or the body the needed activity. Incidental activity is also important. Get up and walk around the house, tinker in the garage or do some household cleaning, as all this is moves muscles and is healthy for the body.

Movement slowly adds up, and people who work in large department stores often note that their fitness trackers indicate that they do over 10,000 steps a day just at the job. As a physician, walking around the office often adds 4-5,000 steps to my day. The benefit of activity is that it promotes stable blood sugars, blood pressure, cholesterol level, and helps maintain lean muscle mass and body composition. Medical studies have shown the incidental activity of people is just as beneficial in maintaining good health, as is the vigorous activity in a gym.

Improving Your Health

It is clear that if you want to improve your health, it is dependent on your daily actions. Regular physical activity throughout the day is one of the best places to start. Other important factors include eating a healthy diet, reducing stress, getting adequate sleep, and avoiding tobacco and electronic cigarettes. Good habits and physical activity help one feel stronger and better, and all these things can be done by anyone, including those with chronic medical conditions.

NSAIDs For Inflammation And Pain Relief

January 23, 2017January 23, 2017 / Thomas Cohn, MD

Nonsteroidal anti-inflammatory drugs (NSAID) are the most commonly prescribed drugs in the world. Generally they are safe medications and they are often available as over-the-counter (OTC) items. The risks and benefits of these drugs are often misunderstood. Taking too much is common; not taking enough to be effective may also be an issue. The directions on how to take the drugs do vary depending on the exact compound. Furthermore, every drug has different strength, so a small amount of one drug could be stronger than a big pill of another one. Lastly, some drugs have unique delivery systems, such as they are available in creams to put on the skin.

Understanding NSAIDs

Medications like aspirin, ibuprofen, naproxen and diclofenac are the most common NSAIDs that are used and available OTC. Acetaminophen (Tylenol) is not a NSAID since it does not have any anti-inflammatory activity. NSAIDs inhibit cyclooxygenase (COX) enzymes, and these affect the making of certain prostaglandins and thromboxanes, leading to their anti-inflammatory abilities.

Inflammation is a cause of pain in many ailments, like osteoarthritis, rheumatoid arthritis, headaches, low back pain, and many causes of muscle and joint pain. Using a medication that blocks inflammation therefore often diminishes pain. If one has ongoing muscle or joint pain, these medications may be helpful. If your pain is due to nerve damage or irritation, like a disc bumping a nerve, or nerve trauma and damage, NSAIDs often do not help. Some of these NSAIDs come in crèmes, especially aspirin, and diclofenac, and using them on painful muscles and joints every four hours as needed can be extremely helpful with little or no risk overall to your health.

NSAID Risks

These medications have been thought to increase the risk of heart disease, especially the risk of a heart attack or stroke. Vioxx was an anti-inflammatory that was pulled from the market because it did increase the risk of heart attacks. Celebrex is very similar to Vioxx in how it works and there was concern it had some of the same risks related to heart attacks. Ibuprofen, aspirin, and naproxen are not as selective for just inflammation as Celebrex and have been found not to increase heart attack risk. In November 2016, a huge study reported that looked at the risk of Celebrex compared to the other NSAIDs and found the risk to be fractionally less. The overall risk for taking an NSAID is 0.7% for having a cardiovascular event. What this means is the risk for heart attacks while taking any of these medications is very low.

The most important risks of this class of drugs are the affects on the stomach, kidney, and on hypertension. Nonsteroidal anti-inflammatory drugs as noted above affect prostaglandins and thromboxane, and these compounds in the body can affect bleeding and blood clots. Taking NSAIDs can irritate the stomach causing pain and bleeding, if this happens, the medications should be stopped and your doctor told about the symptoms. If one is taking a medication to thin blood to prevent a blood clot, an NSAID or aspirin can make one prone to bleeding problems and should also not be taken. The changes in prostaglandins caused by the NSAIDs can affect how well the kidneys work, as one gets older, the kidney function may naturally be diminished and these drugs can cause the kidneys to fail. The affect on the prostaglandins also impacts blood pressure in some people. If you have hypertension, these can make the problem worse and may need to be stopped or changed to a different NSAID. In general, these medications do not affect the liver and do not cause liver damage. There are other reactions to NSAIDs but these are less common, if they seem to be causing some sort of medical problem, talk to your doctor.