pain medication

Surgeon General Wants To Help Stop Overprescribing in Medicine

/ Thomas Cohn, MD

Speaking ahead of the annual meeting of the Association of Health Care Journalists, U.S. Surgeon General Vivek Murthy, MD, MBA, said that he is committed to reducing the number of prescription drug and substance abuse overdoses in the US.

As part of his effort to reduce overdoses, Murthy is reaching out to physicians and medical professionals who prescripe opioids for pain. He plans to write more than a million physicians, nurses, physicians assistants and dentists with a “personal entreaty” to change prescribing practices.

“Nurse practitioners, physicians, and dentists … they want to relieve suffering, they want to treat pain,” said Murthy. “What we have found is that many precribers were never really trained in how to treat pain safely and effectively. “That’s something we want to change.”

In his speech to the AHCJ, Murthy noted that left unchecked, opioids and prescription painkillers can lead people to search for newer, more powerful drugs, like heroin. According to Murthy, 80 percent of heroin users say their addiction began with prescription drugs.

“I see prescribers as being essential part of solution to opioid crisis,” he continued. “Unlike many other substances like heroin and other illicits, the majority of supplies of misused prescription opiates are coming from legally written prescriptions. That means doctors, dentists, nurse practitioners, and physician assistants have the power to turn the tide on the opioid epidemic by virtue of their ability to prescribe, and their ability to inform and educate patients. Our goal is to build a national movement in medicine to take on this crisis as one we’re uniquely positioned to solve as prescribers.”

To get a better idea of the scope of the problem, Murthy’s office plans to produce the office’s first-ever report on substance abuse, addiction and health.

“The goal of that is to bring together the best possible science on treatment and recovery, so we can equip practitioners, patients, and policymakers with the information they need to promote better health and treat addiction,” he said.

Also Addressing Physician Burnout

Murthy stated that opioid and substance abuse overdoses were one aspect of healthcare that he wanted to focus on, but the other topic centered around physician burnout. Physicians and individuals in the medical profession have some of the highest burnout rates of any job, and they routinely score low on tests of emotional well-being. Murthy and colleagues say the emotional drain is pushing skilled workers into other industries at a time when we need to be hiring more doctors.

My colleague Dr. Lance Silverman dives into the topic of physician burnout on his blog.

Heroin Abuse From Chronic Pain Pills

/ Thomas Cohn, MD

Heroin and Chronic PainHeroin abuse used to be considered a rare problem. Over the last five years it has become a major concern, along with the abuse of prescription opioids like Percocet, Norco, oxycodone, hydromorphone and hydrocodone. When prescription drugs are hard to find or to costly, people may turn heroin since it is relatively cheap. Heroin is also becoming cheaper and more pure. It can also be deadly just like prescription opioids.

All narcotics/opioids have beneficial uses for the treatment of pain. They are only one of many tools available to treat painful conditions. All chronic users can become dependent on such medications, meaning that they will have withdrawal symptoms if they suddenly stop their use. Addiction is the use of a substance despite its harm to the person and the inability of the person to stop its use despite knowing the damage the drug is causing.

How Addiction Occurs

Narcotic addiction occurs in many different ways. Often it starts with appropriate medication use and changes to use to get high and numb the brain. Others like getting high off of recreational drugs like marijauna and move from other substances including alcohol and more potent drugs. In the United States, starting in about the late 1980’s, opioids began being pushed for the treatment of pain. Probably over 90% of all opioids used for pain in the world are used in the United States. With the abundance of drugs for pain being used, unused and stolen, supplies have flooded the streets, leading to a massive addiction problem across this country.

Heroin is a potent derivative from the opium plant that gives a person a narcotic type of high. In the 1960’s and before it was crudely derived and not very pure, and was not greatly used. More recently it is much more pure, being manufactured by drug cartels in Mexico, and now it can often be purchased for much cheaper than prescription opioids. As addicts need stronger doses of opioids to get high, they begin to substitute heroin when their drug of choice is not available. Heroin is now being found everywhere in this country, from city to suburb, urban to rural areas.

The newest problem with heroin is that it is being mixed with very potent opioids, especially fentanyl to deliver a stronger high. Unfortunately the mixing of fentanyl may be quite random, and very small amounts are 50 to 100 times more potent than most other opioids. This mixed heroin with fentanyl has now become a deadly problem on the street. If one takes their usual amount of heroin and if it also contains fentanyl, it can cause a lethal overdose. Opioids can be reversed with a drug called naloxone, but only if it is given before the opioids stop a person’s breathing.

The drug addiction crisis with opioids is a multifaceted problem. More money needs to be spent on the treatment of addiction, and managing this as an illness. But to reduce opioids overall, much more money needs to be spent on pain research to better understand all aspects of pain and to develop new and better approaches to managing and curing painful conditions.

Guidelines For Prescribing Opioids For Chronic Pain

/ Thomas Cohn, MD

The Centers for Disease Control and Prevention recently announced some new guidelines for physicians in regards to prescribing opioids for chronic pain control. The official statement is a little wordy, but the CDC also published an infographic to explain the new guidelines. I plan on publishing my thoughts on the new recommendations, but for now, here’s a look at the recommendations as well as a statement from the American Academy of Pain Medicine.

AAPM Statement

“We know that doctors – primary care and pain medicine specialists – are integral in treating pain wisely and carefully monitoring for signs of substance abuse. Abuse and diversion of prescription opioids must be addressed. Opioids are not the usual first choice for treating chronic non-cancer pain, but they are an important option—as part of a comprehensive multidisciplinary approach— that must remain available to physicians and appropriately selected patients,” said Dan Carr, MD, President of the American Academy of Pain Medicine and Professor of Public Health and Community Medicine at Tufts University.

“We need to address both chronic pain and its treatment as public health challenges. This view is endorsed by the National Academy of Medicine and outlined in the draft National Pain Strategy from the NIH. Public health problems are typically complex; well-meaning, but narrowly targeted, interventions often provoke unanticipated consequences. We share concerns voiced by patient and professional groups, and other Federal agencies, that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence. It is incumbent upon us all to monitor the deployment of the guideline to ensure that it does not inadvertently encourage under-treatment, marginalization, and stigmatization of the many patients with chronic pain that are using opioids appropriately.”

Tarantula Venom May Help Provide Chronic Pain Relief

/ Thomas Cohn, MD

Tarantula venom minnesota painWe spoke briefly in the past about how researchers are looking at spiders as a potential source of relief for patients battling chronic pain, and new research suggests that a tarantula may hold some answers.

According to researchers in Australia, the Peruvian Green Velvet Tarantula, native to South America, may help advance our knowledge of chronic pain reception and expression. A bite from the spider isn’t deadly enough to kill, and in fact, it may have some benefits. Researchers say the venom actually helps to inhibit pain receptors in the body.

“Our group is specifically interested in understanding the mode of action of this toxin to gain information that can guide us in the design and optimization of novel pain therapeutics,” said Sónia Troeira Henriques, senior research officer at the University of Queensland’s Institute for Molecular Bioscience.

The peptide toxin, referred to simply as ProTx-II, works to block pain signals by binding to the membranes of nerve cells.

“Our results show that the cell membrane plays an important role in the ability of ProTx-II to inhibit the pain receptor,” said Henriques. “In particular, the neuronal cell membranes attract the peptide to the neurons, increase its concentration close to the pain receptors, and lock the peptide in the right orientation to maximize its interaction with the target.”

Venom and Chronic Pain

Based on the new findings, researchers are hoping to mimic the effects of the venom in drug form. They see at as a new avenue in the pursuit of pain management.

“Our work creates an opportunity to explore the importance of the cell membrane in the activity of peptide toxins that target other voltage-gated ion channels involved in important disorders,” said Henriques.

The Australian team isn’t the only one studying the role of venom in chronic pain management. Researchers out of Germany are exploring the benefits of snail venom in pain control, citing an added benefit that the venom decomposes quickly and thus is less likely to lead to dependency and abuse. That research is farther along, as a drug has already been created using the snail venom. The drug is called Prialt, and it is being used as a spinal pain injection to treat pain from failed surgery, cancer and AIDS.

Obama Weighs In On Opioid Crisis in America

/ Thomas Cohn, MD

President Barack Obama shot down a proposal on Monday from the nation’s governors designed to curb America’s opioid and heroin crisis. The proposal called for limiting the number of high-powered painkillers a doctor could prescribe at a time, but Obama said the move could block access to drugs that people truly need.

“If we go to doctors right now and say ‘Don’t overprescribe’ without providing some mechanisms for people in these communities to deal with the pain that they have or the issues that they have, then we’re not going to solve the problem, because the pain is real, the mental illness is real,” Obama said. “In some cases, addiction is already there.”

Pain Pills Minnesota

The recommendation had received bipartisan support at the National Governors Association’s winter meeting, but President Obama rejected the sweeping proposal. The president thanked the governors for crossing party allegiances to come to a solution, but he didn’t think it adequately addressed the full scope of the problem.

“This is an area where I can get agreement from Bernie Sanders and Mitch McConnell. That doesn’t happen that often,” Obama said.

Opioids in America

According to the Centers for Disease Control and Prevention, heroin and prescription painkillers play a roll in the deaths of 78 Americans every day. Certain prescription opioids are seen as gateway drugs to heroin, which is cheaper and often much easier to obtain.

Vermont Govermor Peter Shumlin criticized Obama for rejecting the proposal, saying, “You can’t convince me that we’ve got 250 million Americans in chronic pain.”

The fact of the matter is that opioids are likely over-prescribed in this country, and while some doctors certainly hand them out too easily, for some patients, it is truly the only option that keeps their pain at bay. For others, surgery or costly therapy sessions are out of the question, so they rely on those painkillers to manage their pain. Dr. Steven Stack, president of the American Medical Association, praised Obama for shutting down the blanket rule which would have undoubtedly hurt a large portion of actual chronic pain sufferers.

“The complexity of the problem makes it difficult to create a successful one-size-fits-all approach,” Stack said.

Stack is right. There is no perfect one-size-fits-all approach to chronic pain care, just like there is no magic pill to solve one’s pain. In the end, we need comprehensive exams to understand to underlying cause of pain, and we need to work with patients to understand their treatment options and the potential implications of each. It’s much harder than simply prescribing a painkiller, and it also takes work on the patient’s end to work to get better and not just rely on their pain pills, but this duel-responsibility approach is what it’s going to take to start reversing the opioid crisis.