Opioids For Long-Term Pain Relief

March 12, 2018 / Thomas Cohn, MD

The latest copy of the Journal of the American Medical Association has a lead article on the use of opioids in the long-term management of low back pain. The article is a study of some 200 people who were managed either with opioid-type medications or without them. The conclusion was that there was no difference in level of function with the use of opioid medication.

There is a large problem with this study, since it does not distinguish between the wide variety of patients who have back pain. Back pain can be due to everything from spine problems to nerve damage and residual surgical issues. As it has been preached multiple times, opioids are only one tool in the treatment of back issues and there are often many different strategies to control pain.

Opioids and Back Pain

The reality of life is that many different things can cause pain, and treatment should be aimed at the cause of pain. Depending on what is causing the sensory complaints, management will vary based on the individual’s needs. A combination of strategies is often necessary to treat every different component contributing to a problem. Treatments may be simple, such as ongoing exercise, to complex, including injections and surgery. Sometimes simple strategies fail and the only medication that does help are opioids. Since these drugs have tremendous problems, they often are not a good solution especially for long-term use. Pain specialists often know a wide realm of treatment options and can help lead one to better choice or a combination of choices.

The biggest problem with the use of opioids is that they are cheap and they have been pushed in the United States as a great, inexpensive tool to manage any type of pain. It takes a lot of work to manage pain, and in this country many have opted out of the challenges. On top of the drug companies pushing these medications, often the insurance companies are equally complicit by not allowing treatments that may be more expensive. Everything from physical therapy, massage, chiropractors, acupuncture and even fitness centers with athletic trainers are often more beneficial than many medications and may well be cheaper. However, most insurance companies turn a blind eye towards alternative treatment strategies. Now that opioids are a problem, insurance companies still want to say no to alternatives to drugs, but are not willing to pay for the better alternatives.

Alternative Treatment Options

The important message from the study of opioids is that for most people there are better treatment strategies than these drugs for the management of pain in the long term. For short-term, these medications may be okay. For surgery and several days immediately afterward it may be reasonable to use them. After that time period, medications that are not addictive may be used with the strategy to return the body to normal functional patterns. The body needs to move and relearn normal movement and function. As the body moves and functions as it was originally designed, the body acts appropriately and does not generate pain sensory signals.

If you have a body that cannot move and function normally due to permanent changes, these may constantly send sensory signals that are interpreted as pain. Designing treatments that bring the body as close to normal motion and function as possible can reduce pain. This is difficult and requires significant effort; rarely is there a magic pill that performs this function. If one gets past the thought that life is pain free and then focuses on making life as close to ideal motion and function, then one can improve their quality of life.

The last take home message is that medicine needs to understand that some people honestly have tried everything available to treat their problems and nothing has worked. If they have worked with a legitimate pain expert, sometimes it is found that opioid medications are appropriate in the management of a problem long term. This should be considered a last option in most cases. Hopefully our culture will get a more realistic understanding of opioids in the management of pain and all those involved in treatment will support the use of reasonable alternative strategies. Initially it may not be cheaper, but a healthier society is likely the final outcome.

Chronic Pain Makes School Difficult For Children

March 8, 2018 / Thomas Cohn, MD

Although the findings may not be all that surprising, new research shows that children with chronic pain are significantly more likely to deal with life events that can contribute to poorer school performance.

According to the research, 81.5 percent of children with a history of chronic pain reported dealing with at least one adverse life event that could have impacted their school performance. Children with chronic pain were more likely to report:

Missing school due to not feeling well.
Missing school for medical treatment.
Having a difficult time paying attention in class.
Finding it hard to keep up with school activities.

Chronic Pain In School Children

As you can see, it’s clearly important for children, their parents and the education staff to develop a comprehensive care plan for dealing with chronic illnesses and flareups. These kids probably feel ostracized enough without having to feel like they’re falling behind on homework or with the curriculum. Here’s a look at some ways all of these groups can come together to ensure everyone is on the same page.

Children need to be proactive about getting homework and lesson plans from the classes they’ve missed.
Parents need to stress the importance of getting homework and ensure children aren’t missing assignments from missed classes.
Parents need to talk with school staff about the child’s potential health issues so it’s on their radar.
School staff need to realize that children aren’t using their chronic condition as a crutch or an excuse.
Parents and children should ensure they get a doctor’s note for medical appointments during class.
If homework extensions are needed, let the teacher know as far in advance as possible.
Consider supplemental education resources, like tutoring or extra credit.
If any party has concerns, they should be brought up sooner rather than later so there aren’t any misunderstandings.
Once you find a routine that works, do what you can to stay in that routine.

Chronic pain can be tough to deal with, but it’s even more difficult if you’re a kid in school trying to learn and make friends. If your child needs help with any aspect of their chronic pain care plan, reach out to Dr. Cohn’s office today.

Staying Healthy and Fit as We Age

February 26, 2018 / Thomas Cohn, MD

Staying fit and being healthy as we get older usually requires work. There’s always the tale of someone who smoked a pack of cigarettes a day, drank a six pack every night, ate whatever they wanted, sat on the couch and lived to ninety years. A few people having amazing genetics and nothing affects them, but this is not the norm. Most people need to take an active approach to life including fitness, diet, rest, and stress. Health is about paying attention to our lives and reducing harm as well as maintaining our bodies and minds.

Your Body is Like A Car

My favorite analogy is that our bodies start out like new cars and generally are like that until we reach adulthood. A new car needs fuel and very little maintenance to keep it running well. If you do not wreck it, the car will run smoothly for our younger years. As the car ages, more and more routine maintenance is needed and as it gets older, major overhauls are sometimes necessary. When we are young, we feed the body and let it run and generally it will be healthy. As a young adult, we need to start doing some general health care such as monitoring our cholesterol and blood pressure, and start purposefully watching things like what we eat, our exercise, and make sure we sleep and reduce our stress. After we turn fifty, technically the body is in old age range, and maintaining our health is needed to keep us running smoothly.

In the 1800’s, the average life expectancy was between forty and fifty years of age. Death was due to injury, trauma, infections, heart problems, cancer and multiple other issues of the time. Since then we have learned how to stay alive such that the modern life expectancy has risen to about 80 years. The caveat however is the body has not evolved much in the last 150 years, so it takes much more work to keep an old body healthy.

How to Stay Fit

Staying fit and healthy does take some work and affects a variety of aspects of your life. If it were easy and simple, everyone would know the secrets and live long without problems. The reality is that it does take effort to be healthy, and everyone is throwing in advice on ways to live. The books, diets, pills, retreats, and machines available for a price to make you live longer and happier are countless. Understanding our history can possibly help us understand our needs into the future.

Exercise is one of the most basic concepts. In the past, we did not sit at desks all day. Rather, we were very active and often constantly moving. Since our sources of survival and income have changed, our amount of activity and movement has plummeted. As we age, exercise to maintain our bodies are essential. Daily stretching for 10 minutes or more is necessary to keep the flexibility of muscle and joints and the health of these tissues. Stretching markedly reduces stiffness and associated pain from muscles, ligaments and joints.

Strengthening is the next pillar needed to maintain the health of muscles as well as bones and other structures in the body. Light strengthening three times a week for 20-30 minutes is needed to maintain muscle and bone health as well as to reduce injury from unexpected events like falls. Lastly, the body needs aerobic conditioning to maintain health including for the heart, blood pressure, muscle endurance, weight control, and to reduce pain from increased endorphin levels and stress reduction. The overall recommendation from the American Heart Association is 30 minutes of exercise 5 times a week, from a simple walk to an intense workout.

Diet and Sleep

Our diet is the fuel that runs our bodies. If we put the wrong fuel in our cars, they won’t run, and it is the same with our bodies. It is becoming clearer that our nutrition plays a huge role in our health. As a doctor, unfortunately we learn very little in out training about diet and nutrition. Curiosity about the subject has slowly been very enlightening. Eating better does take more planning and understanding, especially about processed food, sugars, fats, carbohydrates, and other essential nutrients. Spending some time to read and understand healthy diets helps improve the ability to control the fuel entering your body. Even an old doctor can educate himself; using my drive time to work and back, I am spending time listening to courses on nutrition.

Sleep is one subject we know we need but understand very little about. The purpose of sleep, how much we need, and whether the measures we have are helpful and accurate is debatable. Children need more sleep than adults, and adults often need more than we get nightly. Somewhere over seven hours is recommended every night for adults. Sleep is used by the brain to restore functions, to clean up waste products and to rest the whole body. What constitutes as “quality sleep” is not very clear and those sleep trackers that monitor body motion at night are not accurate, according to most experts. Feeling well rested the next day is probably a reasonable sign of adequate rest.

Lastly, having good mental health is necessary to stay fit. Society tends to ignore our mental health needs. Good mental health is needed to stay physically healthy. The body is dependent on the brain for good function. Emotional health is the part that emanates from the brain that allows us to function well physically. When we are stressed, anxious, depressed, or suffering psychologically, we often cannot put in the energy to maintain physical well being. Once we improves our psychological state, we often can focus our energies to pay attention to the rest of our life. Whether it is meditation or medication that is necessary for good emotional health, without paying attention to our psychological selves, maintaining good physical health is difficult.

Staying healthy and fit as we age requires work on our physical and mental well being. There are multiple pillars that keep up our health and as we age we need to pay more attention to these important aspects of our lives. From sleep, rest, exercise, diet and mental health, they all provide strength and structure to keep going as we age.

Penny-A-Pill Plan Proposed To Prevent Opioid Abuse

February 22, 2018 / Thomas Cohn, MD

Minnesota Governor Mark Dayton has proposed a “penny-a-pill” program in which drug companies would have to pay the state an extra penny for every pill prescribed in the state. The money raised from this tax would go towards an opioid stewardship program that provides opioid prevention, treatment and recovery services.

Gov. Dayton said the program may be able to generate $20 million a year.

“You can call it whatever you want,” Dayton said. “It means that they’re going to pay for the product they’re producing, which is causing this epidemic.”

According to data, there were 395 opioid overdose deaths in Minnesota in 2016. That number represents an 18 percent increase from the previous year, and 194 of the 395 deaths were linked to prescription opioids. The CDC also notes that there are 47 opioid scripts written for every 100 Minnesotans.

One Of Many Changes

The penny-a-pill program is just one of a number of changes aimed at reducing the number of opioid overdoses and deaths here in Minnesota. Two months ago, the state announced new guidelines that affect how area physicians write prescriptions for painkillers. The new guidelines suggest that physicians should:

Prescribe the lowest effective dose and duration of opioids when used for acute pain.
Monitor the patients closely, including prescribing opioids in multiples of seven days.
Avoid initiating chronic opioid therapy, make it so long term prescriptions would include face-to-face visits with the provider at least every three months.

Additionally, Minnesota wants to renew the focus on educating physicians, patients and their families on the potential dangers of opioids, as well as how to spot the signs of a problem.

“One opioid prescription can start the downward spiral in the right person,” said Dr. Rahul Koranne, Chief Medical Officer for the Minnesota Hospital Association.

Minnesota is actually one of the better states in the US when it comes to regulating prescription opiods. The state prescribes the fifth fewest opioids in the nation, which speaks volumes considering there are 47 scripts written per 100 Minnesotans.

Do you think the penny-a-pill program is a good idea? Leave your thoughts in the comments section below.

The Unforeseen Opioid Issue

February 5, 2018 / Thomas Cohn, MD

This week, another issue of opioid use to control pain came to light in the news. In a suburb of Minneapolis, a patient was in a nursing home type facility. Along with whatever issues brought them to the facility, apparently they had pain and were receiving opioid medications. At the nighttime dose, a staff nurse, probably in a hurry, gave a huge dose of the medication instead of the proper dose without noticing the mistake. By morning the patient was dead from an overdose. All opioids can cause breathing problems especially in those who are sick, and too much medication can easily be deadly.

The overdose of anyone by a person administering medications is unfortunate and should never happen. Two lessons are clearly evident. First, always double check to make sure you are taking the right medication and dose, and second, be aware that these medications are dangerous. When prescribing opioids, medical personnel should always be careful on how much medication is being prescribed and try to avoid giving excessive dosages.

If there are no alternatives, then be careful. Evaluate for medications that may interact with the opioids, such as sleep medications that may suppress breathing or anxiety medications. Check the person’s history for other medical conditions that affect breathing, like lung disease and sleep apnea, since opioids may disrupts breathing patterns. Make sure the person is mentally capable of taking the medication correctly, and that they are not suicidal, depressed, or dealing with dementia, because this too can also lead to an opioid overdose.

Narcan’s Role In Preventing Overdose Deaths

Besides the above and a bit of common sense, preventing opioid overdose deaths is important. Many providers are adding a prescription of Narcan nasal spray when writing scrips for opioid medications. This is a medication that can block the effects of opioids and reverse its medical effects completely in the body. Narcan can block the respiratory or breathing problems from an opioid, but it will also reverse any pain relief. It is easy to deliver, it is shot as spray up the nose and will quickly reverse only the opioid-induced problems. However, for the new synthetic opioids like fentanyl or carfentanyl that are being abused with heroin, multiple doses may be needed in treatment.

Now, anyone receiving any significant amount of opioid for pain should receive Narcan nasal spray. The person who is normally taking the opioid may not need the Narcan unless they accidentally take to much medication. Otherwise, if someone else in the home of the opioid user takes the medication on purpose or by accident, the Narcan can be used to reverse the opioid and prevent death. As always noted, opioids are not ideal pain medications and can be easily deadly. Having and using Narcan in cases of emergency can prevent an untimely death.