Could We Soon See A Vaccine For Heroin?

August 8, 2016 / Thomas Cohn, MD

The death of Prince has been a turning point of how serious the opioid addiction epidemic has become. Almost every medical pain specialist has been aware of the problems with opioids, pain and addiction, but now others are taking note. There are many concerns with prescribing opioids, from whether they actually help control pain, are there better treatments, and how many additional problems they are causing. We know one of the big problems caused by opioids that has become horribly worse is opioid addiction. Many people with and without pain are addicted to opioids. A new way to help treat addiction is in development – vaccines.

The information for this blog comes mainly from an article by Susan Giados published in the July 9,2016 issue of Science News Magazine. For those who are interested in a variety of scientific topics, this is a twice a month magazine, usually about 30 pages long packed with short fascinating articles. Well worth looking into.

The Heroin Scene

Heroin and opioid medications are accounting for about 30,000 overdose deaths a year. Here’s how it came to be popular in the US.

1960’s – Heroin first came on the drug scene in big numbers in the early 1960’s. It was a strong drug that produced an intense high. Most users came to the drug while searching for more intense highs, but the drug was not particularly pure or cheap.

1970’s – Major education and opium eradication efforts into the 1970’s suppressed its use.

1980’s and 1990’s – The late 1980’s introduced long acting opioids like OxyContin onto the market, and big pharma pushed these drugs as safe and as the answer to any all pain was simply to take a pill.

2000’s – By the early 2000’s opioids were the first and most common way to treat pain, and every doctor was prescribing them. The rate of addiction rose drastically, and as the awareness has grown, the access to prescriptions has slowly become harder. Opioid addicts now were everywhere.

Now comes into play some very interesting economics. Addiction itself has driven a market to supply people with opioid medication. It spawned an under culture of “pill mills” where almost anyone could go and get a supply of opioid pills. Many people would “doctor shop” for pills, use some and sell the rest for money. Drug cartels started to get into the mix manufacturing and selling them, further fueling addicts. The government then started clamping down on the supply since about 2010. The drug cartels have long had the ability to make heroin, and now they knew they could make large, pure amounts cheaply. For addicts, those who got hooked on pain pills for any number of reasons now saw heroin as a cheaper and often easier to obtain option than prescription medications. Now heroin has become a major problem as more addicts are turning to that to treat their cravings and pain.

Addiction to opioids has become a huge problem. There now are three medications that are used in the treatment of addiction; methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are used to reduce cravings, and must be continued indefinitely. Naltrexone is used to block receptors and is used almost exclusively to reverse opioid overdoses. Unfortunately of those who seek treatment for addiction, only 25% end up receiving medications to help prevent relapsing back into addiction. Vaccines were first attempted in the 1970’s, but the science and cost of development were barriers, and the methadone was cheap and easy to use.

Addition and Vaccines

Now a little additional primer on addiction. Opioid drugs alter the brain pleasure circuitry and cause changes in the structure and function of the brain. Opioids act on the nucleus accumbens in the brain, and they increase the amount of dopamine in the brain. Opioids also act on the mu receptors throughout the nervous system, stimulating dopamine. These are the same chemicals that stimulate the pleasure centers in the brain and reinforce enjoyable activities like eating, sex or listening to good music. Dopamine, in other words, is what is stimulated by compounds like opioids and by stimulating pleasure. Over time, drugs of abuse can change the circuitry in the brain, decreasing the sensitivity of the reward centers and disrupt the centers involved in self control. Addicts tend to lose the ability to enjoy the normal every day activities, and then they need higher and higher doses of drugs to stimulate euphoric/happy feelings. The need to feel pleasure drives the brain, impairs decision making and self-control, and then the only drive is to take drugs just to stay on an even level.

The goal of a vaccine is to train the body’s own immune system to identify the specific offending drug molecules and rid the body of them at even high doses. One of the vaccines being developed is aimed at heroin and its breakdown product morphine. To be effective, heroin in the body breaks down quickly to morphine, and both these compounds need to be targeted to be helpful. The other problem is when going after a drug, there are millions of molecules in the body suddenly, unlike an infection with a few replicating viruses. So to develop a robust vaccine to stimulate the body’s immune systems and chemicals to rid it of certain compounds like opioids is a bit difficult.

So far scientists have been successful in developing a vaccine specific for heroin and the breakdown to morphine that works in rats. The vaccine trains the immune system to neutralize the compounds and even fatal doses of drugs can be handled. The intake of heroin or morphine no longer produces a high, and drug seeking is not pleasurable. A series of three shots was able to produce months of ability to block drug seeking and pleasure by specific opioids. A second vaccine similar to the one for heroin is being developed for fentanyl. After a number of months, the brain starts to reset to more normal patterns of stimuli producing pleasure versus the strong pull to using narcotics. Blocking the drug seeking and pleasure of opioids does also affect all the pain relieving abilities, and the vaccines essentially cause the body to destroy these compounds making them ineffective for any purpose.

Using vaccines is another tool to control addictive behavior in the future once they are perfected for human use. They will be only for specific compounds, like heroin, morphine and fentanyl and not every single narcotic in general. They will be targeted at the most abused compounds and in that way allow a person still to be able to use certain other opioids if necessary for pain control.

Addiction does occur in the pain patient population. The percent of addicted patients in studies is highly variable, on the low side it may be 2-5 percent, although a common number is up to 17% or higher. Addiction is occurring when the need to take a drug is overriding, judgement is impaired and normal activities are suppressed over the needs for getting and taking the medication. Further, the amount of drug needed is escalating fairly rapidly. When addiction becomes an issue, then being weaned from the whole category of drug is needed and appropriate psychological help for addiction and full treatment is necessary.

Minnesota Expands Medical Cannabis To Chronic Pain Sufferers

August 4, 2016 / Thomas Cohn, MD

This past Monday, Minnesota expanded its medical cannabis program to include individuals who are suffering from severe, chronic and intractable pain. Opening the doors to these patients could bring relief to thousands of people whose pain has not been quelled by traditional treatment techniques.

Before the program opened up to intractable pain, the Office of Medical Cannabis announced that they had 1,827 active patients receiving medical marijuana. Although the numbers haven’t been released yet, likely because it will take some time to sift through all the applications and medical material, state planners project that the number of participants may jump to 5,000 or more.

Proponents hope that the influx of patients will ensure those in pain will get the treatment they need, while current members hope their presence will help lower what some feel are extremely high prices.

Minnesota is one of 25 states that have legalized medicinal marijuana, and the vast majority of those states list chronic pain as a qualifying condition. Studies have also shown that overdoses have fallen in those states with medicinal marijuana, and doctors in those states are writing fewer prescriptions for potentially dangerous opioids.

Hopefully those who truly need relief will be approved and find help through the state’s medical marijuana program. I hope the state reinvests some of the profits into future studies to ensure we are doing everything in our power to keep our patients safe, and so we can better understand how cannabis and pain are related.

For more information about the program, including a list of eligible conditions or how to apply, click here.

Women and Elderly With Pain At Elevated Risk For Opioid Abuse

July 25, 2016 / Thomas Cohn, MD

A nationwide survey of alcohol and substance abuse uncovered that chronic pain oftentimes plays a big role in why individuals begin to abuse opioids. The study revealed that individuals with chronic pain are 41 percent more likely to develop prescription opioid use disorders or to become addicted to opioids, according to the new report.

For their study, researchers looked at reported opioid use disorders and demographic factors, including age, gender, family history and other behavioral factors in more than 34,000 adults. The data was collected in two segments over a three-year period.

“These findings indicate that adults who report moderate or more severe pain are at increased risk of becoming addicted to prescription opioids,” explained Mark Olfson, Professor, Columbia University Medical Center in the US. “In evaluating patients with pain, physicians should also be attentive to addiction risk factors such as age, sex and personal or family history of drug abuse.”

Who’s At Risk?

After examining the results, researchers uncovered:

While men or younger adults remain the ones at higher risk for these disorders, women and older adults who became addicted to opioids are observably the ones who also reported chronic pain.

Participants who reported chronic pain with prescription opioid use disorders were also those concurrently suffering from mood and anxiety disorders.

Researchers concluded by saying that the results show physicians need to be more aware of the opioids they’re prescribing and to whom they are prescribing them to. They believe enhanced monitoring of some patients at greater risk for abuse can help prevent people from abusing opioids.

Prescription pain pills can certainly help provide relief for patients with chronic pain, but they should never be viewed as a solution. Exercises, physical therapy and even some surgeries can help provide temporary and permanent relief. Instead of managing pain, we need to keep treating it and solving the problems.

Come Check Out The Minnesota RSD Coalition Potluck Picnic!

July 15, 2016 / Thomas Cohn, MD

If you’re looking for something fun to do next Sunday, considering checking out the Minnesota RSD Coalition Potluck Picnic! The event will take place from noon until 3 p.m. at Hidden Valley Park in Savage, located at 5000 W 132nd street.

You can see the flyer in the sidebar, but here’s what the text says:

Bring a dish to share and don’t forget a blanket and/or chair to sit on in addition to your sunscreen. It’s going to be an afternoon jam-packed with fun, food, laughter, socializing, games, balloons and more for all ages, with maybe even a few surprises tossed in!

Some of the planned events include:

Silent auction
Speaker event
An awards/recognition ceremony
One-on-one support
Balloons for the kids
Playground activities
Walking trails
Lawn Games: croquet, lawn Yahtzee, ball games (kickball, 500, etc).

Water will be provided by the RSD Coalition, but if you want other beverages, you’ll need to bring them yourself. Alcohol is not permitted at the event.

I’m still working on managing my schedule so I can stop by, but I hope some members of the chronic pain community will consider heading over to the potluck picnic next Sunday!

More About The RSD Coalition

The Minnesota RSD Coalition is an organization dedicated to providing support for those affected by Reflex Sympathetic Dystrophy Syndrome (RSD), more recently referred to as Complex Regional Pain Syndrome (CRPS) since 2002.

The MN RSD Coalition believes a positive outlook is a vital part of our care. Everyone has a right to be heard, believed, and treated with respect and dignity. By using a humanistic approach, they encourage each member to become more self-aware, find their inner strengths, learn positive ways of communication, and use various pain reduction techniques.

In my practice I see numerous patients with Reflex Sympathetic Dystrophy Syndrome and Complex Regional Pain Syndrome. It’s not easy to treat, and persistence and a positive attitude are key, two things that are easier done in word than in practice. I commend the RSD Coalition for their work and hope that I can make it out to the potluck next Sunday.

Medical Marijuana, Opioids and Pain Care As A Whole

July 7, 2016 / Thomas Cohn, MD

Late last month in the Star Tribune, there was a large article in the opinion section on pain relief titled “Medical Cannabis as a Valid Alternative to Deadly Opioids.” The second part of the lead says that in states where medical marijuana is available, opioid overdose deaths are down 25 percent. Now one might think that cannabis is a treatment that is good for pain, and that marijuana decreases opioid abuse and death, however, if is important to think about where this article was placed in the paper, in the opinion section.

Just because someone wrote an article on a subject does not mean it is fact. It may be even more important to find out who wrote the article. A medical doctor wrote this article. However, if you read the very last sentence of the article, this doctor just happens to be the co-founder of Leafline Labs, one of two companies producing medical cannabis for Minnesota. If enough people can be sold on his product, he will make significant money. The whole article is making a case for opioids being potentially deadly, and thus a bad treatment for pain. Then comes the pitch how some people have found cannabis helpful in treating pain. Lastly, it states that doctors should certify patients who have pain to be treated by medical cannabis.

It is very true that opioids have potential for addiction and death. It is also true that they can be used to treat pain, and very effectively. Long-term use of opioids is often not overly successful for chronic pain, but for many people it is the only medication currently available, often with other treatment that makes symptoms manageable.

The Cannabis Conundrum

Cannabis is a combination of over a hundred compounds. Scientifically we know very little about any of these compounds. We definitely do not know the long-term side effects to any significant degree. We do not know if there is any single compound in cannabis that helps with pain. We do not know if it is a combination of chemicals that may be helpful. There absolutely needs to be good scientific studies done on whether cannabis can help in certain forms of pain. If there is any benefit, then we need to know what are the risks and side effects of the compounds. Just like opioids, we once thought they were generally very safe, but now we better understand the range of dangers. Cannabis does have risks, as a variety of different compounds can cause problems.

Before everyone jumps on the bandwagon for medical cannabis, one should realize that very little is known about the compound. It may be reasonable for some people where all standard treatments for pain have failed. What is needed is that the United States needs to change its DEA schedule and good research needs to be done on the efficacy and safety of cannabis. Even better, we need research on what each compound in cannabis does do to the human body. Lastly, better understanding is needed on what causes pain and what will effectively treat and prevent pain.