Obesity, Doctors and Diets

September 27, 2018 / Thomas Cohn, MD

Everyone knows how hard it is to be obese and lose weight. I recently was sent through one of my many websites that I watch an article first published by Huffpost on obesity. It was a long article on how society views and treats obesity. I am not sure about the goal of the overall message, but it did bring up some interesting ideas.

For the person who is obese or wants more insight into a different perspective on obesity, this is a good article. As a physician, I am always trying to learn something new, and medical resources are not always the most interesting. Finding a layperson’s view on the subject is often enlightening, and that’s what I found in this article.

Obesity is a major factor in society. It can affect physical and emotional health. The above article talks mostly about the psychological and emotional impacts of obesity. It barely touches on why there are so many people who are obese and struggle with weight loss. There are a few messages about our diets and how many of us view food buried in the article. The majority of the article is about our attitudes about obesity. The message overall is maybe many of us need to rethink our understanding of the struggles of obesity.

Rethinking Obesity

If you’re overweight or obese, the prospect of losing weight is likely on your mind, but it an be intimidating to even take those first few steps towards a healthy lifestyle. Aside from societal pressures, most people lead busy, active lives that don’t always allow us to put our health first. Long hours at the office, driving the kids to and from practices and running errands throughout the week doesn’t always leave us time to get our exercise or cook healthy meals. There are a number of factors working against our ability to lose weight.

That can make the prospect of losing weight seem daunting, so much so that we’re afraid to take the first step. But we need to understand that losing weight isn’t about ALWAYS making the right dietary and exercise choices, it’s about making more right choices than we did in the past. We need to come to grips with the fact that we’re not going to lose 20 pounds in a week. But if we can make small changes – changes that aren’t life altering and are thus, sustainable long term – we can lose half a pound or a pound a week. This will eventually become a new normal, and although your weight loss journey may take longer than initially expected, you’re more likely to end up with sustained results.

Too many people dive headfirst into a diet routine that is simply unsustainable. They start by dramatically cutting calories and exercising hours each day, and while that may lead to five or more pounds of weigh loss in the first week, it’s highly unlikely that you’ll be able to sustain that. Slowly you’re going to start eating worse and working out less, and eventually you’re going to be back to square one because you’re gradually making poorer health choices instead of making smaller, more sustainable choices.

For example, small steps can simply be something like avoiding snacking after 7 p.m., or subbing out your afternoon soda with water. Make small, sustainable changes right away, even if it doesn’t immediately lead to you having a calorie deficit for the day. It’s much more likely that you can stick with these changes and keep moving the needle in the right direction instead of believing you can exercise for two hours daily and cut your calorie intake in half.

We need to rethink obesity and how we tackle the issue if we want to be successful in our weight loss journey.

Genetic Testing And Its Role In The Chronic Pain World

September 17, 2018 / Thomas Cohn, MD

Genetic testing is one of the hot new topics in society and medicine. There are multiple companies providing a variety of types of genetic testing and for a wide assortment of circumstances. The most common we here about is for determining our heritage and background.

These are meant to tell us roughly what our genes tell us about where our ancestors are from Most of these genetic tests take a very small look at selective areas of our chromosomes and do not perform a comprehensive analysis. The tests usually look at select genes that control a limited number of proteins in the body, not even a full one percent of the genetic information on our chromosomes.

These genetic tests that are marketed to consumers have limited value beyond curiosity for the average person. The accuracy is probably as good as a well researched family tree at best. Last year, a couple of these tests were done on a set of identical triplets. These three women have exactly the same genes, but the profiles produced from the genetic tests were not close to being identical. The take home message is that these tests are not at the level that they should be trusted beyond just stoking curiosity in one’s heritage. Any information above that level is mostly speculative.

The common genetic testing companies include 23 and Me as well as Ancestry.com. Besides providing basic information about likely ancestral history, they now are reporting the risk one might have toward some diseases. These include risk of Alzheimer’s and some types of cancer. However, most of these tests have recently been shown to have a false positive rate of 40 percent or higher. This is a result of these tests looking at only a small portion of genes in the total amount of chromosomes, and this approach is not very accurate. Further, these companies that are doing this commercial work often are not following procedures that have adequate quality controls. Thus a significant amount of false information is now being rendered to the average consumer, prompting often further expensive medical testing for the truth.

For the paranoid, these genetic testing results are often in public databases. Your genetic code is now available to the world and without your permission others could access this personal information. In the future this may be the next reason for a denial for insurance since you may have a gene linked to a “possible” medical disease. The government is certainly using the information in cold case databases. The “Golden Gate” murderer in California was traced down through this method. The next venue will likely be paternity cases for adoptions and artificial insemination or similar circumstances.

Medical Value of Genetic Testing

In the medical world, genetic testing does have some value, but in specific areas. The most significant so far are two general areas, identifying diseases that are genetically linked, and to help with finding the right medication for a person. In pain medicine, the ability to process certain medications to be effective in the body sometimes requires certain enzymes. For instance, the ability for hydrocodone (Norco, Vicoden, or Lortab) to be effective requires an enzyme to convert it to an active drug. Without that particular enzyme, hydrocodone is ineffective. Interestingly, all my children happen to be missing the enzyme and when they have had surgery they have had to explain this to all their treating physicians. Another common problem is that certain enzymes are needed to make some antidepressant drugs helpful. If the medication is not working, the patient may not be able to effectively use that particular class of drugs. Most of the time it is more effective just to switch to a different medication than to try to do testing, however if a simple switch does not work, then enzyme or genetic testing may be indicated.

Certain medical diseases definitely are genetically linked. Random genetic testing in someone who does not have medical issues is likely to be costly and currently not especially useful. However, if the person has significant medical issues, clearly identifying a known genetic disease can be helpful in order to know what future issues may be likely. Many of my pain patients happen to have hypermobility of the joints that is linked to abnormal connective tissue. There is a wide range of severity, but it can lead to significant problems from spine curvature, to eye problems and cardiac or vascular aneurysms. It is also often a dominant trait and can pass on to 50 percent of a person’s offspring. Knowing the disease can help in the long-term care and prevention of dangerous complications.

For the curious about ancestry, genetic testing can be fun, but the information may or may not be overly accurate. Know that the information may become part of a public database and the future problems of others knowing this information about you may have a negative impact on your life. If you have certain medical conditions, genetic testing now may become helpful in managing your disease. If you are having problems with a medical condition, sometimes looking deep into a person’s genetic code may reveal helpful guidance, but this should be done with the help of an appropriate medical professional.

Injections and Blood Thinners

September 10, 2018 / Thomas Cohn, MD

53793176 – render illustration of blood thinner title on pill bottle, isolated on white.

A number of patients, for a variety of reasons, are on medications that are considered blood thinners. Many patients have heart conditions that require them to be on a medication to reduce the risk of blood clots. Stopping these medications can cause multiple problems from clotting of blood vessels to pulmonary embolisms and strokes. Being on blood thinners can cause bleeding problems with or without medical procedures. The big question is whether a specific interventional procedure has more risk for a bleeding complication or whether it is safer to stop the blood thinner for the time being.

Up until recently, the decision to halt blood thinners was based strictly on the risk of bleeds in the surgical acute care settings. Many times injection procedures are done without imaging guidance and have definite risks based on the location of needle placement. Procedures for pain management are usually done with fluoroscope guidance and often are done to structures that have low risks for complications from bleeding. Until recently, risks were determined based on the rate of complications seen in the surgical procedures, and then the risks were estimated for the interventional procedures.

New Information

Recently, several researchers have actually studied the risk of many interventional procedures on blood thinners and also studied the risk of complications from stopping blood thinners. For most experienced interventional pain doctors, they can site cases from their own experience of complications from stopping blood thinners and bleeding problems. Stopping blood thinners does cause problems with strokes and with blood clots forming in harmful places. Fortunately after over 50,000 injections, only a couple of times has a problem occurred in my practice.

The latest research has been done in Pennsylvania. One hospital system in a part of the state has enrolled virtually every person in the area, thus allowing one to study the characteristics of various problems. The first thing the researchers did was find all the people on blood thinners. Then they looked at the incidence of complications from stopping blood thinners for any medical procedure, and the number is about 0.75 people per 1,000 for a problem like stroke or blood clot of some type.

Then they looked at the risk for bleeding with typical injections that are thought to be low risk for bleeding, like joint injections, transforaminal epidural injections and medial branch blocks. The findings were that only minor bleeds occurred and the overall risk of bleeding was 1/4,000 people. That means it usually is more dangerous to stop blood thinners for most interventional procedures for the patient than it is to continue them. For a patient on blood thinners, it means they should be concerned whether the procedure they are undergoing needs to have their medication stopped.

In my practice, if I know a patient is on blood thinners and the procedure is low risk, I will not stop blood thinners. Not many physicians are comfortable with this as of yet since the research is not widely distributed. If as a patient, you are concerned about stopping a blood thinner, it is wise to ask whether it is necessary to stop the blood thinner and whether the procedure can be done in such a way that bleeding is not a significant risk. Sometimes a different approach to an injection will decrease the risk of bleeding. Lastly, a physician who is very experienced with injections will usually be able to place a needle for injection with less trauma due to their ability to overcome obstacles of the anatomy in the area. Experience does count and being specially trained in the area of interventional pain medicine helps with being up-to-date with the changing standards of care for challenging patients.

Are Corticosteroid Injections Safe?

September 4, 2018September 4, 2018 / Thomas Cohn, MD

Every year, the majority of physicians need to attend continuing education courses. Sometimes these are online or via written materials, while others are seminars. This year I am on my second course, because unfortunately not all work qualifies for credits. The last course was extremely educational, but was sponsored by a medical corporation and therefore did not qualify for credit.

This week I am again gone from the office attending a conference. One of my goals is always to bring back some pearls to my practice. The first subject I’ve been learning more about is steroids and their role in a patient management program.

Steroids and Their Safety

The main question is whether the corticosteroids that are used in pain injections are safe for the patient. The answer of course is complicated. In a pain practice, corticosteroids are used to bring down inflammation. There are many different types of steroids, as those used for pain control are different from steroids used to build muscles or control hormones. Corticosteroids not only decrease inflammation as well as pain, but can also do many other things in the body. The problems they caused were discovered mainly due to their use for other conditions.

Conditions like asthma, lung disease, and rheumatoid arthritis were all previously treated for years with oral, injected and IV steroids. From their use, we slowly learned some of the issues with these medications. The most obvious was the problems with blood sugars and diabetes. Steroids can make blood sugars elevated, usually for only several days when used in the spine or joints, but sometimes for several weeks. Corticosteroids can also alter the function of the balance of normal hormones in the body, causing problems with blood pressure, emotions, and female or male hormone balance.

One of the biggest worries of with the use of steroids is the cumulative effects like bone loss. Osteopenia and osteoporosis are the bone loss problems that can be increased over time with the use of corticosteroids. As people age, the natural function of bone growth changes and many people develop bone loss. The use of corticosteroids can increase the rate of bone loss. Now it is known that there is a yearly amount of steroid-type injections to try to stay below. That is between 4 and 6 shots total.

Too much steroid can increase bone loss and make osteoporosis worse. The problem with osteoporosis is that bone fractures can become more common. It can lead to problems like broken hips from a fall to spontaneous vertebral body fractures in the spine. The vertebral compression fractures can be fairly painful and cause spinal deformities.

The bottom line on the use corticosteroids in the management of pain is that they are not fully safe, but they can be used as part of an overall strategy to manage painful conditions. The total amount of steroids should be monitored, and if a person has had a number of incidents of exposure to this medication, then monitoring for side effects is necessary. If one is a diabetic, blood sugars should be watched whenever using these medications.

Most people may need to be watched for bone loss, and then bone density monitoring is necessary. Osteoporosis is a silent disease with only 25 percent of those who have it being aware of the problem and seeking treatment. Since pain physicians often use the medication in their injections, it should be a routine concern to monitor patients who are receiving shots. If you are at risk for bone loss, make sure that your doctors test you for it, it can even happen to young and seemingly healthy individuals.

That’s all for now, off to another conference lecture!

Dr. Cohn

Opioid Prescriptions Reach A 15-Year Low

August 29, 2018 / Thomas Cohn, MD

The number of opioid prescriptions in the United States has fallen dramatically, and prescriptions now sit at their lowest levels since 2003 according to new data from the Food and Drug Administration.

The data shows that 74 million metric tons of opioid analgesics were dispensed in the first six months of 2018, down more than 16 percent from the first six months in 2017. Although opioid prescriptions have been declining for the past couple years, the bigger decrease in 2018 is likely linked to lawmakers, doctors and patients working against the problem of opioid dependence.

“These trends seem to suggest that the policy efforts that we’ve taken are working as providers, payers and patients are collectively reducing some of their use of prescription opioid analgesic drugs,” said FDA commissioner Scott Gottlieb, MD.

Not All Good News

If we just look at the headline, it’s easy to infer that this is good news. Fewer patients relying on passive and potentially dangerous treatment options should be a good thing, but there are some drawbacks. For starters, the opioid crackdown is undoubtedly hurting a section of patients who use these medications properly and need them to control their discomfort. I’ve talked to patients who have found it harder to get the medications they rely on, and it’s troubling. Good people are getting caught up in the crackdown on opioids.

Perhaps more shocking is that despite the sharp drop in opioid prescriptions, opioid overdoses continue to rise. Although the data from 2018 wasn’t available, nearly 49,000 Americans died from opioid-related overdoses in 2017. This includes overdoses from fentanyl and heroin, which can be eventualities for individuals who become addicted to opioids.

“It isn’t necessarily the case that more people are suddenly switching from prescription opioids to these illicit drugs. The idea of people switching to illicit drugs isn’t new as an addiction expands, and some people have a harder time maintaining a supply of prescription drugs from doctors,” said Gottlieb. “What’s new is that more people are now switching to highly potent drugs that are far deadlier. That’s driven largely by the growing availability of the illicit fentanyls.”

Police data shows that a record amount of fentanyl (1,640 pounds) and heroin (5,500 pounds) have been seized by law enforcement this year, and we’re not even two-thirds the way through the calendar year.

Clearly we’re still losing the war on opioid overdoses, even if we hear headlines that suggest prescriptions are at a 15-year low. Chronic pain patients are caught in the crossfire, and overdose-related deaths continue to surge. We need to invest more money into understanding and treating chronic pain conditions in order to really make a difference.