Overprescribing Opioids Is A Problem In Our Own Backyard

July 13, 2017 / Thomas Cohn, MD

New findings published in the Annals of Surgery suggests that clinicians at the Mayo Clinic in Rochester were routinely writing opioid prescriptions for surgical patients that exceeded regulatory guidelines currently being drafted by the state of Minnesota. The findings also uncovered significant differences in opioid prescribing among the Mayo clinics in Rochester, Arizona and Florida, as well as within surgical procedures.

Study senior author Elizabeth Habermann, who also serves as the scientific director of surgical outcomes research at Mayo, said the findings help highlight where improvements can be made.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Opioid Overdoses In America

According to the Centers for Disease Control and Prevention, the number of deaths involving prescription opioid overdoses have nearly quadrupled since 2000. In fact, more than 90 people died each day from either a prescription opioid or heroin overdose in 2015 alone.

Study co-author Dr. Robert Cima said doctors have been so focused on ensuring patients have their pain minimized as much as possible after surgery that they often don’t consider the possible long-term side effects of the prescriptions they’re filling.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said Dr. Cima, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

I have no doubt that the Mayo Clinic will adhere to the new guidelines being drafted at the state level in short order, but this story speaks to the larger issue of just how unregulated opioids are at some of the nation’s best hospitals. And if it’s happening there, you can bet it’s happening to a larger degree at lesser care centers.

However, these findings do cast light on the problem and should help push us towards a solution, but it’s not necessarily going to come from the top down. It needs to start with doctors. We need take time with each patient and push them towards active treatment techniques instead of passive treatments like opioids. Opioids certainly have their role in pain management, but they shouldn’t be over-relied on, as it appears they are.

Could We Be Pain Free In The Future?

July 11, 2017 / Thomas Cohn, MD

Although not as much money is being spent on understanding pain as doctors would like, there is still some promising research taking place throughout the world. For example, new research published in Nature Neuroscience took a closer look at re-wiring the brain’s transmitters when it mistakenly interprets signals as pain.

The research began by looking at mice who had peripheral nerve damage and chronic pain from a previous leg surgery. In these mice, a broken circuit in the pain-processing region of the brain caused hyperactivity that led to pain for more than a month. Scientists realized that the peripheral nerve damage deactivated a set of interconnected brain cells, called somatostatin (SOM), which usually work to lessen pain signals.

Fixing The Broken Circuit

Researchers were interested in learning if this connection could be fixed, and if it could, how we’d go about repairing it. One method they tried was to manually activate the SOM interneurons, and they found that this led to a significant decrease in the development of chronic pain.

“Our findings suggest that manipulating interneuron activity after peripheral nerve injury could be an important avenue for the prevention of pyramidal neuron over-excitation and the transition from acute postoperative pain to chronic centralized pain,” the authors, led by neuroscientist Guang Yang at New York University School of Medicine, conclude. They believe future drug therapies or magnetic brain stimulation could mend these SOM interneuron connections and prevent pain signals from misfiring.

The authors are cautiously optimistic, but they realize that there is a big difference in the brains of mice and the brains of humans. The study needs to be repeated and the results verified before any similar testing in humans could take place, but it’s a start.

“Our study provides, to our knowledge, the first direct evidence that impaired SOM cell activity is involved in the development of neuropathic pain,” the researchers wrote.

They hope to confirm their results and examine whether manipulating other cells could play a role in the reduction of chronic pain. If they can, we may have specific cells in which to base our intervention techniques. This is exciting.

Why Are We Treating Pain The Same As We Did During The Civil War?

July 4, 2017July 4, 2017 / Thomas Cohn, MD

It is no secret that there is an opioid problem in the United States. It seems like there is a new report being published every week on the problems with opioids in this country. This week the government published data on the number of emergency room visits related to opioid use in a single year.

The data shows roughly a 100 percent increase in the last ten years in the number of hospital visits and admissions related to opioid problems. Not surprising is that despite some differences from state to state, in general, the problem affects everyone equally – male and female, rich and poor – just like any other addiction. The focus of most data being published is on opioid addiction. Unfortunately, rarely is someone talking about some of the reasons behind the problem, especially as it relates to how the United States treats pain.

How The US Treats Pain

It is really no surprise that there is an opioid problem in the United States. Pain is a very complex set of medical issues, but unlike diabetes or cancer, very little money has been spent on any aspect of pain as a medical problem, and medical school and physician training in understanding and managing pain is virtually nonexistent. Research sponsored by any government or industry sources is minimal compared to all other areas, maybe 2 percent of all money spent by the National Institute of Health and there is no comprehensive strategy to look at treating pain. Most importantly, the tools used to treat pain are the same tools we used at the time of Civil War – opioids. Most other diseases from hypertension to diabetes and cancer over the last fifty years have seen major advancements in how we treat these conditions, but not pain.

On top of the publishing of new data of how many people are being affected by opioids, the news media is full of sensational information on every aspect of the opioid epidemic. Time magazine this week had information on how drug companies and drug treatment centers are profiting from opioid problems. One of the biggest lobbying groups for money and guidelines on opioids are addiction specialists and drug treatment centers; just a slight conflict of interest. Then the sensational news moves to all the individuals who have become addicts and the problems of addicts. Unfortunately, opioid addiction and how it affects individual lives is not really significantly different from other addictions from food to alcohol, it’s just less glamorous. The latest highlight in the news is the potent drugs and overdoses, and how just touching some of these illegal drugs or using for the first time can cause overdoses.

Opioids are a problem in the United States and more data does not help solve the problem – it just makes it sensational. The real issue that is being ignored is the issue behind opioids and how we treat pain. Most of the pain treatments available date back to before the Civil War. Pain is extremely complex, and to solve the opioid issue the United States needs to get serious about finding better pain management tools and invest in them.

JAMA’s Approach To Chronic Pain Is Misguided

June 26, 2017June 26, 2017 / Thomas Cohn, MD

Every week, the prestigious Journal of the American Medical Association (JAMA) publishes short articles that address important topics in medicine. Last week one of the articles was on taking care of chronic pain patients in primary care medical practices.

In the era of opioid abuse, one would think educating primary care physicians on pain would be beneficial. This article unfortunately was a catastrophe. The information on addiction was wrong and the treatment of pain was overly simplistic.

Understanding Opioid Addiction

Opioid addiction is a significant issue today. Yearly over 30,000 people die due to opioid-related incidents. This is nearly as many people as those who die in automobile accidents. However, addiction is an illness in itself, and of all the people who use opioids, only a small percentage of about 5-7 percent at most ever become addicted. Addiction to opioids is no different then other addictions and requires psychological intervention and medical detoxification.

Chronic pain is a very complex disease, and has many causes. There often is not a single problem involved and finding solutions to improve the issues present takes a deep medical understanding of many different fields. One must be able to identify and understand all the medical problems contributing to pain. Having a solid knowledge of rheumatology, internal medicine, orthopedics, neurology, and musculoskeletal medicine are just a few of the skills needed in pain medicine. In reality, it does not matter how people progress to a chronic pain condition, what matters is that 1/3 of the adult population has problems with chronic pain.

The article in JAMA recommends that primary care physicians need to see the pain patients frequently, with shared decision making, compassionate care, promoting shared decision making, and use an interdisciplinary approach. They should work with motivational interviewing, and have physical therapists and psychologists in the office to work with them and the patients.

This article was written by physicians from the University of Michigan, and pardon my language, is crap. From experience, these physicians are in academics and they are tremendously sheltered from the pressures of most practice situations. Most primary care physicians have 15 minutes at the most to see a patient and they do not have any other support like psychologists in their practice or physical therapy. At the University of Michigan, pain patients are also referred out to the Physical Medicine physicians. The advice in this article is of extremely low use.

What We Should Be Doing

Primary care physicians need far more practical advice on management of chronic pain. First off, chronic pain is not a single medical condition but most commonly it is the response to multiple medical problems. The role of primary care medicine is, more importantly, to identify that there is a problem and help quarterback and guide a patient to the correct treating physicians. With limited time for each visit, send the patient to experts in pain management such as a physical medicine physician who actually has the appropriate training and resources to treat complex problems.

Secondly, avoid the quick fix by trying to hand out medication, especially opioids and many of the other drugs on the market since developing a comprehensive management strategy is necessary. Again this type of management is not really primary care and working with a specialist is more productive. Once a specialist has developed a successful treatment approach, be willing to take over and maintain the program. Third, realize pain is extremely complex, often with no cure, and the goal of treatment is to improve function and make the symptoms more manageable. The best advice for primary care physicians is to learn who are the knowledgeable and successful pain management experts in your area and use their expertise to help manage these complex patients.

Pain Catastrophizing and Chronic Pain Care

June 20, 2017June 20, 2017 / Thomas Cohn, MD

When it comes to managing chronic pain, it’s imperative to take as much care of your mental health as it is your physical health. Ignoring your mental health can lead to more negative attitudes towards your pain, which can lead to even more problems according to a new study.

A new report out of the Stanford University School of Medicine suggests that individuals who negatively fixate on their symptoms have been found to report greater pain intensity and are more likely to be prescribed opioids. Interestingly, the association was much higher in females than it was in men.

“When it comes to opioid prescriptions, pain catastrophizing has a greater effect on the likelihood for having a prescription in women than it does in men,” said medical student and lead researcher Yasamin Sharifzadeh.

Pain Catastrophizing

According to researchers, “pain catastrophizing” is defined as the cascade of negative thoughts and emotions in response to actual or anticipated pain. When you begin to let these negative thoughts continue to build and take hold over your pain, it can actually amplify the pain process and lead to greater pain and increased disability. Previous studies have shown that pain catastrophizing has been linked to increased pain sensations, but this is the first study to find a correlation between it and an increased likelihood of being prescribed opioids.

For their research, Sharifzadeh and her team analyzed clinical data from more than 1,800 patients with chronic pain. After analyzing the data and parsing out the results between genders, researchers came to an interesting conclusion.

“In men, it is pain intensity that dictates whether or not they are prescribed opioids,” Sharifzadeh said. “However, in women, there is a more nuanced issue where relatively low levels of both pain catastrophizing and pain intensity are associated with opioid prescription. Pain catastrophizing and pain intensity are working together in determining if a woman has an opioid prescription.”

This is especially problematic when you consider that women are more likely to suffer from chronic pain, be prescribed pain relievers and given higher doses for longer periods than men, according to the Centers for Disease Control and Prevention. However, by recognizing this correlation, doctors can help to mitigate this risk.

“If physicians are aware of these gender-specific differences, they can tailor their treatment,” Sharifzadeh said. “When treating chronic pain patients — especially women — they should analyze pain in its psychological aspect as well as its physical aspect.”

If you feel like your mental health is fighting a losing battle with chronic pain, reach out to your doctor. Contact Dr. Cohn today.