pain medication

Nonsteroidal Anti-inflammatory Drugs And Safety

/ Thomas Cohn, MD

Are NSAIDs safe?The FDA recently ruled that available evidence does not prove that the painkiller Naproxen, often sold under the name Aleve or Naprosyn, is linked to greater reduction in heart disease than other nonsteroidal anti-inflammatory drugs (NSAIDs) on the market. A previous study suggested Naproxen was less dangerous to the heart than NSAIDs like Ibuprofen or Celebrex, but the FDA advisory panel did not find enough evidence to corroborate the statement.

The science of nonsteroidal anti-inflammatory drugs (NSAID) like Ibuprofen, Naproxen, and Celebrex is quite complex. The mechanism and effect on the heart attack risk is not really fully understood. These drugs reduce inflammation in the body by blocking enzymes known as COX-1 and COX-2. The newer drugs in this group were a bit more selective in blocking COX-2 enzymes, which led to a reduction in stomach discomfort. However, the overall effect of all these drugs is that they may disrupt the balance of other enzymes in the inflammatory cycle throughout the body and actually lead to more hardening of the arteries and an increased risk of heart attack and stroke. That said, the increased risk is similar to the risk of a poor diet, smoking, genetics, and diseases like diabetes.

The risk of all NSAID medications seems to be that they may increase the risk of hardening of the arteries and heart attack or stroke. The newer COX-2 drugs like Celebrex, and previous ones Vioxx and Bextra, made this more evident since they became very widely used. Once the effect was found with the more selective COX-2 drugs, further studies have shown all these medications have the same potential risk.

NSAID Use In America

The use of NSAIDs is widespread. The medications can be very helpful in controlling pain related to injury and chronic inflammation due to degeneration of joints and neck and back problems. Many people do take these medications on a long-term basis to control pain levels. These medications can be taken fairly safely, but knowing that they can cause problems, a person should work at reducing all their other risks to prevent heart issues.

The main issue with NSAID medications is not heart attacks with most people, but stomach irritation and bleeding and kidney injury. All these drugs are very well known as significant causes of gastrointestinal bleeding due to the enzyme affects of the COX system on the lining of the stomach. Severe bleeding is a common side effect from these drugs. The COX enzymes and other affected enzymes also can lead to damage to the kidneys. In reality, these drugs have hurt more stomachs and kidneys than caused heart attacks.

The take home message on all medications is that any drug has risks and can have bad side effects on the body. Whenever taking a medication, one has to decide whether the benefit going to outweigh the risk. If you can change your lifestyle such that a drug is not needed, that would be the best option. If changing your lifestyle options is not sufficient, then discussing the risks and benefits with your healthcare provider is the next step with regards to any medication.

Related source: Reuters

Can Marijuana Relieve Pain?

/ Thomas Cohn, MD

MarijuanaThere is currently a raging controversy about legalizing marijuana, especially for medicinal purposes.  A few states have recently legalized it, and several other states (including Minnesota) are considering it. This article will examine the potential benefits of marijuana for managing pain.

Marijuana Compounds & Ingredients

The active ingredients in marijuana are cannaboids, and there are at least 84 different ones present in the plant.  There are also 483 known compounds in marijuana.  The main compound is THC, which has psychoactive components.  For medical purposes, it has been used and approved for glaucoma and poor appetite related to chemotherapy and cancer.  Unfortunately, there are claims about the success of the plant for many other conditions, but very little scientific support to determine the reality of these claims.

Studies have shown that marijuana has psychoactive effects, some positive, and some negative. A few of the more common effects include:

  • Heightened mood
  • Relaxation, and euphoria
  • Decreased short-term memory
  • Impaired motor skills and judgment
  • Anxiety and paranoia

Marijuana & Pain

Marijuana has been known to have some impact on pain. Some studies show its effectiveness in managing nerve pain such as:

Why it works it not understood, but there are multiple areas in pain pathways that it may modulate.

The Need for Better Research

The problem with marijuana is that there are many compounds in the plant when taken as a whole.  Some of the chemicals may be beneficial, while others may cause problems.  On a scientific basis, most medical doctors want to know the specific compounds that are effective for any condition and use just that compound.  Marijuana has 483 different compounds and at least 84 cannaboids, and the whole plant is on the “Black List” – thought to be dangerous to society.  In the United States, research on marijuana is strictly controlled.  The variety of plants grown is extremely limited by the U.S. government and the restrictions on handling the plant make good research extremely difficult.

In reality, it is likely that there are beneficial cannaboids for a variety of painful conditions.  Good research is needed to determine which compounds are effective for what conditions.  The U.S. government needs to at least legalize marijuana for medical research, and get serious about determining the real safety issues with the various compounds.  Control of marijuana for safety versus making it illegal on all fronts is wise.

Heroin & Pain Medication: The Problem with Overprescribing

/ Thomas Cohn, MD

heroinThe number of heroin-related deaths has drastically increased over the last several years in Minnesota and across the nation. In the past, heroin was a drug in the shadows, shot up into veins for an immediate high.  It was a problem in the 1960’s and early 1970’s and then faded away for a while.  Today, it is back with a vengeance, and its resurgence is linked to prescription pain medications.

Heroin & Prescription Drugs

Today heroin is more pure than ever and is relatively cheap at small amounts.  The street cost of heroin is often less than that of prescription narcotics.  The availability of both heroin and prescription narcotics has led to our current crisis.  When prescription drugs are not available, people turn to heroin to obtain the high they need to prevent narcotic withdrawal.  Unfortunately, overdosing on heroin is easy.

A heroin addiction often begins with prescription opioids or narcotics.  These medications can be legitimately used to treat pain, but they have become overly prescribed and not closely monitored by physicians.  Many people are not controlling the medications they receive and are selling them for personal profit.  The movement of prescription opioids to the street, and the use of these medications for a high is now a major problem.

Pain Cannot be Cured by a Magic Pill

Patients today often think that medicine has a magical solution to their pain and that they are entitled to opioid pain medications.  There are many treatments for pain, but there is no magical pill that will resolve a person’s pain entirely. In the United States, we prescribe over 90% of all opioids in the world – surely we do not have that much more pain.

At one time, pain was undertreated and ignored by medication.  Education and awareness over time improved treatment, but the pendulum has swung past the rational treatment of pain.  Opioid medication has become the simple and easy treatment option for those in pain. But pain medicine is a complex specialty aimed at an appropriate management of the problem.  Good pain management is a comprehensive treatment, not an opioid pill.

The Solution is Proper Pain Management

Heroin and opioid drug abuse are now significantly intertwined.  Addiction is a disease that does not go away. Once a person has an issue with addiction, no matter what the drug, they will always be prone to addiction to other compounds.

Addiction is a serious problem, and treatment of pain is much more than treatment with opioids.  To decrease drug abuse across the country, physicians need to use pain management experts to develop good treatment programs for pain beyond just a pill.

Can Antidepressants Relieve Pain?

/ Thomas Cohn, MD

antidepressantsPain and depression are closely linked in the brain, and medications used in depression can be helpful in the controlling pain.  Some antidepressants directly impact pain, while others only affect depression.

Antidepressants are most helpful in treating pain caused by damage to nerves or by an overactive nervous system (aka neuropathic pain).  Specifically, antidepressant medications can help treat the following painful conditions:

Acute injury and surgical pain may be helped, but is still being studied.

Types of Antidepressants

There are two types of antidepressant medications that are used to control neuropathic pain:

  1. Tri-cyclic antidepressants (TCAs), such as amitriptyline, Nortriptyline, and desipramine
  2. Serotonin/noradrenaline reuptake inhibitors (SNRIs) such as Cymbalta and Savella

Antidepressants such as Zoloft, Prozac, Celexa, and Effexor have no affect on pain.  These medications decrease nerve transmission and nerve sensitivity. The TCAs have many side affects including dry mouth, low blood pressure, sedation, and urinary problems.  The newer SNRIs have very few side affects.  Cymbalta is very effective in a number of neuropathic pain situations including diabetes, radiculopathy, and fibromyalgia, while Savella only is known to work in fibromyalgia.

Pain & Depression are Closely Linked

The nerve fibers that transmit pain sensation travel through the brain in the same regions that process emotional signals.  These regions actually interact with each other.  Stimulating depression centers can increase the perception of pain.  When depression is not controlled, and a patient does have pain, rarely will the pain be controlled no matter what the treatment.  Therefore, treating depression is often essential in effectively treating pain.  Many people do not want to admit that they might be depressed, and thus not treating the depression does affect the pain level perceived.

Pain and depression in the brain are closely linked.  Neuropathic pain is often treated with a variety of medications, many of which are antidepressants.  Pain itself can change a person’s function and activity level, and cause depression.  Treating the concomitant depression that pain may cause does help manage the severity of pain in many patients.  Some medications treat both pain and depression, others may only treat depression, treating both together is often very effective in controlling pain.

Do Pain Medications Cause Kidney Stones?

/ Thomas Cohn, MD

kidney stoneKidney stones are tiny pieces of mineral or salt in the urine that are incredibly painful when passed. Pain meds are often used to ease discomfort during stone passage. But can these pain medications also cause kidney stones?

What are Kidney Stones?

Kidney stones are considered one of the most painful acute conditions.  They are caused by a variety of things such as:

  • How the body metabolizes various compounds (calcium, for example).
  • Not drinking enough water
  • Other medical conditions like gout
  • Genetic predisposition

As stones are passed from the kidney through the ureters to the bladder, they can be extremely painful.  Stones are often as small as a grain of sand. As they are passed from the kidney they irritate the structures on the way out of the body.

Identifying & Preventing Kidney Stones

Stones are often suspected when there is blood in the urine without any additional signs of infection.  In most cases, once you have a kidney stone you have no choice but to pass it. The only thing you can do is take pain meds to manage the pain during passage. In more severe cases, surgical procedure may be necessary to remove the stone. Analysis of the stone after it is passed can determine a prevention strategy moving forward.

Pain Medications & Kidney Stones

Pain medications are often used to control the extreme pain caused during the passage of a kidney stone.  It is common that people when passing a stone have such severe pain that they go to a hospital.  Powerful opioid and narcotic medications are useful to control the severe discomfort.

Pain medications themselves have not been known to cause kidney stones.  They have been used as an essential tool in the treatment of acute passing of stones.  Treatment is usually only necessary for a few hours to several days with opioid medications.  In rare cases with people who have recurrent stones, frequent use of opioid medication on a temporary basis is necessary. This should only be a temporary solution until a renal specialist can develop a more definitive management strategy.