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.

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.

An Update On Daith Piercings

daith migraineI wrote my first article on Daith piercings about a year and a half ago. As many know, this has been advocated for the treatment of headaches. The questions I have been asked since that time have been numerous but the most common question is, “Will it work for me?” I obviously cannot tell if it work for anyone in particular. I have heard from many that it has helped them manage their migraine headaches. Most interesting to me was some of my regular patients have tried it successfully.

Daith Piercing Information

Daith piercings are a specific type of ear piercing. The ear cartilage midline toward the front of the ear is pierced. This type of ear piercing has been around for 3,000 years, but the name “Daith piercing” was probably started in the 1990’s. The placement of the piercing is at the entrance to the ear canal and has symbolic meaning as the “Guardian to the Gate.” This piercing can be quite painful, and since it is through bony cartilage, care must be given to keep the site clean and to prevent infection.

There are many types of headaches, and only certain types of headaches will respond to Daith piercings. Those most likely to improve are migraines that are sensitive to ear stimulation, and likely to be one sided in nature. Daily headaches may be caused be a variety of factors – most common are muscle tension and stress headaches. Muscle tension headaches are caused by neck muscles tightening up, often associated with the position one has while working on a computer. Stress type headaches are caused by psychological factors that make a person anxious.  The most common headache in my practice are those associated with neck problems; either from nerve and disc problems or from the joints in the neck causing pain. These types of headaches are best treated successfully by managing the underlying causes.

Managing Headaches

The headaches that have been managed by Daith piercings are those that are migraine headaches. If you have been diagnosed by a neurologist with definite migraine headache (not self diagnosed), Daith piercings may be a treatment option. Over the last 18 months of studying this subject, an interesting correlation occurred to me that this treatment was similar to acupuncture and vagal nerve stimulation. All these treatments seem to affect the vagal nerve via a branch near the ear, which sends signals back to the brain that may affect various neurotransmitters and hormones that lead to vascular headaches.

Unfortunately, the true scientific proof and medical evidence with regards to Daith piercings is not present. All the results when one researches the topic seem to be stories that it worked for them. There is some basis as noted above why it may work. For those who are interested, a few cautions should be remembered. First, this is specifically going to work best for migraine headaches. If you have frequent and sometimes severe headaches, and they are not easily managed, first see a medical doctor and possibly a neurologist and get a good diagnosis made, and try conventional treatment. The cause should be treated first and may be straight forward to manage. If the headaches are migraines, and they are not responding to management, Daith piercing may be reasonable. Physicians normally do not perform this procedure, so do not ask them to do it. Only get this done by someone who does body piercings and is familiar with this particular one. It is extremely important that meticulous care is performed before and afterwards to keep the area clean and free from infection. Since this is through ear cartilage, near the brain, an infection in the area can be very dangerous and should be treated aggressively by a doctor.

If you want to run a test before piercing, first try massaging the area of the ear when you have a headache and see if that makes a difference. Another possibility is to try acupuncture to see if that works. Most acupuncturists will report what they do is different than the piercing and this is not going to be equal to the piercing, but it may be safer and easier for a test. If you go ahead with a piercing, make sure you try to prevent an infection in the area of the piercing.

Why Pain Is Such A Complicated Process

Pain ProteinIn 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.