chronic pain

New Pain Medication Issues: The Zohydro Case

/ Thomas Cohn, MD

ZohydroA new pain medication has debuted and has set off major controversy. The new medication is called Zohydro, and it is a long-acting form of hydrocodone.  This is the same medication as Vicodin or Norco, without the acetaminophen. Vicodin and Norco are the most abused short acting opioid/narcotic medication. Despite knowing this, the FDA recently reversed its stance and approved the high potency long-acting drug. Zohyrdro will certainly help some people who deal with chronic pain, but it will also undoubtedly be abused by others. This begs the question, will Zohydro cause more harm than good?

The answer to question is up in the air, but it certainly looks like it will cause significant harm. It will cause problems, especially since some physicians will ignore the risks and prescribe the drug because it will do a great job relieving pain. This new drug can be easily abused, and has no abuse-deterrent properties. Many potent opioids have abuse-deterrent properties like smaller doses and pills that are designed so the user can’t alter the contents to snort or inject the substance, but Zohydro has no such properties. It will be abused.

Physician Care

Pain physicians, at their annual meeting last week, came to the understanding that opioids are important, but the most potent medications need to be abuse-deterrent. Opioids have a tendency to be abused, and therefore pain physicians have an obligation to help reduce abuse. This new medication adds very little to our treatment regimen, but it opens up more opportunities for abuse.

There are many abuse-deterrent formulations that can be used to treat pain. As far as pain physicians are concerned, there are just to many medications available that are being abused. In reality, it is unlikely we really need this medication.

Pain physicians would like to see more pain medications designed with abuse-deterrent properties. These are medications that have properties which do not stimulate a “high”. These tend to be slower acting, or have specific properties that do not stimulate the brain areas that give a rush. The future in pain care is developing more medications that treat pain but do not lead to abuse. Opioid/narcotic abuse is rampant in the United States, and physicians can play a key role in reducing this problem. Aggressively prescribing Zohydro is not one of those ways.

Genetic Testing and Pain

/ Thomas Cohn, MD

Genetic Testing PainGenetic testing is a new area of pain management in which enzymes are studied to help better define what medications may be helpful in treatment. Many physicians assume that if a drug is not working, the patient is probably not taking the medication correctly, or somehow is abusing the drug.

As technology and science has improved, so has our understanding of how various drugs are processed in the body, including many drugs used for pain. We now know what enzymes control the metabolization of drugs into a person’s system, and not all people have the same enzymes in their bodies.

A case in point is my own family. I likely have a missing CYP2D6 enzyme and have passed it on to at least two of my children. Several years ago, one of my sons had knee surgery for a torn muscle. Post-operatively he was given Vicodin. After the surgical anesthesia wore off, in the middle of the night, he was screaming in pain despite taking his medication. We ended up in the ER and changed his medication to Oxycodone. This resolved the problem and he was off the medication within several days. My daughter had a similar issue after surgery, and we again found that Oxycodone worked best to help control the pain. In the past, after surgery, I’ve noticed that Vicodin has done virtually nothing for me, but I just dealt with it. In retrospect, this is not a coincidence, but a genetic variation that now can be tested.

Enzyme Trials

Today, most medication is prescribed on a trial basis and we just see if it works. If it does not, we just look for another treatment. In cancer treatment, genetic testing has become essential; We are learning that medication effectiveness for various tumors can be determined at least partly by various genetic markers. The lessons that we are learning from cancer are now being applied to other areas of medicine. The enzymes responsible for the metabolization and processing of various drugs is starting to be understood. The interactions of various drugs with each other are also being better understood as this chemistry is being determined.

Genetic testing is done for several reasons. There are many drugs that interact; If you are on multiple medications for any number of reasons, testing may help clarify possible interactions and allow for more informed decisions to be made if medications need to be adjusted. The most important reason may be if a person is having trouble with medication effectiveness of treatment. Genetic testing may reveal interactions or enzymes that prevent a medication working properly. If the treatment you are receiving is working, there probably is no reason to undergo genetic testing.

Science and technology are moving forward quickly. The changes in the future may guide us to better tailored treatments for the individual. At this time we are just scratching the surface of understanding these higher levels of information. The future appears bright, but patience is necessary since new treatments take time to safely make it to the market.

Pain Injection Risks and Safety Procedures

/ Thomas Cohn, MD

Pain InjectionsMany patients with pain can benefit from various types of injections. These pain injections are preformed by interventional pain physicians who specialize in managing pain and reducing chronic aches.

Training of interventional physicians is variable; they include those trained in Anesthesia, Radiology, and Physical Medicine and Rehabilitation. A good interventional pain physician will be board certified in their specialty and have years of experience.

Types of Pain Injections

The appropriate injection will be determined once the problematic area is assessed. Most injections can be performed with minimal discomfort and will take only a few minutes once the procedure begins.

Every injection has the same four risks. They are:

Risk of Infection – The first risk is infection. Cleaning off the skin, and using sterile techniques and medications reduces this risk.

Bleeding Risks – The second risk is bleeding. If the patient does not have a bleeding disorder or is not on anticoagulation medication, then this is not a problem.

Allergic Reaction – The third risk is an allergy to a compound used with the injection. The most common is an allergic reaction to the X-ray contrast, however this risk is very small, less than the risk of being hit by lightning, and can be treated.

Needle Damage –  The largest risk is the possibility of a needle causing damage to the structure that is being treated. Damage during a spine injection to the spinal cord or to a vascular structure that may cause damage to a nerve, spine or the brain is always a concern. Risk is minimized by using real time X-ray guidance known as fluoroscopy, and by having an experienced and knowledgeable physician administer the injection.

Post-Injection Safety

Some pain clinics require all patients to have a driver for any procedure, but it usually depends on which injection you’re receiving. In the vast majority of procedures, the patient will feel the same or better shortly after receiving the injection. If the patient is nervous, I usually recommend they have someone drive them to and from the clinic, as there is little reason to compound the injection with fear. This is also a good piece of advice for anyone who will be receiving an injection for the first time. If you feel fine on the ride home from your first appointment, feel free to drive yourself to any follow-ups.

If you need help to move or drive before the procedure, it is unlikely the injection will give you the ability to do so in the immediate aftermath. In these cases, you absolutely should plan on having a driver. If you are sedated for your procedure, you’ll be required to have a driver since this definitely impairs the ability to make safe decisions behind the wheel.

After the injection is complete, the physician will likely use a local anesthesia to reduce discomfort around the injection site. This will make your drive home more comfortable, especially if you received an injection on your lower back or hips.

A good pain physician should be able to make you comfortable during the procedure. They can answer your questions and describe the procedure so you know what to expect. You should always meet the physician before the procedure so you can ask any questions you might have ahead of time.

The Link Between Anxiety, Depression, and Pain

/ Thomas Cohn, MD

pain and depressionAccording 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.”

This is one of the best descriptions of what pain is and is used worldwide to explain the experience of pain.

Pain and Emotion

Pain is an emotional experience.  Emotions such as happiness, sadness, and anxiety are generated in the brain.  Thus, pain and anxiety are intimately linked in the brain in terms of the locations that generate these perceptions.  As noted in the definition, pain has unpleasant emotional components, which most people perceive as anxiety.

The link between pain and anxiety is, in reality, more than just theoretical.  Sensation that is interpreted as pain is processed in several areas of the brain.  Some of the main regions of pain sensation are in very close proximity to the regions that process emotions of anxiety and depression.  When there is prolonged activity in the areas that process pain sensation, the areas nearby that process depression can be activated.  The areas then can spontaneously interact, pain sensations can be interpreted as anxious emotions, and anxiety can be misinterpreted as pain.

Anxiety and Chronic Pain

Those who have chronic pain often become depressed and anxious.  The two sensations become intermingled, and often the pain is greatly amplified by the depression.  Treating the emotional consequences of pain is often as important as treating the physical causes of pain.  If the depression and anxiety are not controlled, the pain is not controlled.  Once the depression and anxiety are controlled, insight into pain can occur and pain often becomes manageable.  There may be a physical cause to the pain, but if the emotional components are not controlled, then the pain is not controlled.

Comprehensive Treatment

Since pain, anxiety, and depression are intimately linked in the brain, comprehensive pain care involves treatment that is aimed at all aspects.  A comprehensive pain program looks at both physical control of pain and emotional control of the consequences of pain.  These programs link psychological approaches to pain, with physical methods.  A pain psychologist is often involved in patient treatment.  Medications for chronic pain that affect both physical signals of pain and emotional components then become understandable in their effectiveness.

Pain is a complex medical issue.  It has both physical and emotional components.  The physical side is the tissue damage and perception of signals.  The emotional side is the anxiety and depression that is linked to the chronic pain signals.  Treating chronic pain, due to its emotional components has long involved a multidisciplinary approach that includes psychological management.

How to Relieve Pain from Rheumatoid Arthritis

/ Thomas Cohn, MD

joint painRheumatoid Arthritis (RA) is an autoimmune inflammatory disorder that affects the joints.  It can cause painful swelling and deterioration of the joints.  It is often symmetrical, starting in the smaller joints and moving to larger joints as the disease progresses. RA impacts the synovium, the lining of the joints and eventually the cartilage, causing thickening and destroying the joint structure and alignment.  The damage is caused by inflammation, which is triggered by the body fighting and destroying the joint tissues.

Inflammation & Pain

RA is an inflammatory process.  Inflammation itself is painful.  Whenever a person has an injury, inflammation occurs.  In injury cases, this is a limited process, as the damaged tissue heals, the inflammation disappears, and the pain resolves.  In rheumatoid arthritis, the joint inflammation is an ongoing process.  Therefore, as long as joints become inflamed, pain can be a problem.

The diagnosis of rheumatoid arthritis is made based on exam and the findings of inflammatory markers in the blood being elevated as well as the finding of specific blood markers for rheumatoid factors.  The disease can be followed by the extent of inflammation, and whether the markers in the blood for inflammation are controlled.

Controlling Pain from Rheumatoid Arthritis

In the past, controlling rheumatoid arthritis was very difficult. Originally the main medications were steroids that had many side effects, especially when used long term.  Pain medications could control symptoms, but had no effect on the disease.  About 30 years ago, some cancer drugs were being used to control the immune system and these decreased the activity and severity of the disease.  In the last ten years, a number of drugs have been developed that specifically suppress the immune system.  These drugs, when they are effective, do a remarkable job at stopping inflammation, and markedly slow or eliminate the joint destruction.  When inflammation is stopped, minimal pain is present and there is no need for additional pain medications.

Controlling the disease process with the appropriate medications is the key to management of rheumatoid arthritis.  If you have RA, the disease should be managed by a Rheumatologist, a doctor specializing in the management of these types of conditions.  Pain is a characteristic of inflammation. If pain is present, this usually means that medications need to be adjusted to better control the disease.  Rarely, when RA is well managed, will a patient need any additional pain medication.