Examining Germs, Bacteria and the Hand-Washing Debate

September 3, 2014 / Thomas Cohn, MD

The prevention of the spread of disease is important. Lately in the news there have been stories saying we should stop shaking hands to prevent disease. For doctors, wearing ties is out, and coats is of serious question. Sterile technique for any procedure is a major ritual. In reality, are we going a bit crazy with our fear of germs? The answer is probably yes, but we do need to use some common sense.

Our bodies depend on bacteria to maintain our health. The mouth and colon are filled with bacteria that digest our food and are essential to us getting the right nutrition. The skin has bacteria all over it, which prevents the wrong bacteria from taking hold. We use yeast to create food and drink for us daily.

There are microorganisms that help us live, and others that make us sick. If we live in a germ-free bubble, the body never learns to distinguish good and bad, and the immune system in our bodies becomes unable to fight the correct germs. The best example is our ability to fight the flu virus. Children are much more prone to get sick from the flu every year since they have not had exposure to these viruses and the body has no antibodies to fight the virus. Older adults have developed antibodies to many strains of the flu and often do not get sick from the various strains spreading every year.

Hand Washing and Bacteria

Healthy people will have a variety of germs on their hands. Touching another person or shaking their hand should not be an issue. As a physician, washing hands between patients is logical, especially if treating sick people who may have contagious problems. Treating healthy people with pain problems, or many other problems like high blood pressure or high cholesterol, should not be an issue of spreading disease.

In the past, physicians that touched their patients – categorized as hands-on doctors – were found to be the best liked and most successful healers. For a physician, washing hands in-between patients makes sense to prevent the accidental spread of unknown infections. Shaking a patient’s hand and touching a patient allows one to establish a good relationship and do a good exam. The body can handle normal germs in the environment and our immune system is geared with this ability. Recognizing the conditions when contamination can occur and preventing those issues is the important message. If you are healthy, the body should be able to control most common germs and it is okay to shake a person’s hand and not panic.

Study: Medical Marijuana Leads to Fewer Overdose Deaths

August 26, 2014February 17, 2016 / Thomas Cohn, MD

A new study published in the Journal of the American Medical Association found that states that have legalized medical marijuana report significantly fewer overdose deaths than states that haven’t legalized medical cannabis.

The Study

For their study, researchers analyzed mortality data and medical marijuana adoption across the US between 1999 and 2010. Only 13 states adopted medical marijuana by the end of data collection, but the results were fascinating.

“We found that there was about a 25% lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law,” said lead author Dr. Marcus Bachhuber.

Looking solely at 2010, Bachhuber said states with medical marijuana laws experienced about 1,700 fewer deaths than what would have been expected based on numbers prior to medical marijuana legislation. Bachhuber said medical marijuana can be a viable option for individuals suffering from certain chronic pain conditions.

“It can be challenging for people to control chronic pain, so I think the more potions we have, the better,” he said. “But I think it’s important, of course, to weigh the risks and benefits of medical marijuana.”

As I mentioned in previous blog posts, the issue I have with marijuana is that it contains so many compounds that haven’t been sufficiently studied. I’m all for conducting more research on medical marijuana, but I don’t think the results of this study mean every state should immediately legalize medical marijuana.

It’s certainly an eye-opening study and raises many good points, but one of the main objectives of any good pain doctor is to control for as many variables as possible. That’s much harder to do with marijuana. You don’t know how the compounds in that specific plant are going to react with that specific person.

The American Academy of Pain Medicine echoed similar sentiments when discussing the recent findings.

“AAPM believes that we need to do research on cannabinoids to determine its safety and efficacy,” said Dr. Lynn Webster, former AAPM president. “The problem with medical marijuana is that we never know using marijuana what chemicals are being ingested. That makes it really unpredictable, but the use of cannabinoids may well have a place in the treatment of pain and other diseases. The AAPM believes that the DEA should reschedule cannabinoids from Schedule I to Schedule II so that it will make it easier for research to be conducted.”

There will almost certainly be more research on medical marijuana in the near future, but until more is known, it can’t be viewed as a perfect solution.

Related source: CNN.com

Pain Making it Hard To Sleep? We Can Help

June 25, 2014 / Thomas Cohn, MD

Pain often causes sleep problems. In patients with chronic pain, sleep problems occur in over 50 percent of patients. Problems with sleep 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 the issue if a complex process, and it won’t happen overnight.

4 Pain-Related Sleep Problems

Sleep problems can be divided into four categories:

Pain making it difficult to fall asleep
Chronic pain causing frequent awakening during the night
Pain may prevent restorative deep sleep
Waking up too early each morning because pain makes it impossible to fall back asleep

Each type of problem may need a different solution, and patients often experience more than one of the above conditions. The first step in treating the issue is by practicing good sleep hygiene. Activities that cause problems prior to sleeping include drinking caffeinated beverages and alcohol. Alcohol may initially cause tiredness but later in the night often disrupts sleep cycles.

Exercising late at night is another no-no. Exercise will help keep you awake, and napping during the day may also lead to decreased tiredness. The bedroom should be considered place only for sleeping and not for watching TV or doing work-related activities. The bedroom should be considered a calming and relaxing place.

Physician Treatment

When the simple things 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 that are preventing good sleep, and they can help formulate a plan to combat the problem. Multiple medications are available to help with sleep, but many can actually interfere with parts of this sleep cycle. Narcotic medications and older 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 to keep 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. Sleep studies can also be helpful to determine other medical problems that need to be treated to improve sleep.

Chronic pain often interferes with sleep, and poor sleep can lead to worsening pain. Improving sleep at night can often greatly improve the quality of life. Sleep problems can be simple, but often with chronic pain they are complex. A sleep study is sometimes needed to determine all problems associated with the lack of sleep. The solution to a good night sleep may require multiple changes and routines. The help of a pain specialist or a sleep expert may be necessary to find the right solution.

Treatment of Facet Joint Pain

May 19, 2014December 11, 2015 / Thomas Cohn, MD

Facet joints, also known as zygoaphoseal joints, are the posterior joints that articulate on each side of the spine between each vertebral body. The joints are at each level of the cervical, thoracic and lumbar spine.

The facet joints are similar to the joints in your fingers. The wear and tear of the finger joints is similar to what happens in the rest of the body, but in the back it is caused by increased weight carried by these joints in the cervical and lumbar regions. Degeneration often occurs starting at about age 30, but trauma can cause earlier changes to these joints.

Diagnosing Facet Joint Pain

The facet joints can cause pain. The pattern of pain for the neck joints has been mapped out by extensive studies. The thoracic and lumbar region have less defined patterns of pain but are generally midline at about the level of the problem. Unfortunately, imaging studies like MRI scans and CT scans often do not show changes in these joints that correlate to pain. If the discs in the spine have degenerated at a certain level, the space between the bones is decreased. Definitive diagnosis of facet joint pain can only be made through diagnostic nerve blocks to the joints.

The initial management of suspected facet joint pain is always conservative. Acute pain often responds to a variety of treatments, including:

Chiropractic adjustments
Massage
Physical therapy
Heat and ice
Stretching

Nonsteroidal anti-inflammatory medications like naproxen or ibuprofen and crèmes can also be very effective. Acute pain often responds to the above measures within a short period of time.

Prolonged Pain

Facet pain and spinal pain that continues for more than six months often needs more aggressive treatment if conservative methods have failed. At this point in management, having a Physical Medicine Pain Specialist is helpful to best guide treatment tailored to the patient’s needs. Diagnostic imaging of the spine at the level of concern is beneficial to determine an effective management program. Starting with an epidural injection in the region is effective to help lower the overall level of spine sensitivity to pain signals. The next step involves diagnostically blocking the nerves to the joints to confirm the joints are actually causing the pain. If the tests are positive, then the treatment is usually “burning” the nerve, or using radiofrequency neurolysis or ablation. A special needle and machine are used to create a microwave signal along the nerve, severing it from the joint. This is often done with sedation, but is still a quick outpatient procedure. Pain relief will often last about a year, is about 70% successful, and combining this with good conservative care may completely resolve the problem.

Can Genetic Switches Turn Off Pain?

February 12, 2014June 24, 2014 / Thomas Cohn, MD

A recent article published in Forbes this month describes research in England that found a connection between DNA and perceived pain levels.

The Study

The study tested perceptions of pain across 1,000 identical twins. Researchers attached a heat source to each twin’s arm and began to increase the heat, telling each participant to press a button when the heat became too much to handle.

The results of the study showed that many of the twins did not have identical perceptions of pain. Researchers then took blood samples from a select group of twins in which the differences in pain perception were highest. From these blood samples, researchers found several segments of DNA that appeared to be different between the twins.

As most studies go, this is interesting but it’s a relatively weak finding, all things considered. Pain is far more complex than this study makes it out to be. As a result, this study really does not show anything useful.

Pain Perception is based on Emotional Experiences

Pain is an emotional response to perceived sensory changes. Identical twins have the same genetic make-up, but they do not have the same life or emotional experiences and therefore will likely have different perceptions of pain. Analyzing the differences in genetics between two twins and postulating that these contribute to differences in perceived pain is highly unlikely. The most likely explanation of the difference in pain perception is the difference in life experiences. There clearly was no control of these variables and this is well known to have a significant effect in pain perception.

Unfortunately, this is only an interesting side light of a story on pain. When the most important variables that impact pain perception have no control, no conclusion can possibly be accurate beyond the wildest of guesses for the results. Bottom line, this makes for an interesting story and nothing more.