Is The Web A Useful Resource for Medical Information?

December 8, 2014 / Thomas Cohn, MD

The web can be a very good place for information, but one has to be careful at which places they look for info. There are many commercial based sites that try to sell products based on your search criteria. Other sites are the equivalent of an infomercial for a medical practice or institution, while some may simply be a personal blog. Various organizations also sponsor sites, and some are very good, while others are pushing their philosophy toward a certain problem as the only true solution. The best sites seem to try to explain the science behind a problem and explain the variety of solutions available.

The sites that I have found the best are sponsored by the government or large medical organizations. For instance, the Mayo Clinic has a huge amount of information on a variety of topics. They write informational pages on various topics, like medical problems, the typical history, diagnostic studies that may be needed and treatment options. Other good places to look for factual information include insurance companies, health organizations, medical groups, and large universities. Many of these places have fact sheets available on topics of interest that are good reference material. The U.S. government also sponsors information, often from the National Institutes of Health, on a variety of issues.

Then there’s the gray area source of Wikipedia. Generally this source can is an excellent place for information and entries are written by top notch experts on a disease, however, it can be also written by someone who actually has no medical background and just decided to write an article for the site. The information found on this site should be verified with other sites and not be taken as a sole source of data.

The Internet and Chronic Pain

The internet can provide an excellent resource of information for the self motivated person. I have found it useful for baseline information about various pain conditions. I also use it as a resource for patients who want more information on certain topics, like exercises for low back pain. Youtube also has videos that demonstrate a variety of things from exercises to surgical procedures.

Cellphones have brought the internet to the palm of the hand. For a quick definition or piece of information it can be wonderful. Medical providers can find a variety of references for free that help make diagnoses, identify medications and there uses, and for dosing information. That said, reliable and free information in app form is hard to find. iPhone apps are a huge business, but I’ve found no beneficial free exercise apps for patients with chronic pain. There are some inexpensive apps for exercise, but read the reviews first to see if they are going to be helpful for your situation.

The internet is like the Wild West from long ago. There are many very good sites and areas to find educational information about a variety of conditions. The better sites are free and often sponsored by large medical institutions, such as the Mayo Clinic, Johns Hopkins University, other not-for-profit organizations or the U.S. government. Some doctors are also prolific writers and work at trying to educate their patients through the web. Unfortunately, in the pain world, there are also some terrible sites that are forums to gripe about a condition, and the doctors who “know nothing.” The internet can often be a very good starting place for information. It is also a good place to develop questions such that you can have a good discussion with your doctor about what to do next in your management.

The Health Conditions For Medical Marijuana in Minnesota

November 19, 2014 / Thomas Cohn, MD

As Minnesota moves toward the end of 2014, the medical marijuana laws are starting to take effect. Minnesota’s laws have very strict rules with regards to the use of marijuana for medicinal purposes. It is restricted to only certain conditions and only two forms will be available; Pill or oil for vaporization.

Health care practitioners will have a limited role in the Minnesota medical marijuana program. Patients will be strictly controlled and monitored, and only limited conditions have been approved for treatment. Furthermore, all medical marijuana will be controlled and distributed only through specific state controlled distribution sites.

Medical Conditions For Marijuana in Minnesota

Minnesota has legalized cannabis for only seven medical conditions. The conditions are cancer, glaucoma, AIDS, Tourette’s syndrome, ALS, epilepsy and Crohn’s disease. Medical marijuana is also available to individuals with a terminal illness with a life expectancy of less than a year who are experiencing pain, suffering, nausea or wasting. The Department of Health can add new medical conditions to the list, but the Minnesota legislature has the power to veto any additions. The first condition that should be added before any other condition is intractable pain. The Commissioner of Health would need to provide a report to the legislature on the reasons why it would qualify for cannabis use in order to add chronic or intractable pain to the list of approved conditions.

Medical providers in Minnesota are not required to participate in the marijuana program. However, a provider who does participate has multiple responsibilities under the law. A participating provider who certifies a patient must continue to follow the patient once they start the program. A patient cannot have a casual relationship with the provider; they must undergo a comprehensive evaluation, including history and physical exam, development of a treatment strategy, determination of a qualifying condition, and be counseled on the risks and benefits of medical marijuana, knowing full-well that this is an experimental treatment. The patient must give informed consent to all aspects of management and be followed regularly to determine if the treatment is effective. Furthermore, their medical records must be shared for research and tracking purposes with the Department of Health. The patient must be re-certified for the program annually.

Medical Marijuana Dosage

The cannabis derivative and dose will be determined by the pharmacists that are associated with the program. They will provide instructions to the distribution centers on the cannabis type and dose to be delivered. The pharmacists with the Department of Health will also be in charge of evaluating data on the forms of medical marijuana available, and the study of the patients and their response to treatment, as well as reviewing the existing scientific data on cannabis.

The program planned for medical marijuana in Minnesota will be a very rigid, structured program for the use of this compound. It is designed to limit the inappropriate use of marijuana for recreational enjoyment. It is also meant to use cannabis as a medication, and to study the patients and its effectiveness in a comprehensive management environment. Hopefully, the program can be implemented and be effective. For now, until more scientific evidence becomes available, chronic pain will not be included in Minnesota’s program.

How Obesity Makes Pain Problems Worse

November 17, 2014 / Thomas Cohn, MD

More information is now becoming available about how obesity can contribute to pain problems, sometimes in unexpected ways. Obesity is a known factor for osteoarthritis of the knees, and increased weight leads to mechanical stress on the knees, causing premature deterioration. Another factor is problems directly related to adipose tissue, fat, and products this tissue produces. Fat produces compounds that influence inflammation. These compounds can make weight bearing and deterioration worse.

Recent studies have shown that weight and thus mechanical stress is a main cause of knee degeneration. The majority of the patients that have knee degeneration are significantly obese. Other factors for knee arthritis often include multiple injuries and repetitive trauma from activities like sports or running. Running can be especially damaging with the impact on hard surface. That said, conversely, losing weight can actually relieve symptoms in patients with knee osteoarthritis. Managing knee pain is closely associated with managing your weight.

Hand Pain and Obesity

Unlike knee arthritis, hand arthritis is not typically related to mechanical stress of weight. Studies have found in these cases, the chemical factors related to inflammatory compounds have significant impact on these joints. The relationship between inflammatory compounds and hand joint deterioration have confirmed that hand arthritis is more common in the obese. Research has now begun to identify the chemical compounds that are increased in obese individuals with arthritis to determine how their presence can best be deterred.

Obesity causes mechanical stress and now we know fat releases chemicals that cause inflammation and pain. Reducing weight does decrease mechanical stress on joints. It may also decrease the amount of available inflammatory compounds that also cause damage to joints. Pain has many causes, but since individuals can have significant control over their own weight, managing it is one of the best ways to decrease your likelihood of developing arthritis in your joints.

4 Sleep Problems Made Worse By Chronic Pain

November 6, 2014 / Thomas Cohn, MD

Pain often causes sleep problems. Sleep problems occur in over 50 percent of patients with chronic pain. Sleep disruption can worsen pain and affect your whole life. Patients will often feel rundown, tired, depressed and very stressed. Relationships with your family, your spouse, and at work may be affected. Solving sleep problems is complex and may take significant time.

Sleep problems can be divided into 4 categories:

Difficulty falling asleep
Troubles staying asleep
Inability to achieve deep restorative sleep
Waking up and being unable to fall back asleep

Each type of problem may need a different solution. A person with chronic pain may have multiple problems with their sleep cycle.

Sleep Hygiene

Good sleep hygiene is the most important initial treatment of sleep problems. Activities that cause problems prior to sleeping include drinking caffeinated beverages and alcohol. Alcohol may initially cause tiredness, but later in the night it often disrupts sleep cycles. Another activity you should avoid before bed is exercise. Physical activity can stimulate the body and keep you awake. The bedroom should be considered a place for sleeping and not for watching TV or doing work related activities. The bedroom should be considered a calming and relaxing place. Other helpful habits include trying to wake up at the same time each day and if awake in the middle of night, don’t spent significant time lying in bed but get up and do another activity until tired again.

When simple tweaks and conservative treatment does not help improve sleep, working with your physician for a more comprehensive treatment strategy is beneficial. A sleep study is often especially helpful in determining the issues preventing good sleep. Sleep studies are also helpful in planning a treatment strategy to solve all related problems.

Multiple medications are available to help with sleep, but many can actually interfere with parts of this sleep cycle. Narcotic medications and other antidepressants may help with pain at night but often interfere with portions of the deep sleep cycle. Newer medications like Ambien and Lunesta are helpful in allowing the patient to fall asleep, but may not be helpful in keeping a person asleep. Recently, melatonin at doses of 5-10 mg has been found to be helpful in maintaining good sleep cycles and reducing pain.

Chronic pain often interferes with sleep, which can lead to worsening pain. Improving your sleep cycle can often greatly improve the quality of life. Sleep problems can be simple, but often with chronic pain they are complex. The solution to a good night sleep may require multiple changes and routines, but with the help of a pain specialist and a sleep expert, relief can be found.

Pain Management for Senior Citizens

November 3, 2014 / Thomas Cohn, MD

A recent article in the latest edition of the Journal of the American Medical Association discusses the problems with opioids and the elderly. The article discusses the fact that there has been a large increase in hospitalizations tied to the usage of these medications. The problems are multifaceted, as overuse, over reliance and lack of understanding all lead to health problems in the elderly.

Chronic pain is a major health issue, especially as we grow older. Recent studies have shown that about a third of the population suffers from some sort of medical problem that causes chronic pain. Unfortunately, the science of treating pain has not kept up with the recognition of it as a problem. Furthermore, we have recognized the risks of acetaminophen with liver toxicity and the dangers of anti-inflammatories like ibuprofen with the kidneys. With the dangers of those drugs, opioid use has been pushed.

The practice guidelines for the management of pain from the American Geriatric Society has actually promoted the use of opioids for moderate to severe pain. They have discouraged the use of stand-by drugs like acetaminophen and anti-inflammatories. Unfortunately, in the elderly, opioids are very difficult to use safely, especially if one is not an experienced clinician. Senior citizens tend to be much more sensitive to medications, and “regular” doses can cause falls, liver toxicity, cardiac toxicity and cognitive impairment. Furthermore, half of the authors of the guidelines had significant financial ties to manufactures of opioids.

Careful Management

Chronic pain in the elderly, as it is in any other group of patients, is not one size fits all solution. Pain is a complex entity and needs to be treated as such. The multiple causes of the pain need to be diagnosed and each contributing factor should be treated with the most appropriate management option. Joint related pain may be best treated with an anti-inflammatory medication while neuropathic pain may need a seizure type drug. Furthermore, depression may be a factor and that may also need separate treatment since pain and depression centers in the brain are closely situated.

Management of pain is complex. Careful determination of all the causes and selective treatment by a skilled and knowledgeable practitioner is beneficial. More research on pain and treatment is necessary since the problem is so large. Pain specialists are often the experts needed to find the best management options.