pain medication

Opioids – Understanding Dependence Vs. Addiction

/ Thomas Cohn, MD

addiction dependenceAnother misleading article appeared in the paper again last week, this time it is again about the opioid crisis. The headline gets the story wrong, and is truly misleading. It says in the headline “Third of long-term opioid users addicted”. The story is from the Washington Post-Kaiser Family Foundation survey of 622 users of opioids for over two months. In the article it states one third of users are either addicted or dependent on these powerful painkillers. The critical information is in one word that was left out headline and it was the word “or”. Addiction and dependence are two very different things, and two-thirds of the people had neither of the problems. Deaths from opioids are indeed a crisis, as the yearly total of opioid deaths are in the region of 30,000 in the United States – about the same as the number killed by either auto accidents or gun violence.

Chronic Pain

Chronic pain is an extremely difficult medical problem. Pain is caused by hundreds of issues and there is no simple solution to many of the problems related to pain. It is not a glamorous condition, and despite the deaths related to opioids, not much is being done to find better treatments for pain. There has been little government support for finding treatments to pain while billions are being spent to treat addicts. There are no moonshots or big government programs to fund research into better treatments for pain. With a third of the population in the world dealing with pain, it is a wonder why so little is spent on finding solutions.

Addiction Vs. Dependence

To understand the article noted above, knowing addiction and dependence are two different things is incredibly important. Dependence is a condition where the body becomes adapted to a chemical, and if the compound is stopped, then the body goes through withdrawals from that compound. There are a number of compounds like this that are medicines including anxiety drugs and many others. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. In addiction there is an inability to abstain from behaviors that are detrimental to one’s physical and emotional health.

People who have chronic pain may use opioids to control symptoms and allow for increased daily functions. If they have been on the medications for a long time, then they may or may not be dependent on them physically. If they are suddenly stopped, and you are dependent, the body would go through withdrawals. Understanding pain and dependence is a medical problem and treated best by experts in Physiatry and Pain Medicine.

Addicts use a medicine like opioids for pain relief, but mostly they are used for the pleasure it creates in the brain. They crave the reward it gives and will do whatever it takes to obtain pleasure even if it is causing physical, legal, behavioral, or emotional destruction. Addicts are unable to control their cravings and will continue the activity despite the harm it is causing. The number of pain patients that are truly addicts alone range from estimates at about 5-7% to about 17%. The addicts are usually those who are using pain medicines illegally and are dying. Understanding addicts and treatment is a Psychiatry and Addiction Medicine problem.

Finding a Solution to the Pain

Chronic pain affects a third of the world population. There are not enough good treatments available and the research in this field is poorly funded. Opioids can be a very effective treatment for some people, but they have many drawbacks. Most people can use these medications safely if needed. Addiction is a separate disease, and opioids have now become a tempting drug for many to satisfy their needs. Possibly the best solution to the opioid crisis is finding a solution to pain versus treating another cause of addiction.

Pain Management Needs To Be A Complimentary Approach

/ Thomas Cohn, MD

Complementary medicineA recent publication in Mayo Clinic Proceedings explored the benefits of complementary therapy in the greater picture of pain management. This is a subject we’ve preached on the blog time and time again; There is no magic pill for chronic pain, and you need to put in the effort to have the best results. Oftentimes this comes in the form of other activities in conjunction with the standard care of rest, rehab, physical therapy, etc. Some of these complementary methods include:

“Medications may not completely relieve chronic pain or can produce unwanted side effects, including the potential for addiction. Thus, many people may turn to complementary health approaches to help manage their pain,” said Richard L. Nahin, PhD, MPH, lead epidemiologist at the National Center for Complementary and Integrative Health.

Complementary Medicine Benefits

Without going into too much detail, the article looked at a number of complementary approaches to common chronic ailments. What they found was that acupuncture and yoga were beneficial for individuals with back pain, acupuncture and tai chi had benefits for knee osteoarthritis, and massage therapy was proven useful for individuals with cervical spine and neck pain. Considering that more than 120 million Americans deal with some sort of chronic pain, these complementary approaches have the potential to positively affect millions of people.

This beneficial link is important because unfortunately many people have to pay out of pocket for some of these treatment techniques. In fact, national data suggests that people pay more than $8.5 billion annually for out of pocket complementary treatments for back pain alone. Now that there’s a link between these approaches and chronic pain improvement, there may soon be a push to make some of these options at least partially covered by insurance. It may require insurance companies to spend a little more in the short-term, but if it helps people recover faster and more fully, it could greatly reduce expenses in the long run.

We need to continue investing money into chronic pain research to find the best methods to treat pain, reduce costs and help patients.

PTSD An Approved Condition For Medical Marijuana In Minnesota

/ Thomas Cohn, MD

PTSD medical marijuanaThe Minnesota Department of Health added post-traumatic stress disorder as a qualifying condition under the state’s medical marijuana program on Thursday.

“PTSD presented the strongest case for potential benefits and a … lack of treatment alternatives,” said MDH Commissioner Dr. Ed Ehlinger.

PTSD comes in many forms, and there’s no one-size-fits-all treatment for individuals who are dealing with the psychological condition. Medical marijuana will not work for everyone, but like we mentioned in our post on Daith piercings for migraines, medical marijuana will provide another potential low-cost treatment option. Medical marijuana is by no means cheap, but trying the initial treatment is much less costly then certain therapy sessions or countless doctor visits, so it opens a new door for individuals with PTSD.

Coming In 2017

Although PTSD has been added to the list of approved conditions for medical marijuana in the state, it was not granted immediate approval. PTSD won’t be considered an active condition until August 1, 2017. However, this doesn’t mean that it will be easy to get clearance from a doctor for PTSD. Military veterans will need to get a doctor’s diagnosis and approval in order to be eligible, but that recommendation cannot come from any Veterans Affairs hospital because marijuana is considered illegal under federal guidelines. They will need to get approval from another physician, and oftentimes it’s difficult to get a new physician to declare you eligible for the medical marijuana program, as doctors are leery of patients jumping from doctor to doctor to try and find a doctor that will grant them approval.

PTSD was the only condition added to the list of approved conditions on Thursday, as Ehlinger and the Minnesota Department of Health shot down proposals for other conditions like arthritis and depression.

Surgeon General Issues Report On Addiction

/ Thomas Cohn, MD

substance abuse opioidsThe Surgeon General issued a groundbreaking report of the current state of addiction in America, saying alcohol and drug abuse are some of America’s most pressing public health concerns.

Substance Abuse Disorder

According to US Surgeon General Dr. Vivek Murthy, more than 20 million Americans – more than the number of people who have all cancers combined – suffer from some form of substance abuse disorder.

“Alcohol and drug addiction take an enormous toll on individuals, families, and communities,” said US Surgeon General Dr. Vivek Murthy. “Most Americans know someone who has been touched by an alcohol or a drug use disorder. Yet 90% of people with a substance use disorder are not getting treatment. That has to change.”

The report, titled “Facing Addition in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” marks the first time a US Surgeon General has dedicated a report to the problem of substance abuse and misuse. Not only does the report examine the statistics behind substance abuse in America, but it also attempts to tackle the cultural shift in how substance abuse is viewed and the stigma behind it in America.

Surgeon General’s Report

According to the Surgeon General’s Report, as many as one in seven people in the US will develop a substance use disorder at some point in their life. However, only 1 in 10 receives treatment for their disorder. The report goes on to state that nearly 48 million Americans used an illicit drug or misused a prescription in 2015, while 67 million reported binge drinking in the last month. Many of these individuals are young, but substance abuse can strike at any age.

“Although substance misuse problems and use disorders may occur at any age, adolescence and young adulthood are particularly critical at–risk periods,” Dr. Murthy said. “Preventing or even simply delaying young people from trying substances is important to reducing the likelihood of a use disorder later in life.”

The biggest finding from the report was that only 1 in 10 people with a substance abuse disorder will receive treatment for their condition. Actions like the Mental Health Parity and Addiction Equality Act of 2008 and the Affordable Care Act of 2010 have helped people get access to these services, but many people choose not to get help due to the stigma associated with substance abuse.

“Families across this country are fighting addiction –they’re fighting an illness, as well as a stigma. They’re doing all they can, and we should do no less. At the US Department of Health and Human Services, we have worked hard to make our nation healthier and save lives by increasing access to evidence–based treatment for those who need it,” said HHS Secretary Sylvia M. Burwell. “While there’s more to do, this historic report provides us guidance and outlines important steps we can take to move forward, build on our progress to address this public health crisis, and make a difference for more Americans.”

Dr. Murthy says that going forward, we need to change the way we think about substance abuse disorders to lift this stigma to ensure people who need help come out of the shadows and get the help they need.

“It’s time to change how we view addiction,” said Dr. Murthy. “Not as a moral failing but as a chronic illness that must be treated with skill, urgency and compassion. The way we address this crisis is a test for America.”

Ibuprofen and Naproxen For Chronic Pain

/ Thomas Cohn, MD

Ibuprofen Chronic Pain NaproxenNew findings on the success of certain anti-inflammatory drugs uncovered that ibuprofen may not be the best option for individuals with certain types of chronic pain.

The study took a look at the success of a couple of different anti-inflammatory medications – ibuprofen, naproxen and celecoxib –  in managing chronic pain caused by inflammation. Researchers tracked thousands of patients who took one of the three medications for pain management over the course of roughly two years. The conditions being treated were most often osteoarthritis and rheumatoid arthritis.

Anti-Inflammatory Drug Findings

At the outset, researchers expected individuals in the celecoxib group would have slightly more adverse heart events, as the drug and similar drugs were believed to be linked to potential heart problems. However, not only was that not the case in this study, celecoxib actually outperformed the other two medications.

Researchers found that celecoxib did not cause more heart attacks, strokes or deaths compared to ibuprofen, and it actually exhibited lower rates of kidney problems.

“In almost every measure, ibuprofen looks worse, naproxen is intermediate and celecoxib is the best,” the study’s lead author wrote.

However, researchers cautioned against simply switching off of ibuprofen simply because of the study results. If you don’t have a preexisting heart condition or you don’t take ibuprofen on a regular basis, you shouldn’t have to worry about additional heart risks. If your current regimen is working, then discuss any potential changes with your doctor before switching up your routine.

Additionally, researchers noted that the study did not evaluate celecoxib’s effectiveness at treating chronic pain itself. Instead, they were only examining at whether or not specific anti-inflammatory drugs came with additional health risks.