Kratom and Chronic Pain

January 10, 2018 / Thomas Cohn, MD

kratom Every once in a while the herbal supplement kratom makes the news. Last November the FDA decided to classify kratom as a schedule 1 drug like heroin or marijuana, but after some opportune lobbying, the decision was put on hold. It is a substance that has been around for hundreds of years, mainly in Southeast Asia, and what it is and what it does is still poorly understood. Recently, some have claimed that it has the potential to be helpful in managing pain and opioid withdrawal.

The Truth About Kratom

Kratom is an herbal substance derived from the leaves of a Southeast Asian tree of the Mitragyna species, which is an evergreen. The leaves are either chewed or used to make an extract. Traditionally, in Southeast Asian cultures it was used for wound healing, coughs, intestinal infections, and to relieve stress and enhance moods, especially for those in boring repetitive labors.

The effects of kratom are dose dependent. At a low dose it acts like a stimulant, and at moderate to high doses it can act like an opioid. Even at low doses it can cause problems like:

anxiety
agitation
nausea
loss of appetite

At high doses, especially on a frequent basis, serious side affects can occur similar to problems with opioids including hypertension, weight loss, constipation, and even seizures and psychosis. Sudden stopping of high dose kratom can mimic withdrawal from opioids. The full pharmacology has been studied only in animals.

Kratom was first reported as an opium substitute in Malaysia and Thailand in the early 1800’s. From the traditional use, it has now become an herbal substitute for opioids for either managing pain or for withdrawals. In most of the world its sale and use are either controlled or prohibited. In the United States, the DEA was going to list it as a Schedule 1 drug like heroin, but due to legislative pressure they decided to leave it alone. In November of 2017, the FDA noted concern about sales and marketing since it can have serious side effects. Further, there have been no quality scientific studies on the effectiveness of kratom for either pain or prevention of withdrawal.

Substances like kratom should be considered very carefully before use. Like any herbal substance, this is not a pure drug and its potency can vary. The difference between an herbal substance and a medication like ibuprofen or aspirin is the dose and chemistry is fairly well understood with predictable effects. A dose of a herbal substance like kratom may be variable and the effect can be as toxic as regular use of opioids.

There may be beneficial properties to kratom, and further actual scientific studies would be useful. Perhaps a pure extract someday may lead to a very helpful compound to treat pain. However, until further understanding is determined, kratom use may be fraught with the same issues of any other opioid-type compound.

The Gender Disparity of the Opioid Crisis

January 8, 2018 / Thomas Cohn, MD

A recent opinion piece in the Star Tribune shined a light on the problem different genders face in the opioid crisis, particularly the challenges faced by women.

One of the main talking points is that deaths from opioid overdoses have increased much faster for women than for men. Female deaths from opioid overdoses have increased 400 percent in recent years compared to 265 percent for men. Both of these numbers are very problematic, but it helps to show that the opioid crisis is affecting each gender differently.

When opioids affect women, it can oftentimes have a bigger trickle down affect than when it affects men. As the article states, in most American families the woman is the primary caregiver, and the woman’s well-being is often closely tied to the health and future of the children. Opioid abuse by the primary caregiver can often lead to problems down the road for the children, and it increases their likelihood of having their own battles with substance abuse. When opioids negatively affect women, it rarely impacts just one person.

Fixing The Problem

The article went on to suggest some ways to reduce opioid disparity and the larger problem of gender-based health disparities in the United States. Some of the proposed solutions include:

Addiction risk education for doctors and patients
More education has led to fewer opioid prescriptions and in some places, a downturn in overdose deaths
Better emergency room treatment
Education campaigns to change dosage standards for women
Increased doctor education in states where women disproportionately suffer from conditions like obesity, high blood pressure, diabetes, chronic pain and heart problems
Stop cutting insurance coverage for certain programs like Medicaid and Medicare

It’s clear that there’s no one-size-fits-all answer for fixing the opioid crisis and gender-based healthcare disparities throughout the country, but the first step is to help spread awareness that a problem exists. Then we need to put a plan of action in place and stop making the bottom line a higher priority than the health of the patient in our office.

Opioids certainly have a place to help patients when properly assigned and administered, but far too often they are being blindly prescribed and without safety measures in place if abuse begins. The Star Tribune article is a step in the right direction by calling attention to the problem, but now we need doctors, patients and our legislatures to follow through. For the sake of women and families across the country, I hope we can work towards a solution.

Loneliness and Chronic Pain

December 22, 2017 / Thomas Cohn, MD

Chronic pain is difficult to manage for a variety of reasons, and pain is only part of the problem. Chronic pain disrupts your social life, and it can leave you feeling isolated or with feelings of loneliness. Maintaining a healthy mindset and combating these feelings of isolation are key in treating the whole issue of chronic pain. Today, we share some ways to avoid feeling alone if you’re dealing with a chronic condition.

Preventing Isolation With Chronic Pain

Here are some things you can do if you’re feeling like your chronic pain condition is making it difficult to connect with the outside world:

1. Join A Support Group – The key to avoiding feelings of isolation when battling a chronic pain condition is to remember that you are not alone. At times it may seem like you are alone, but there are so many others dealing with the same condition. Ask your doctor if they know of any support groups for people living with your condition, or perform a simple online search. Odds are a support group is only a couple clicks away!

2. Lean On Close Friends – Not everyone is going to understand what you’re going through, and that’s fine. However, odds are you have a couple friends that are sympathetic and understand what you’re going through. Make plans to connect with these people, even if it’s just once or twice a month for coffee. Pain can sometimes interrupt these plans, but your close friends will understand and adapt, and making plans gives you something to look forward to instead of just dwelling on your pain condition.

3. Exercise – Exercise releases endorphins in your brain that can enhance your mood, and it also gives you a sense of accomplishment. Pain can make exercise difficult, but odds are you can find a few exercises that you can perform without pain getting in the way. Exercise also helps to combat chronic pain, so aside from helping put you in a positive frame of mind, it’s also helping you fight against chronic pain.

4. Talk About Your Emotions – Don’t bottle up your emotions. It’s helpful to talk about your feelings and vent about your frustrations when it comes to chronic pain. If you don’t want to talk to your friends or family about your feelings, bring them up to a doctor, your support group or a therapist. It’s important to remember that these feelings are normal, but hiding them or trying to mask them can actually make them worse. You’ll also feel more connected with others if you open up to them about what you’re going through.

For more tips on combating feelings of loneliness or isolation, reach out to Dr. Cohn and his team today.

Concerning Behaviors Associated With Pain Pill Abuse

December 14, 2017 / Thomas Cohn, MD

Opioid management is probably the most charged topic that we talk about frequently on our blog. Many of our patients and readers take some type of opioid medication to help manage their pain, and they get nervous or angry when they hear big government talk about restricting opioid access due to an increase in overdoses. The majority of people take their pain pills responsibly, and they are concerned that the minority who are abusing pills will make it impossible for them to get the opioids they depend on.

Opioids certainly have value in a pain management program, but we also don’t believe they should be the only treatment option that is being tried. And if you are going to take opioids, you need to be sure you use them responsibly and they aren’t abused by others in your home. One way in which doctors and family members can help stop painkiller abuse is by looking for certain concerning behaviors that are often associated with opioid abuse. We take a closer look at some of those behaviors in today’s blog.

Behaviors Associated With Pain Pill Abuse

Here are some of the behaviors that doctors and family members can look for that may suggest a person is dealing with a substance abuse or pain management problem:

Missing appointments.
Taking their pills for something other than pain.
Using more medication than prescribed, or asking for a refill before the prescription end date.
Repeated inquiries to get an increased pill dosage.
Being aggressive or hostile to healthcare staff or family members.
Taking medication in combination with alcohol or other drugs.
Lack of participation in other treatment modalities.
Bouncing around from doctor to doctor or clinic to clinic.

If someone you now is demonstrating a few or all of these behaviors, reach out for support. Contact Dr. Cohn or reach out to your specialist to learn ways to talk to your loved one about painkiller abuse and how to get them the help and support they need. It’s never an easy conversation, but it’s one that needs to happen.

The consequences of painkiller abuse can be deadly, so don’t sit back and do nothing. Contact a healthcare provider or addiction services center to ask about the next steps in the process. We’ve also compiled a few links that you can check out if you suspect that a friend or family member is abusing pain pills. Please don’t hesitate to reach out if you have any questions.

Thoughts On Attending The Latest Pain Conference

November 20, 2017 / Thomas Cohn, MD

Every physician is required to obtain continuing education credits. Depending on a when one was board certified, the types of boards one has, and what state you live in, the number of credits needed each year varies.

At least once a year, I try to attend some sort of conference in order to to add to my knowledge about how to treat pain. This year I have ventured into the new realm of the American Society of Regional Anesthesia (ASRA). Since pain care crosses the line into a number of different disciplines, one of the best ways to improve is to pick up knowledge outside your normal specialty.

Thoughts From The ASRA Meeting

For the last several days I have been at the annual pain meeting of the ASRA. It is a group of about 5,000 practitioners, which is actually one of the smaller major groups involved in pain management. Each group has a different focus, and finding a good balance is hard. So far I have enjoyed the meetings; it’s like being back in an intense school all day long. Best yet, most of the information has been very relevant to my regular practice. It also has included a lot of practical knowledge, and there hasn’t been too much esoteric academic information or stuff aimed at an someone just beginning to practice pain medicine. Many of the pain conferences are aimed at physicians who do not do any advanced procedures or only at physicians doing injections, and both extremes can be lacking balance for patient treatment.

One of the most important things a conference does is challenge your thinking. Hopefully questions are entering your mind about what can you improve upon and how to do better patient care. A conference like this is great. It is not focused on a single topic and there are many areas of my practice it could impact. General topics have ranged from very specific aspects of implantable pain technologies to the best ways to evaluate and treat very specific medical problems. One odd topic that has caught my interest is how to deal with changing government regulations to prevent burnout of physicians.

The hot topic at any of these conferences is now opioid use and abuse. However, at a pain conference it is not about a crisis of addiction, but a crisis of lack of treatments available to treat complex pain. The money is being spent on addiction management and not finding treatments that would manage the root cause of pain, and thus markedly reduce addiction.

The hardest thing at a conference (besides sometimes staying awake) is trying to sift through what is truly good information. After going to enough of these conferences, one begins to recognize those who are in it for self promotion. Every conference seems to have several people who promote the latest fad. If there is no money to be made with regards to a topic, the information is probably more science and less sales.

Learning new information is good. Missing seeing patients is tough, but the time gone is for the good of all patients in order to provide the best care. Benefits will be made on everything from what to do for patients to learning new things that may help tough patients. New treatments now will be tried for everything from CRPS to knee or elbow problems. The only sad part of going to these conferences is that often I see no other pain physicians from my location, but I’m certainly glad I went to this conference.