Zohydro in Minnesota: A New Twist on an Old Drug

May 7, 2014December 11, 2015 / Thomas Cohn, MD

In the last couple months, the FDA has approved Zohydro for use as a pain medication. It is an old medication – Hydrocodone – in a new package. Hydrocodone is the opioid/narcotic medication in drugs like Vicodin, Lortab, and Norco, and up until now has always been combined with acetaminophen. It is now made into a form that is extended release and is not combined with any other drug.

The drug is meant to last for up to 12 hours and comes in strengths from 10 mg to 50 mg. The big issue is that there is no abuse deterrent design in this new product.

Abuse Likelihood

Hydrocodone is currently one of the leading drugs that is abused. It is the most prescribed pain medication in the United States, and 98% of worldwide consumption occurs in the USA. Furthermore, this medication needs to be metabolized in the body into a broken down state to be effective, and in 5-10% of the population, it has very little effectiveness. Now, with this new formulation, it is available in a high concentration and has the potential to be easily abused.

Zohydro, in the Pain Specialist community, has received a very cold reception. It has one main benefit; it is no longer used in combination with other drugs. It has many more problems, and the manufacturer and FDA did not listen to the warnings by the specialists who might prescribe the medications. I was actually involved in a focus group evaluation by a manufacturer of either this drug or a similar drug. As with most pain specialists, this drug is likely going to be a highly abused drug that adds little to options for pain management.

Time will tell if this drug will be helpful in pain management. At this time, there are a number of other short and long acting pain medications. A generic short acting Hydrocodone without a combination drug would have been welcomed to help prevent side effects and toxicity of acetaminophen. It would be affordable and useful for short-term pain control. Any new potent pain medication should employ an abuse deterrent formulations, otherwise the increasing pain medication abuse problem will only worsen.

Implantable Pain Control Devices

May 5, 2014December 11, 2015 / Thomas Cohn, MD

Pain control has become a complex science, and new treatments and technologies are rapidly being developed. It was amazing to see the new scientific leaps that are being made in our knowledge of pain during my visit to the annual pain conference this year. The mechanisms of pain generation, transmission, and perception are all being intensely studied. New chemicals and methods to interfere with the eventual delivery of signals to the brain are being discovered. It is still several years until most of these research findings become part of our practical treatment of pain, but the future looks encouraging for those battling chronic pain.

As I mentioned above, pain management is a complex science. There is usually not a magic solution to control symptoms. Most treatments incorporate tools to help better control pain and optimize a patient’s ability to function. Treatments are to diminish the intensity of pain, not to eliminate all pain. Often a patient has multiple generators of pain signals and a combination of interventions is necessary to best control symptoms. Unlike a simple cut where a Band-Aid or stitches will cure the problem, pain often requires the skills of a Pain Management Specialist to develop an individualized strategy to control symptoms and maximize function.

The Role of IPCDs

Implantable pain control devices (IPCD) are tools employed when simpler strategies are not working. These are tools to use in combination with other treatments to maximize function. They do not totally eliminate pain. Two high technology devices have been developed to be implanted into the body: a spinal cord stimulator, and an implantable intrathecal medication delivery pump.

A spinal cord stimulator is the basic IPCD used to control pain. The spinal cord stimulation acts as a pacemaker that paces out the delivery of sensory signals at the spinal level that prevents pain signals from being delivered to the brain. These devices have been available for over 20 years, and three different companies make competing similar units. Over the last ten years, as technology has improved, so have these stimulators. They are programmed to deliver an electrical signal to the spine from a position in the epidural space. For the right patient, they can be a life saver, as they dramatically increase pain control and often reduce the need for medications.

An intrathecal implantable medication pump is more complex. These pumps deliver medication directly into the spinal fluid. The drugs need to be specially compounded by a pharmacy, and only a limited number of drugs have been used in this fashion. Pumps can deliver medications to receptors that are only accessible by being present in the spinal fluid, and often these same medications do not transfer from the blood to the spine or brain. A lot can go seriously wrong with medication delivery directly to the spine. These are also only effective in highly selective and very motivated patients. Once implanted, the patient is married to the pain clinic and there may be significant additional limitations especially on travel and freedom to be away from the clinic that fills the pump.

Pain is a very complex problem. If your pain is not well controlled, working with an experienced pain physician to develop the correct strategy is necessary. Implantable devices are tools to help control symptoms, but they are complex and not magical solutions. There are new developments in pain control being researched now. A good pain specialist will help find a pathway to a better solution.

Marathon Running Pain and the Weekend Warrior

April 21, 2014May 24, 2017 / Thomas Cohn, MD

The marathoner and all of us have something in common; when we do activities to the extreme, we all have pain. Running a marathon is a grueling event and it stresses the entire body. The whole body often is sore afterwards, both physically and mentally. The best trained athletes are even sore after this event. The weekend athlete and the rest of us often suffer from similar pain when we do too much of an activity that we are not used to performing.

A marathon runner will have pain after a run for a number of reasons. Most will have muscle soreness in the legs from build up of lactose and from some muscle strain. Ice, heat, fluids, and over-the counter medications will take care of symptoms. Joint pain may also be present for the repetitive bounding of pavement. Again, this pain should disappear in several days as the body heals itself. In general, all pain should resolve within days. If there is an isolated area of pain, sometimes a more severe injury has occurred and further medical evaluation and treatment may be necessary.

The weekend warriors suffer from similar issues. Spring yard work is the classic example of people stressing out the body. We rake the yard for hours, lift bags of dirt, move heavy rocks, and kneel in the garden. Then we exercise for several hours and wonder why we hurt the next day. The simple answer is we strained muscles and irritated joints that were not prepared to do that level of activity. The treatment is the same as it is for marathoners; short term rest, ice, heat, fluids, and if necessary, over-the-counter medications for several days. Rarely, do we strain or injure something bad enough to need medical attention.

Preventing Injuries

Preventing injury is the most important concept to remember whether you are a marathoner or weekend warrior. The marathoner needs to train for long distances, gradually increasing time and distant travelled. The weekend warrior needs to learn to pace themselves with activities. Do not try to get everything done in one short amount of time. Split up the tasks that need to be done. As one would say, stop and smell the roses. Take your time and you will not hurt yourself.

The long winter is over and we all want to get out and get active. Take it one step at a time. Try to remember to pace yourself through all those tasks that need to get done. It will all get done, just take your time and enjoy the journey. Have some fun, and there will be a lot less pain and you will still get to the end of the line.

Woods Undergoes Surgery For Lumbar Microdiscectomy

April 9, 2014December 11, 2015 / Thomas Cohn, MD

Augusta National Golf Club will have a different feel to it when golf’s first major gets underway tomorrow as its most polarizing figure, Tiger Woods, won’t be in attendance. Instead, he’ll be recovering from a recent back surgery.

Tiger Woods has been having back problems for over a year. The initial reports said he was only dealing with a bulging disc that would not need surgery, but this week it was announced that Tiger underwent an operation called a Microdiscectomy since conservative care failed. Since we can only make educated guesses as to what is wrong, we can give only a basic primer on Tiger and lumbar pain management.

Woods’ Woes

Hopefully Tiger is only dealing a single lumbar disc problem. This type of injury and corresponding surgery is best only for pain into the leg caused by an isolated herniated lumbar disc. He has tried the basics; rest, physical therapy, working with another golf pro on body mechanics, and medications to control pain and back spasms. It sounds like he has also tried injections, and despite all these efforts, he is still having issues. The latest MRI scan of his back showed a disc herniation bumping a nerve root that is most likely the cause of his pain. After not being able to play up to his usual standards, Tiger decided it was time to consider surgery.

A Microdiscectomy is a minimally invasive surgery, often using only a small incision of about an inch in length. Using special tools, the surgeon removes a small portion of bone, possibly a joint, and the offending piece of disc. The surgery is usually done as a hospital inpatient operation with an overnight stay to monitor for complications. The patient should be up and active within a day, and often has significantly improved leg pain. This stands to reason, as Tiger didn’t announce that he had undergone surgery until a few days after the operation, and the media was none the wiser. If one does not perform heavy work, returning to employment can occur within a week.

Complications and Rehab

As with any surgery, especially back surgery, there are risks of complications. In properly selected patients, success is at about 90 percent. Spinal fluid leaks, infection, recurrent disc problems, scar tissue, and ongoing pain may be seen despite surgery. The surgery will only be successful for very select group of patients who have failed all conservative care. It will not cure back problems that are related to multi-level disc problems.

The rehabilitation from a Microdiscectomy surgery is fairly rapid. Activity including stretching and walking is encouraged within a week. Guided strengthening and back exercises are often reasonable to start within a month. By three months post surgery, most activity should be possible if treatment has been successful.

Hopefully Tiger will be able to return to golf within three months. Looking at the timetable, that puts his return right around the U.S. Open, which is historically played on the third weekend in June. A more reasonable projection would be that he could return for The Open Championship, which takes place in late July.

Time will only tell what more may happen with his back. Since professional golf at the highest level is very demanding, hopefully this surgery will work and there will not be any complications. If Tiger retires, we will know, it was not the perfect cure.

The Devastating Consequences of Addiction

April 2, 2014December 11, 2015 / Thomas Cohn, MD

Addiction is one of the leading concerns for physicians in the field of pain medicine. Pain management is a broad and complex field with a range of treatments crossing many different disciplines of medicine. When pain is chronic, there is often not a magical single solution or pill. Pain is managed – it may not be cured – and the patient will have to do a significant amount of individual work and treatment to keep the pain under control.

What is Addiction?

Addiction is a disease of the brain. It is often described in terms of the “4 C’s” of behaviors that are seen. The four C’s are:

Loss of Control
Continued Use Despite Harmful Consequences
Compulsion
Craving

The first C is for loss of control over use. One pill is not enough, and the person will take more and more until they pass out. The behavior does not stop at one episode; it continues multiple times. The second C is continuing use despite harmful consequences. An addict may be hospitalized for repeated overdoses of medication. Some people steal medications of others, or sell their medications in order to be able to afford more drugs in the future. The third C is a compulsion to use a drug. One may not have any pain, but continues to use the drugs because they want the “high”. The fourth C is a physical craving for the substance. If they stop the drug, they will go into a withdrawal. They will physically shake, become nauseated and have other symptoms.

Addiction is a bio-psycho-social issue. There are multiple circumstances that surround addiction, but a big influence is a person’s environment, which may stimulate addiction. If the people you associate with and the activities they participate in promote addiction, for instance hanging out at the bar drinking every evening, addiction can occur.

If a person has family members that have an addiction issue, genetically they are also prone to the same problem. Certain chemicals to the brain also stimulate addiction. Compounds that increase dopamine levels in the brain can cause a prone person to have problems. Opioids and some antidepressants affect dopamine and taking these medications can promote problems in an at-risk individual.

Addiction Prevention

Pain medicine physicians have many solutions to pain. Pain physicians are trained to recognize which medications may lead a person towards addiction, and to spot addiction symptoms at early stages. A physician will shy away from certain medications if they see that a patient has had a problem with medication abuse in the past. Prescribing drugs that are less likely to lead to addiction is one way to prevent addiction, but there are a lot of related prevention techniques that should be discussed and implemented by your physician.

If you have ever had a problem with addiction, a wise pain physician will help you find a solution to your problem and try to avoid a new issue. Pain is difficult to treat and it will take significant effort on the part of the patient and treatment team to develop a reasonable solution over time. New discoveries will also improve management. There is hope on the horizon.