Pain Management – Out With The New, In With The Old?

October 2, 2017 / Thomas Cohn, MD

Comprehensive chronic pain programs (CPP) have a long history, and they used to be the mainstay of treating pain. Up until the mid 1990’s, they were present across the country and there were several hundred present in the United States. With the widespread adoption of the use of opioids and the ratcheting down of medical expenses by insurance companies, many of these programs were eventually forced out of existence.

These programs cost between $5,000 and $20,000 and sometimes involved 2-4 weeks or more of inpatient care. In retrospect, considering the cost of surgeries and medications, these programs were probably a cheap investment for high quality proven outcomes. Today there are very few of these programs left – less than 100 nationwide – and we are suffering from a crisis of pain management and opioid addiction. In Minnesota, there only several left in the state.

Comprehensive Chronic Pain Programs

The typical chronic pain program is a behavioral based approach to pain with an emphasis on weaning off of all opioids. Nonaddictive medications are fine, and surgical or interventional approaches to pain are usually not a part of the program. Most of the emphasis is on changing behavior as it relates to pain. There is guided physical therapy, often aquatics, dietary advice and significant amounts of group and some individual psychological intervention toward the effects of pain on mood and activity level. The goal is to increase activity and function and show a person that their pain levels are often minimally impacted.

These programs are most successful for those whom have withdrawn from life and interactions. A typical patient in one of these programs is depressed, isolated, sedentary and not working. They often are very focused on taking medications and feel their pain prevents them from doing anything. However, to be successful in such a program, they must want to change their lifestyle.

Unfortunately, if you have chronic pain and are maintaining function in life, these programs often have little to offer. For a person who is well adjusted, with multiple outside of the home interests, working full-time, trying to exercise, doing meditation and not taking opioids, these programs have minimal things to offer that would be worthwhile. Pain management for many complex chronic pain patients is often much more difficult. Further, there are very few physicians in general who specialize in pain, and even fewer who have the interest, knowledge and experience to deal with many of these people.

Finding a chronic pain program is often not too difficult, and asking your insurance company or physician will probably get you pointed in the right direction. Finding a good pain physician that will meet your needs can be extremely challenging. A good place to start is a Physical Medicine and Rehabilitation Physician that is board certified in pain. After that, look for recommendations and then visit with the doctor to see if they can meet your needs. Finding the right physician is often difficult, and unfortunately there are no easy answers when it comes to pain management.

Consider Chronic Pain When Voting on Tuesday

November 7, 2016 / Thomas Cohn, MD

It is not glamorous, but voting is essential. One of the most important issues to medical practitioners is the need to maintain access to healthcare. The United States is one of the wealthiest nations in the world, but we also have one of the most expensive systems with some of the poorest outcomes. The tough decisions that would make healthcare more affordable are often blocked for ridiculous reasons, especially those protecting big business and privacy. Currently, like it or not, the biggest issue is the Affordable Care Act (ACA), known as Obamacare. Voting is critical if you want to maintain access to healthcare.

Many of those who have pain have chronic conditions, or have had injuries to the back or neck. Prior to the ACA, health insurance companies could deny care to those with a previous injury or chronic condition, or could just make insurance costs so high that it was not a feasible expense. Despite its recent problems, more people do have health insurance and costs are more affordable for those who do have chronic conditions. Without the ACA, in the past myself, and two of my kids would likely have been unable to be insured, do chronic health issues or back problems. If you have never had a health problem, insurance is easily obtainable. Now, the law requires everyone have insurance, spreading the risk pool across a wide spectrum and reducing costs. Throwing out the ACA and the guaranteed ability to be insured at a reasonable cost is not an option in life for most patients with chronic pain.

Healthcare Costs in America

The cost of the healthcare is an issue in this country. The problem is our elected representatives have no onus to develop sensible healthcare changes in our country. The first thing that is necessary is that insurance companies should be allowed to work across state lines to broaden their base of clients and lower their overall risk profile. They also should be considered basically minimal profit, such that the cost reflects the product, not the profit to investors. Second is to move to a better level of control of the drug/pharmaceutical industry. The fact that the government does not place any control on these companies have led to the outrageous charges for medications. If one buys the same drug in Mexico, India, or Canada, the cost often is 10 percent of what is paid in the United States.

Data is the best way to improve our healthcare system. The best way to improve our system is actually quite simple; every person must have a unique medical identification code, and every medical record is kept electronically in the same way in one single system. If anyone sees a doctor, every other doctor who treats that person can see what has been done and will not need to duplicate tests or services. Statistics then can be data mined for any condition and treatment and soon it would become clear to see what works and what doesn’t work for any management option. The cost should plummet once we stop repeating tests and start seeing what really works for management of various problems.

Going backwards and throwing out the ACA is not viable option for anyone who needs to see a physician regularly or who has had a chronic medical issue. Vote for those who recognize the need to maintain the ability to obtain insurance. Also, vote for those who will stand up for changes to big businesses like the insurance and pharmaceutical industry. Lastly, get over the fear of the government having access to your personal health data, if they know everything about you financially since you pay taxes, what is the difference if they are actually trying to improve your health and make the system less costly? The United States ranks about number 40 in the world for the quality of healthcare, behind many third world countries. It is time people step up an vote for leaders who will improve the quality of our lives, not the politicians’ own pocket books.

5 Ways to Eat Better in the New Year

January 25, 2016 / Thomas Cohn, MD

It is a New Year and a lot of people have made resolutions to eat better and lose weight. There are countless diets one could follow and everywhere you turn someone has a suggestion on what to do to become healthier. In reality, as science becomes more involved in understanding obesity and weight, the more complex the whole subject becomes. People originally thought taking in fewer calories than you burned was all you needed for weight loss, but unfortunately it is now much more complex. However there are some simple rules that may improve your diet and health.

Diet Rules To Remember

1. Eat more plants – As your mother said, eat your vegetables, especially fresh vegetables. Add in more whole grains, fresh fruit, and beans. Maintain a variety of these items in your daily intake. All these plants have essential nutrients and many contain compounds that bolster the immune system, improve digestion, fill you due to fiber and contain healthier varieties of carbohydrates that foster less weight gain. From the wide variety of plants and vegetables available, there should be a number of things that are tasty to eat.

2. Don’t eat more calories than you need – If you fill full at a meal, stop eating, even if your plate is not empty. Wait a little time after you eat before deciding on a dessert, since it takes time for the signals from your stomach to get to the brain and to tell it you did eat enough. Along the same line, slow down your eating, this will also give the brain time to determine it has had enough nutrients. Drinking more fluids also gives the stomach a feeling of fullness and may decrease the need for more food. Lastly, track your weight on a weekly basis (daily monitoring is deceptive and can vary) and if it is trending up, decrease the food intake. Tracking your exercise also may be helpful, a fitness tracker will give you a baseline level, if you are not moving you will not burn the calories you take in.

3. Eat less junk – This is food that is full of empty calories with no nutritional value. Start easy by eliminating candy, cookies, and things like energy drinks, or sugary donuts, pastries or desserts. These foods all are high in calories and carbohydrates. Yes they give you a quick dose of energy, but they are all easily converted to fat in the body. An occasional reward is ok, but small amount is more beneficial. The one exception may be to have a small piece of dark chocolate, this actually does have health benefits.

4. Eat a variety of foods you enjoy – Look at your current diet and determine what foods are healthy, and what you enjoy. Increase the amount of food that is healthy such as fish, chicken, turkey, and lean meats as well as vegetables, fruits and grains. Lower the amount of refined carbohydrates like white rice and pastas. Control the total portion size you eat, but you do not have to rid yourself of anything bad. The most important thing is increase healthy food you like,

5. Learn to cook yourself – Prepared meals and restaurant food is often not the healthiest. Most commercially made meals have high sodium amounts, refined carbohydrates, high calories from fats, and are not particularly good besides the taste. Restaurant meals and fast food is often high in fat, carbohydrates, and calories with few nutrients for the portion size. Cooking at home teaches one to use fresh ingredients, and it is much easier to institute healthier choices. Choosing fruits and vegetables, small portions of whole grain carbohydrates, and leaner cuts of meat or fish becomes much easier. Taste of the food may also improve, and cooking can be extremely relaxing and a time to interact with others.

In the New Year take a step forward toward a healthier lifestyle. Make some changes in your life and enjoy the changes you see in yourself. If you keep everything the same, your life will be the same. If you make some changes toward a healthier lifestyle, eating better, and exercising, the results over time should be evident.

Medical Marijuana: Why It’s Different

November 11, 2015May 10, 2016 / Thomas Cohn, MD

Recently, one of the two suppliers of medical marijuana to patients in Minnesota offered a tour of their facility to a small group of leading pain physicians. The business is fascinating and a completely different model from anywhere else in the country. In the rest of America, marijuana for medical purposes is not highly regulated, and is sold by minimally regulated distributors selling whatever types of marijuana they feel might be useful. Needless to say, it is basically the same marijuana that is being sold for recreational purposes to get high.

Minnesota has taken a very different approach to the legalization of marijuana. First, the legislature has recognized that there may be some legitimate medicinal value to marijuana, and that for certain conditions it may be helpful. The legislature also felt recreational marijuana had a spectrum of problems and wanted to avoid adding to the problems of abused substances. Therefore, in Minnesota, only medical marijuana is available, and it is tightly regulated.

There are only two producers of medical marijuana currently allowed in Minnesota. These producers can provide only to patients that have been certified with certain conditions approved to receive such medication. The patient receives extracts from the marijuana plant to ingest as a pill, concentrated liquid, or to inhale as a vapor. It is not available for smoking or as an additive in food. The formulation received by the patient is determined by a pharmacist, and adjusted as well as titrated to help with a patient’s particular symptoms. The pharmacist also will evaluate the effectiveness of the treatment every time the patient is seen, and information for the State is being kept on the treatment, its effectiveness, and what is being given to the patient.

Medical Vs. Recreational Marijuana in Minnesota

Medical marijuana is usually very different than the marijuana found on the street. For most medical conditions, the cannabinoids of interest are the “CBDs” and not THC, the part that gets one “high.” From research done around the world, plants with different amounts of CBD to THC are being grown to produce the desired amounts of these compounds to be used in the medications. Unfortunately at this time, isolating specific CBDs known to exist has not yet been the focus of manufacturing. The medications manufactured currently just have specific amounts and ratios of CBD and THC.

The producer that I visited was extremely interesting. The growing of the plants is very high tech. From the plants used to the growing conditions, all aspects are tightly controlled. After the plants are harvested, the components are isolated and carefully extracted and made into the medicines for each particular individual.

Not all patients who have been qualified by a physician will be accepted by the medical marijuana distributors. Further, since all medical marijuana is considered experimental, none of the cost of treatment is covered by insurance. Doctor visits regarding certification, follow up visits, and all drug and pharmacy costs are cash only and no credit cards are accepted. Medication costs are also fairly expensive since they are made at a custom pharmacy with strict quality controls for safety and purity.

Medical marijuana is truly a product currently for those who have failed conventional treatment. The treatment is only now for certain conditions. If qualified, it may or may not work for any individual. The cost is quite expensive, not supported by insurance, and is cash only. The benefit is medical marijuana is designed as another medication tool to help control symptoms of certain conditions. It is consistent and manufactured like most other drugs to be pure and safe. It is not designed for recreational use and getting high.

Chronic Pain Patients May Soon Be Eligible For Medical Marijuana in Minnesota

September 11, 2015September 11, 2015 / Thomas Cohn, MD

Minnesota officials are considering adding chronic pain to the list of approved conditions for the state’s medical marijuana program.

Meetings about adding intractable pain to the list of approved conditions for medical marijuana began two weeks ago, but so far officials aren’t any closer to a decision. Should state officials add chronic pain to the approved list, chronic pain sufferers would be able to begin purchasing medical marijuana next summer.

Officials are a little leery about adding the chronic condition to the list for a few reasons:

How many would apply? – State officials say they are unsure how many chronic pain sufferers would apply for medical marijuana, and they don’t know if their suppliers would be able to meet the increased demand. Early estimates said it could eventually triple or quadruple the 5,000 patients they currently expect to apply.

Defining chronic pain – Many people deal with pain, but how would chronic pain be defined under the program? One insider suggested that chronic pain would be defined as pain for which “no relief or cure of the cause of the pain is possible,” though the definition could be open to interpretation.

How will doctors respond? – According to the advisory panel tasked with deciding on whether or not chronic pain will be added to the list of approved conditions, some doctors and clinics are leery about sending their patients to buy medical marijuana. There are so many compounds in marijuana, and we don’t have extensive knowledge of how all those compounds will interact with different types of chronic pain.

Decision Time

According to reports, the decision to add chronic pain to the list of approved conditions falls with Department of Health Commissioner Ed Ehlinger and his advisory panel. The panel is comprised of medical professionals and health experts who will help Ehlinger make a decision by the end of the year.

Additionally, the Minnesota legislature can expand Ehlinger’s decision should they feel it’s too strict, or they can place more restrictions on the program should they feel it’s too interpretive.

Related source: Star-Tribune