Antidepressants and Kidney Stones

May 14, 2014December 11, 2015 / Thomas Cohn, MD

Kidney stones, also referred to as renal stones, are extremely painful. These stones are not like rocks found on the ground. In fact, kidney stones are usually about the size of a grain of sand, which is surprising considering how much pain they can cause. It can be a terribly painful event for a person to “pass” a kidney stone from the kidney to the bladder and out the body. So how can we prevent against these minuscule monsters?

Causes of Kidney Stones

Kidney stones are caused by numerous things, only some of which are preventable. The three main causes of kidney stones are:

Poor Diet
Medications
Genetics

A person can change their diet and they are stuck with the genes passed on from their parents, but today I want to talk about role medication plays in the development of kidney stones. More specifically, if antidepressants can cause kidney stones.

Antidepressants and Kidney Problems

There area wide variety of antidepressants on the market. The newer antidepressants have significantly less adverse problems then many of the original medications. As with all medications, antidepressants have been linked to some adverse reactions.

Developing a kidney stone as a side affect from antidepressants is a rare adverse reaction. In my research on the subject, I found that there weren’t many cases directly linking antidepressants to kidney stone development, but some medical professionals believe antidepressants could be the reason why a patient developed a stone if no other causes could be identified. It was very hard to find any definitive evidence that kidney stones were related to the use of common antidepressant medications.

The conclusion correlating kidney stones and antidepressants is weak. There are many much more common causes of stones. If you develop a stone it is best to look for the common causes, and have your primary care physician do a comprehensive evaluation. Oftentimes patients want to know exactly why a condition developed, and without strong evidence doctors sometimes blame the medication. The reality is that stones are likely not related to most antidepressants.

Zohydro in Minnesota: A New Twist on an Old Drug

May 7, 2014December 11, 2015 / Thomas Cohn, MD

In the last couple months, the FDA has approved Zohydro for use as a pain medication. It is an old medication – Hydrocodone – in a new package. Hydrocodone is the opioid/narcotic medication in drugs like Vicodin, Lortab, and Norco, and up until now has always been combined with acetaminophen. It is now made into a form that is extended release and is not combined with any other drug.

The drug is meant to last for up to 12 hours and comes in strengths from 10 mg to 50 mg. The big issue is that there is no abuse deterrent design in this new product.

Abuse Likelihood

Hydrocodone is currently one of the leading drugs that is abused. It is the most prescribed pain medication in the United States, and 98% of worldwide consumption occurs in the USA. Furthermore, this medication needs to be metabolized in the body into a broken down state to be effective, and in 5-10% of the population, it has very little effectiveness. Now, with this new formulation, it is available in a high concentration and has the potential to be easily abused.

Zohydro, in the Pain Specialist community, has received a very cold reception. It has one main benefit; it is no longer used in combination with other drugs. It has many more problems, and the manufacturer and FDA did not listen to the warnings by the specialists who might prescribe the medications. I was actually involved in a focus group evaluation by a manufacturer of either this drug or a similar drug. As with most pain specialists, this drug is likely going to be a highly abused drug that adds little to options for pain management.

Time will tell if this drug will be helpful in pain management. At this time, there are a number of other short and long acting pain medications. A generic short acting Hydrocodone without a combination drug would have been welcomed to help prevent side effects and toxicity of acetaminophen. It would be affordable and useful for short-term pain control. Any new potent pain medication should employ an abuse deterrent formulations, otherwise the increasing pain medication abuse problem will only worsen.

Implantable Pain Control Devices

May 5, 2014December 11, 2015 / Thomas Cohn, MD

Pain control has become a complex science, and new treatments and technologies are rapidly being developed. It was amazing to see the new scientific leaps that are being made in our knowledge of pain during my visit to the annual pain conference this year. The mechanisms of pain generation, transmission, and perception are all being intensely studied. New chemicals and methods to interfere with the eventual delivery of signals to the brain are being discovered. It is still several years until most of these research findings become part of our practical treatment of pain, but the future looks encouraging for those battling chronic pain.

As I mentioned above, pain management is a complex science. There is usually not a magic solution to control symptoms. Most treatments incorporate tools to help better control pain and optimize a patient’s ability to function. Treatments are to diminish the intensity of pain, not to eliminate all pain. Often a patient has multiple generators of pain signals and a combination of interventions is necessary to best control symptoms. Unlike a simple cut where a Band-Aid or stitches will cure the problem, pain often requires the skills of a Pain Management Specialist to develop an individualized strategy to control symptoms and maximize function.

The Role of IPCDs

Implantable pain control devices (IPCD) are tools employed when simpler strategies are not working. These are tools to use in combination with other treatments to maximize function. They do not totally eliminate pain. Two high technology devices have been developed to be implanted into the body: a spinal cord stimulator, and an implantable intrathecal medication delivery pump.

A spinal cord stimulator is the basic IPCD used to control pain. The spinal cord stimulation acts as a pacemaker that paces out the delivery of sensory signals at the spinal level that prevents pain signals from being delivered to the brain. These devices have been available for over 20 years, and three different companies make competing similar units. Over the last ten years, as technology has improved, so have these stimulators. They are programmed to deliver an electrical signal to the spine from a position in the epidural space. For the right patient, they can be a life saver, as they dramatically increase pain control and often reduce the need for medications.

An intrathecal implantable medication pump is more complex. These pumps deliver medication directly into the spinal fluid. The drugs need to be specially compounded by a pharmacy, and only a limited number of drugs have been used in this fashion. Pumps can deliver medications to receptors that are only accessible by being present in the spinal fluid, and often these same medications do not transfer from the blood to the spine or brain. A lot can go seriously wrong with medication delivery directly to the spine. These are also only effective in highly selective and very motivated patients. Once implanted, the patient is married to the pain clinic and there may be significant additional limitations especially on travel and freedom to be away from the clinic that fills the pump.

Pain is a very complex problem. If your pain is not well controlled, working with an experienced pain physician to develop the correct strategy is necessary. Implantable devices are tools to help control symptoms, but they are complex and not magical solutions. There are new developments in pain control being researched now. A good pain specialist will help find a pathway to a better solution.

Visculosupplements for Knee Pain

April 28, 2014December 11, 2015 / Thomas Cohn, MD

Degeneration of the knee is a common condition that occurs as we age. Early problems are often minor injuries to the ligaments and meniscus, and they usually heal with conservative or surgical care. Over the age of forty, we start getting deterioration of the joint space and cartilage. Pain then becomes more consistent, and the knee moves less well and becomes swollen and stiff. Ignoring the knees becomes difficult and walking hurts, so many individuals seek medical attention.

When the simple treatments for degeneration/osteoarthritis do not work, one of the next levels of management is injectable medication. At this point in treatment, a Physical Medicine Pain expert can guide you through the best comprehensive program with the least additional pain. Usually the first level of injection is a cortisone type of injection, best done either with ultrasound or fluoroscopy. Long-acting cortisones include methylprednisolone and triamenacelone, which help control inflammation in the knee for three to six months.

The Benefits of Visculosupplements

Visculosupplements may be beneficial if steroids are not helping. These are injections of buffered hyaluronic acid that promote normal joint fluid production and lubrication. The first compound approved by the FDA was about 20 years ago – Synvisc – and is still used but has significant problems with allergic reactions. Now there are many three-dose regimens that work very well and are very purified without any issues with allergic reactions. The three-dose process may be the best to actually stimulate joint fluid production. In February a single dose regimen, Monovisc, was approved. Whether this will work well remains to be seen. Previous single dose regimens have not been quite as effective.

With all osteoarthritis and degeneration of the knee treatments, conservative measures with injections are necessary. Lifestyle changes including weight loss, exercise, and sometimes using adaptive equipment like braces or canes can be helpful. Using anti-inflammatory medications including creams may also help.

In the United States these visculosupplements are only approved for the use in the knee. In other countries they are used successfully in many different joints. They can be used safely in other joints, but the medication cost would be the responsibility of the patient. They have been used in the hip, pelvis, elbows, and hands. As a safe conservative treatment especially for the knee, these injections are a time-tested success.

The Devastating Consequences of Addiction

April 2, 2014December 11, 2015 / Thomas Cohn, MD

Addiction is one of the leading concerns for physicians in the field of pain medicine. Pain management is a broad and complex field with a range of treatments crossing many different disciplines of medicine. When pain is chronic, there is often not a magical single solution or pill. Pain is managed – it may not be cured – and the patient will have to do a significant amount of individual work and treatment to keep the pain under control.

What is Addiction?

Addiction is a disease of the brain. It is often described in terms of the “4 C’s” of behaviors that are seen. The four C’s are:

Loss of Control
Continued Use Despite Harmful Consequences
Compulsion
Craving

The first C is for loss of control over use. One pill is not enough, and the person will take more and more until they pass out. The behavior does not stop at one episode; it continues multiple times. The second C is continuing use despite harmful consequences. An addict may be hospitalized for repeated overdoses of medication. Some people steal medications of others, or sell their medications in order to be able to afford more drugs in the future. The third C is a compulsion to use a drug. One may not have any pain, but continues to use the drugs because they want the “high”. The fourth C is a physical craving for the substance. If they stop the drug, they will go into a withdrawal. They will physically shake, become nauseated and have other symptoms.

Addiction is a bio-psycho-social issue. There are multiple circumstances that surround addiction, but a big influence is a person’s environment, which may stimulate addiction. If the people you associate with and the activities they participate in promote addiction, for instance hanging out at the bar drinking every evening, addiction can occur.

If a person has family members that have an addiction issue, genetically they are also prone to the same problem. Certain chemicals to the brain also stimulate addiction. Compounds that increase dopamine levels in the brain can cause a prone person to have problems. Opioids and some antidepressants affect dopamine and taking these medications can promote problems in an at-risk individual.

Addiction Prevention

Pain medicine physicians have many solutions to pain. Pain physicians are trained to recognize which medications may lead a person towards addiction, and to spot addiction symptoms at early stages. A physician will shy away from certain medications if they see that a patient has had a problem with medication abuse in the past. Prescribing drugs that are less likely to lead to addiction is one way to prevent addiction, but there are a lot of related prevention techniques that should be discussed and implemented by your physician.

If you have ever had a problem with addiction, a wise pain physician will help you find a solution to your problem and try to avoid a new issue. Pain is difficult to treat and it will take significant effort on the part of the patient and treatment team to develop a reasonable solution over time. New discoveries will also improve management. There is hope on the horizon.