The Benefits of Hyaluronate Sodium For Knee Osteoarthritis Injections

knee injectionsIn general, the development of hyaluronate sodium for knee osteoarthritis dates back to the early to mid 1990’s. The full mechanism on how these compounds work has not been fully understood, but it is believed that they stimulate the cells in the joints to produce joint fluid and thus provide lubrication and cushioning within the joint. In the United States, these compounds have only been FDA approved for the use in the knee joint, but around the world they have been used successfully in a number of joints including shoulders, hands, hips and feet.

Knee Joint Injections

The first compound used was Synvisc. This has been produced from the rooster combs (the flesh on the top of their head) and was highly refined. Initially, it was administered in a series of five injections and has gradually been changed to a single injection. Orthopedic knee surgeons were the first to perform such injections and still probably perform the most of these injections. Since it was the first product on the market, many physicians are likely to use it.

From experience, however, it has significant drawbacks. The number one is that since it is refined from an animal product, there is a definite significant percentage of people who will have an acute inflammatory reaction to this injection. The reaction in the joint is not distinguishable from a joint infection and does often require further intervention, from checking the patient for infection, aspirating the joint, possible hospitalization, and further injection of the joint with steroid.

Since the early 2000’s, artificial hyaluronate sodium compounds have been genetically engineered and are absolutely pure compounds without any material that could cause an allergic response. All these compounds are somewhat similar and have similar effectiveness. Again, initially they came in a series of five injections, but they then refined it to a series of three injections, and now some are a single dose injection. The effectiveness in a variety of studies ranges for reducing knee pain from about 10 percent of people to 30 percent and a maximum of up to 50 percent. Injections often have to be repeated every six months to be most effective.

Who Would Benefit From Knee Injections?

The indications for these injections are osteoarthritis of the knee. Patient selection includes those who cannot take NSAID medications like ibuprofen, those who have not had long relief with steroid joint injections or are limited with steroid use, and those who have mild to moderated degenerative changes to the joint.

Once a patient is found to be a candidate for hyaluronate sodium joint injections, product selection is the next issue. In reality, this is the grey zone for recommendations, and experience with these products is helpful. Manufacturers of the products are pushing the single dose compounds, which these are convenient, however from providers it seems these may be somewhat less effective at producing results than those that are a series of three injections. Again, patient selection may be the most important factor but this is hard to tell definitively. The products that are a series of five injections do not seem to work better than those that are three injections. Further, none of the products are really better than the others when they are genetically engineered pure chemicals.

Choosing the hyaluronate sodium products for injection is based now on several practical issues. The first is to choose an artificial product that is pure. From personal experience, it is a nightmare to deal with an inflammatory reaction to one of these products and the only one that has this issue has been Synvisc, and you’d be best to avoid this injection unless you have a very experienced orthopedic surgeon who can assess your risk of a bad reaction. The best results are from genetically engineered pure products that are a series of three injections, since these tend to induce the cells in the knee to produce joint fluid on their own.

Single shot products may not be as good at inducing the knee cells to produce lubrication from a technical standpoint. The choices then are from three products that include Hyalgan, Euflexxa, and Supartz. These should all produce relatively equal results for the patients, but again on average if the knee osteoarthritis is not extreme, relief in about 30 to 50 percent of the patients is expected. All these products are FDA approved for the knee and the services to provide injections are usually covered by all insurances and are not considered experimental.

The last selection criterion is based on product cost and if an insurance carrier has a specific drug preference. The recommendation for a hyaluronate sodium supplementation product therefore would be one of the three products that include Hyalgan, Euflexxa, or Supartz unless the insurance carrier requires a single shot product, either Orthovisc or Monovisc.

Beyond the above discussion, all these injections should be done with some type of visualization procedure, either fluoroscopy or ultrasound to prove needle location and delivery to the joint space. Secondly, for those patients who want the state of the art treatment and who can pay cash, studies indicate that PRP injections have about a 50 percent success rate for pain relief for at least six months at a time. Furthermore, for the cash paying clientele, they can also use hyaluronate products as well as PRP in many of the joints in the body with about a 50% percent success rate.

Cutting Back On Opioids Could Reduce Pain

opioids cutting backIt may sound counterintuitive, but new research suggests that reducing long-term opioid intake could actually lead to lower pain levels in patients with chronic pain.

More than 10 million Americans are currently prescribed a long-term opioid to deal with a chronic pain condition. The number of people who get these prescriptions continues to grow, and not surprisingly so too do opioid overdose deaths. Used correctly, opioids can work wonders for individuals who have been struggling to find a way to take control of their chronic pain, but far too often they are overprescribed and knowingly or unknowingly abused.

Long-term opioids should only continue to be used if you’re still seeking active treatment options to address the painful condition. Since opioids are a passive treatment option, they are only masking the pain, and they aren’t actively working to correct the problem. They can work wonders when paired with active solutions like physical therapy or exercise because it can lessen pain during these crucial strengthening times, but if you’re not actively working towards a solution, long-term opioids are just dulling the pain while your body begins to crave larger doses of the drug to be effective, which can lead patients down the path of addiction.

Reducing Long-Term Opioid Intake

Researchers conducted a systematic review of 67 published studies in order to determine the effects of discontinuing long-term opioid therapy for patients with chronic pain conditions. Although they admit that the overall quality of evidence was not superb, they found an association between long-term opioid dose reduction and improvements in pain, function and quality of life.

“It’s counterintuitive that pain and well-being could be improved when you decrease pain medication…but patients felt better when dosages were reduced,” said Dr. Erin Krebs, medical director of the Women Veterans Comprehensive Health Center, part of the Minneapolis Veterans Affairs Health Care System, and an author of the study.

However, study authors echoed what we’ve been saying in this blog, that long-term opioid reduction shouldn’t be done by itself. It should be reduced with the oversight of a licensed physician and paired with other multidisciplinary approaches and behavioral interventions to continue actively pursuing pain reduction and function improvement. Hopefully future studies can take a closer look at this idea and provide some clearer solutions with stronger evidence so we can continue doing everything in our power to help patients fight back against their chronic pain conditions.

Overprescribing Opioids Is A Problem In Our Own Backyard

opioid problems mnNew findings published in the Annals of Surgery suggests that clinicians at the Mayo Clinic in Rochester were routinely writing opioid prescriptions for surgical patients that exceeded regulatory guidelines currently being drafted by the state of Minnesota. The findings also uncovered significant differences in opioid prescribing among the Mayo clinics in Rochester, Arizona and Florida, as well as within surgical procedures.

Study senior author Elizabeth Habermann, who also serves as the scientific director of surgical outcomes research at Mayo, said the findings help highlight where improvements can be made.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Opioid Overdoses In America

According to the Centers for Disease Control and Prevention, the number of deaths involving prescription opioid overdoses have nearly quadrupled since 2000. In fact, more than 90 people died each day from either a prescription opioid or heroin overdose in 2015 alone.

Study co-author Dr. Robert Cima said doctors have been so focused on ensuring patients have their pain minimized as much as possible after surgery that they often don’t consider the possible long-term side effects of the prescriptions they’re filling.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said Dr. Cima, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

I have no doubt that the Mayo Clinic will adhere to the new guidelines being drafted at the state level in short order, but this story speaks to the larger issue of just how unregulated opioids are at some of the nation’s best hospitals. And if it’s happening there, you can bet it’s happening to a larger degree at lesser care centers.

However, these findings do cast light on the problem and should help push us towards a solution, but it’s not necessarily going to come from the top down. It needs to start with doctors. We need take time with each patient and push them towards active treatment techniques instead of passive treatments like opioids. Opioids certainly have their role in pain management, but they shouldn’t be over-relied on, as it appears they are.

Could We Be Pain Free In The Future?

mouse vaccine painAlthough not as much money is being spent on understanding pain as doctors would like, there is still some promising research taking place throughout the world. For example, new research published in Nature Neuroscience took a closer look at re-wiring the brain’s transmitters when it mistakenly interprets signals as pain.

The research began by looking at mice who had peripheral nerve damage and chronic pain from a previous leg surgery. In these mice, a broken circuit in the pain-processing region of the brain caused hyperactivity that led to pain for more than a month. Scientists realized that the peripheral nerve damage deactivated a set of interconnected brain cells, called somatostatin (SOM), which usually work to lessen pain signals.

Fixing The Broken Circuit

Researchers were interested in learning if this connection could be fixed, and if it could, how we’d go about repairing it. One method they tried was to manually activate the SOM interneurons, and they found that this led to a significant decrease in the development of chronic pain.

“Our findings suggest that manipulating interneuron activity after peripheral nerve injury could be an important avenue for the prevention of pyramidal neuron over-excitation and the transition from acute postoperative pain to chronic centralized pain,” the authors, led by neuroscientist Guang Yang at New York University School of Medicine, conclude. They believe future drug therapies or magnetic brain stimulation could mend these SOM interneuron connections and prevent pain signals from misfiring.

The authors are cautiously optimistic, but they realize that there is a big difference in the brains of mice and the brains of humans. The study needs to be repeated and the results verified before any similar testing in humans could take place, but it’s a start.

“Our study provides, to our knowledge, the first direct evidence that impaired SOM cell activity is involved in the development of neuropathic pain,” the researchers wrote.

They hope to confirm their results and examine whether manipulating other cells could play a role in the reduction of chronic pain. If they can, we may have specific cells in which to base our intervention techniques. This is exciting.

Why Are We Treating Pain The Same As We Did During The Civil War?

civil war painIt is no secret that there is an opioid problem in the United States. It seems like there is a new report being published every week on the problems with opioids in this country. This week the government published data on the number of emergency room visits related to opioid use in a single year.

The data shows roughly a 100 percent increase in the last ten years in the number of hospital visits and admissions related to opioid problems. Not surprising is that despite some differences from state to state, in general, the problem affects everyone equally – male and female, rich and poor – just like any other addiction. The focus of most data being published is on opioid addiction. Unfortunately, rarely is someone talking about some of the reasons behind the problem, especially as it relates to how the United States treats pain.

How The US Treats Pain

It is really no surprise that there is an opioid problem in the United States. Pain is a very complex set of medical issues, but unlike diabetes or cancer, very little money has been spent on any aspect of pain as a medical problem, and medical school and physician training in understanding and managing pain is virtually nonexistent. Research sponsored by any government or industry sources is minimal compared to all other areas, maybe 2 percent of all money spent by the National Institute of Health and there is no comprehensive strategy to look at treating pain. Most importantly, the tools used to treat pain are the same tools we used at the time of Civil War – opioids. Most other diseases from hypertension to diabetes and cancer over the last fifty years have seen major advancements in how we treat these conditions, but not pain.

On top of the publishing of new data of how many people are being affected by opioids, the news media is full of sensational information on every aspect of the opioid epidemic. Time magazine this week had information on how drug companies and drug treatment centers are profiting from opioid problems. One of the biggest lobbying groups for money and guidelines on opioids are addiction specialists and drug treatment centers; just a slight conflict of interest. Then the sensational news moves to all the individuals who have become addicts and the problems of addicts. Unfortunately, opioid addiction and how it affects individual lives is not really significantly different from other addictions from food to alcohol, it’s just less glamorous. The latest highlight in the news is the potent drugs and overdoses, and how just touching some of these illegal drugs or using for the first time can cause overdoses.

Opioids are a problem in the United States and more data does not help solve the problem – it just makes it sensational. The real issue that is being ignored is the issue behind opioids and how we treat pain. Most of the pain treatments available date back to before the Civil War. Pain is extremely complex, and to solve the opioid issue the United States needs to get serious about finding better pain management tools and invest in them.