Understanding Opioids, Addiction and Naloxone

April 17, 2017 / Thomas Cohn, MD

Chronic pain patients have a multitude of possible treatments available for the management of symptoms. Strategies often include exercise, physical therapy, chiropractic care, massage, injections and medications. One of the more frowned upon treatments is opioids, but sometimes they are used successfully. With the current opioid crisis, many pain patients fear using them and want to be safe if they have them in their possession.

Opioid Safety

The most important rule with regards to use of any medication, especially opioids, is to never take more than what has been prescribed. Opioids can build up in the body and suddenly become deadly if too much is taken. Running out early can cause opioid withdrawal syndrome and while it is uncomfortable, it is not dangerous to your health. If you are taking opioids, expect your doctor to closely monitor your medication and behavior while taking these drugs. Since they are highly addictive and abused, most doctors will tightly control prescriptions and refills. Drug testing, opioid contracts, behavior screenings, depression screenings and monitoring of other medications are standard. Mixing of medications like sedatives, anti-anxiety treatments like benzodiazepines, and using any street drugs often will lead to ending a prescriptions for opioids, and often there is zero tolerance of any safety rules due to the extreme danger inherent with opioid misuse.

Mixing Street Drugs and Opioids

The latest step in opioid safety is the prescribing of naloxone in addition to the opioid. Naloxone is a drug that can block the opioid receptors for most opioid-type drugs, and it can prevent an accidental or purposeful overdose. In Minnesota it can be obtained at most pharmacies even without a prescription, and can be given effectively as either an injection or as an intranasal spray. Anyone who is routinely taking an opioid or has opioid medications in the home should likely have naloxone too, in case they accidentally or purposefully take too much, or someone else takes their medications. If you are on these medications, ask your doctor about having a safety prescription for naloxone.

Using street drugs for an addiction to opioids or for pain is high-risk behavior. The singer Prince was using Percocet obtained from street sources to control his hip joint pain. The Percocet he obtained had allegedly been mixed with fentanyl, which is an extremely potent opioid and caused his overdose death. If you are addicted to opioids, are using them to get high, use heroin, or have family or friends that is misusing opioids, you can obtain naloxone and this may save someone from an overdose death.

Successful Opioid Treatment

Opioids can be helpful in treating pain, but they are extremely difficult to use due their limited safety. More physicians are very reluctant to prescribe these medications and their long-term efficacy and safety is limited. More information has become available on how opioids actually tend to increase pain over time versus being helpful. Pain management specialists will work with patients to find alternative strategies to these dangerous medications.

One last issue with regards to all medications, especially opioids, is how to dispose of unused or outdated prescriptions. In the past, medications were often flushed down the toilet or thrown out in the trash. The environment does not do well with those methods, and it tends to lead to contamination of our waterways and ground water. Freshwater fish are starting to show significant levels of some commonly disposed medications. The best way to get rid of unwanted medications is to bring them to your local police or sheriff’s department where they have disposal lock boxes. These medications then are handled as hazardous waste and usually incinerated at high temperatures to completely destroy them and turn it to relatively safe ash.

If you’re struggling with an opioid addiction or want a doctor to help get to the bottom of your pain, contact Dr. Cohn today.

How Unregulated Opioid Use Can Lead To Heroin Addiction

April 12, 2017 / Thomas Cohn, MD

In the 1960s, the drug culture was known for psychedelics, LSD and marijuana. Eventually, some of those users sought a stronger high, and that led them down the path to heroin. At least that was the message pushed by the government in its fight against drugs.

Heroin was actually not that common and it was often a drug of addiction found in Vietnam veterans due to its availability in that region. Intense drug programs and interventions to rid production significantly reduced heroin use in the U.S. from the 1970’s through about 2000. In the 1990’s, the era of everyone needing opioid pain management began and along came Oxycontin. The quick and easy option for most doctors to treat pain was to write a prescription for the magical opioid pill. For the last ten years, we now have discovered the rising tide of opioid addiction and now deaths from overdoses is catching up to the number from auto accidents.

Link Between Pills and Heroin

Oxycontin first came on the market in the 1990’s and was extensively marketed as a safe drug for management of pain. The manufacturer would fly physicians to resorts, wine and dine them, and then try to hire them to lecture other doctors on the wonder of their drug. By about 2005, some of the problems with addiction were becoming evident. The government convinced the manufacturer to develop a formulation that would deter abuse by making anti-crush pills, and these came on the market around 2010. It was still a potent drug, but it was not as fun to take and the pills became expensive on the black market. However, the damage had been done and now the main way to treat pain was with opioids, any many people had become addicted to the powerful medication.

A study recently done by the University of Pennsylvania and the Rand Corporation explains why heroin has now become a problem. The development of the new formulation of Oxycontin made this drug more expensive and harder to abuse. Heroin has become cheap, more pure, and once you’re hooked on opioids, it is now easier and less expensive to obtain. So once a person is addicted to pain pills, the cheaper route to get high and prevent drug withdrawal is to use heroin.

Now the latest trick for those with an opioid addiction to get high is to use heroin or oxycodone that is mixed with another synthetic opioid like fentanyl or cor-fentanyl which are a hundred to over a thousand times stronger. These drugs are often been manufactured in China or India, and they can be easily mailed anonymously without much suspicion into the U.S. If mixed wrong, these newer synthetic opioids are often deadly.

Takeaway Points

The message from the opioid crisis is that pain has many ways to be treated, and left unregulated the use of opioids is often more dangerous then helpful. Addiction is a disease; without treatment, some resort to the use of heroin since it is cheap, and many cut that drug with other potent drugs that are deadly.

Stopping the opioid crisis will take time and effort. Treating pain is not just about taking opioids – that has led to the addiction crisis. Money needs to be spent on pain research and the development of better pain management strategies. A third of the population has issues with pain, making it more prevalent than heart disease, cancer and diabetes combined. To solve the problem of pain and drug abuse, a concerted government investment into pain research and better medical management is needed.

Minnesota Medical Marijuana System Tough On Chronic Pain Patients

April 7, 2017 / Thomas Cohn, MD

One of the approved conditions for medical marijuana in the state of Minnesota is intractable pain. Intractable pain is pain that can’t easily be tracked to a specific source and treated successfully, and many patients with chronic pain are deemed to have intractable pain. So you’d think the medical marijuana program in Minnesota would be beneficial for chronic pain sufferers? Well, according to a recent article in the Star-Tribune, it’s anything but easy.

Jumping Through Hoops

Minnesota is at least moderately progressive in that it allows medical marijuana as a treatment option for some conditions, but there are still a number of issues with the current state of the program. For starters, the majority of doctors in Minnesota – including those who specialize in treating chronic pain – are not approved to certify patients for the medical marijuana program. The reason being is that the health care system employers prohibit these doctors from prescribing it. Some doctors who treat rare and severe illnesses can prescribe the treatment, but the vast majority cannot.

So, most doctors are unable to prescribe it. You’d think the state would compile a list of doctors that could prescribe medical marijuana to those who qualify, but no state-provided list exists. Instead, patients need to search the web, call clinics and try to track down a doctor who can prescribe the treatment on their own.

Footing The Bill

Once you’ve tracked down a doctor and had your medical records faxed over to the clinic, you finally get to meet with a specialist who can prescribe medical marijuana. But, according to the Star-Tribune columnist who sought medical marijuana for her pain, since the appointment was for medical marijuana certification, her insurance wouldn’t cover it. So the $844 bill for the 90-minute session would come out of her pocket.

If she would be approved by the state, she’d have to pay a certification fee. That runs $200, and it needs to be renewed each and every year. Moreover, after you pay your certification fee, your treatment needs to be approved by the state. If you are approved, you then have to fill out a Patient Self-Evaluation Form. Finally, after that is approved, you can visit a Cannabis Patient Center, where any purchases once again aren’t covered by insurance, so you’re paying out of pocket. Oh, and forget writing it off as a medical expense, as medical marijuana is not legal under federal law, so the expenses can’t be written off.

The author detailed how she would need to return to the clinic four weeks after receiving the medical marijuana for a follow-up appointment that again would not be covered by insurance (and again at six months). In all, she estimated that her start up costs would fall just short of $2,000 just to get into the program – and that’s without purchasing any medical marijuana.

There are good intentions behind the legalization of medical marijuana in Minnesota, but the program currently has many faults. These patients who are in incredible pain are repeatedly being asked to jump through hoops and open their wallets just with the hope that they can get in the program and find a solution for their pain. The current system is broken, and while we’d like to see more money being poured into medical marijuana research to ensure we increase treatment effectiveness, we can’t expect the solutions to happen on their own. We need to revamp the process for getting medical marijuana for patients with intractable pain.

Why Chronic Pain Patients Feel Targeted By Opioid Crackdowns

March 28, 2017 / Thomas Cohn, MD

As opioid overdoses continue to rise in the US, the government, lawmakers and medical personnel are all trying to figure out the best way to reduce these unnecessary deaths. Obviously restricting access to opioids would reduce the number of people who can get their hands on them, and in turn reduce overdose deaths, but it would also unfairly target people who need the pills. People like those suffering from chronic pain. So it’s understandable to see why when lawmakers propose strict rules for who can access these medications that chronic pain sufferers feel like they are being targeted and singled out.

It’s a tough balance to strike, and unfortunately it seems that as a nation we are more focused on what is easy and cheap instead of what will really address the root problem. Putting a band-aid over a large gash might stop some bleeding, but the wound won’t close correctly without stitches. Simply restricting access opioids and painkillers might stop some abusers from getting the pills, but it won’t solve the whole problem. We need to put some stitches in place.

Solving The Opioid Crisis

We’re not going to sit here and pretend we have all the answers for solving the problem of opioid addiction and overdose, but like we said above, simply restricting access is not going to solve the problem, and many innocent people who rely on those medications may no longer be able to access them. Instead, here are some steps that will help address the root problem.

1. Doctor Education – The vast majority of doctors understand that opioids do not address the root problem, but sometimes they are confused by a diagnosis or have seen other treatments fail and they fall back on them. Other doctors cut corners and prescribe pills freely and dangerously. We need to provide better understanding at the top level of how these drugs should be used, how to spot signs of abuse and how to ensure patients are safely taking their medications so that overdoses don’t occur.

2. Systemic Pressure – This problem will be harder to solve, but in many cases doctors are told to see as many patients as possible. If a doctor is feeling overwhelmed or rushed to see a number of patients, they can sometimes fall back on easy solutions like opioids. Doctors need to take their time with each and every patient and ensure they are giving them the best care possible. It’s possible the best care will involve opioids, but it should also involve therapy, exercise and regular abuse checks.

3. Patient Education – Patients also lack understanding of opioids and their abuse potential. Opioids are not a magic pill that will cure your pain, but they can provide temporary relief so other rehab techniques like exercise, swimming or physical therapy are more bearable. Opioids are a passive treatment, and they need to be paired with an active treatment option for best results. Patients also need to learn the warning signs of abuse for themselves and for loved ones who may have access to their pills.

4. Pill Technology – Medical researchers are looking into new abuse-deterrent opioids. They are creating pills that can’t be crushed or that become gooey if a user tries to extract the solution for injection. Other pills come in an extended release form and can’t be manipulated to give an elevated or intense high. More research into abuse deterrent options could prove useful.

Simply saying we need to restrict access to opioids will not solve the problem, and many chronic pain sufferers will be affected instead of those who are actually abusing the pills. That’s why so many patients feel targeted by these proposals. It won’t be easy to reverse this trend, but if we put in the time and money, it can be done.

The Benefits and Drawbacks Of Medical Marijuana

March 20, 2017March 20, 2017 / Thomas Cohn, MD

Recently, 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.