Medical Marijuana in Minnesota 

/ Thomas Cohn, MD

Medical MarijuanaThe debate for legalizing marijuana is continuing in Minnesota. Bills are progressing through the legislature, but nothing as of yet has been decided. There are some very vocal groups supporting medical marijuana in Minnesota, with one of the most passionate groups being parents with children who are prone to seizures. The medical and law enforcement communities are less excited about the legalizing of medical marijuana.

It’s interesting to note that the Senate and House bills are not legalizing the smoking of marijuana. Instead, they’ve proposed the legalization of state-dispensed marijuana in pill or liquid form for vaporizing. There will be fees paid by the user and pharmacy, and it appears that it will be restricted to only certain medical conditions.

Qualifying Conditions

The Senate has created a list of conditions that would make a person eligible for medical marijuana. Some of the conditions include:

  • HIV
  • Glaucoma
  • ALS, MS, and Crohn’s Disease
  • PTSD
  • Seizures
  • Some forms of Chronic Pain

The Senate and the House do not agree on some eligible conditions, as the House is not supporting medical marijuana for PTSD or chronic pain.

The legal community is not thrilled with legalizing marijuana due to concerns about control and abuse. There are so many prescription medications that are currently being abused, and the law enforcement community does not want to add to the existing problems. Tight restrictions on use may control the availability and abuse potential, but these problems are unknown. In states where less restrictive medical marijuana laws are present, abuse is a large problem.

The medical community is not thrilled with marijuana at this time more on a scientific basis. There are at least 84 cannaboids associated with different forms of marijuana. All these compounds have different actions in the body and they have not been studied in depth. The compounds that are helpful in various conditions have not been isolated. In general, it is bad medicine to give people drugs without knowing all of the potential side effects. Medically, we have no idea if these compounds may cause cancer or other horrible problems later in life.

Marijuana may have some very good attributes for treatment in some conditions, but at this time we are only guessing what may be helpful or dangerous. The best solution would be to get serious in testing and scientifically studying the various ingredients in marijuana. Legalizing does not really help in our understanding of the plant. Research is needed to determine the real nature of the cannaboids in the plant. A national effort to appropriately study marijuana would be beneficial.

Zohydro in Minnesota: A New Twist on an Old Drug

/ Thomas Cohn, MD

Zohydro in MinnesotaIn the last couple months, the FDA has approved Zohydro for use as a pain medication. It is an old medication – Hydrocodone – in a new package.  Hydrocodone is the opioid/narcotic medication in drugs like Vicodin, Lortab, and Norco, and up until now has always been combined with acetaminophen. It is now made into a form that is extended release and is not combined with any other drug.

The drug is meant to last for up to 12 hours and comes in strengths from 10 mg to 50 mg. The big issue is that there is no abuse deterrent design in this new product.

Abuse Likelihood

Hydrocodone is currently one of the leading drugs that is abused. It is the most prescribed pain medication in the United States, and 98% of worldwide consumption occurs in the USA. Furthermore, this medication needs to be metabolized in the body into a broken down state to be effective, and in 5-10% of the population, it has very little effectiveness.  Now, with this new formulation, it is available in a high concentration and has the potential to be easily abused.

Zohydro, in the Pain Specialist community, has received a very cold reception. It has one main benefit; it is no longer used in combination with other drugs. It has many more problems, and the manufacturer and FDA did not listen to the warnings by the specialists who might prescribe the medications. I was actually involved in a focus group evaluation by a manufacturer of either this drug or a similar drug. As with most pain specialists, this drug is likely going to be a highly abused drug that adds little to options for pain management.

Time will tell if this drug will be helpful in pain management. At this time, there are a number of other short and long acting pain medications. A generic short acting Hydrocodone without a combination drug would have been welcomed to help prevent side effects and toxicity of acetaminophen. It would be affordable and useful for short-term pain control. Any new potent pain medication should employ an abuse deterrent formulations, otherwise the increasing pain medication abuse problem will only worsen.

Implantable Pain Control Devices 

/ Thomas Cohn, MD

pain control devicesPain control has become a complex science, and new treatments and technologies are rapidly being developed. It was amazing to see the new scientific leaps that are being made in our knowledge of pain during my visit to the annual pain conference this year. The mechanisms of pain generation, transmission, and perception are all being intensely studied. New chemicals and methods to interfere with the eventual delivery of signals to the brain are being discovered. It is still several years until most of these research findings become part of our practical treatment of pain, but the future looks encouraging for those battling chronic pain.

As I mentioned above, pain management is a complex science. There is usually not a magic solution to control symptoms. Most treatments incorporate tools to help better control pain and optimize a patient’s ability to function. Treatments are to diminish the intensity of pain, not to eliminate all pain. Often a patient has multiple generators of pain signals and a combination of interventions is necessary to best control symptoms. Unlike a simple cut where a Band-Aid or stitches will cure the problem, pain often requires the skills of a Pain Management Specialist to develop an individualized strategy to control symptoms and maximize function.

The Role of IPCDs

Implantable pain control devices (IPCD) are tools employed when simpler strategies are not working. These are tools to use in combination with other treatments to maximize function. They do not totally eliminate pain. Two high technology devices have been developed to be implanted into the body: a spinal cord stimulator, and an implantable intrathecal medication delivery pump.

A spinal cord stimulator is the basic IPCD used to control pain. The spinal cord stimulation acts as a pacemaker that paces out the delivery of sensory signals at the spinal level that prevents pain signals from being delivered to the brain. These devices have been available for over 20 years, and three different companies make competing similar units. Over the last ten years, as technology has improved, so have these stimulators. They are programmed to deliver an electrical signal to the spine from a position in the epidural space. For the right patient, they can be a life saver, as they dramatically increase pain control and often reduce the need for medications.

An intrathecal implantable medication pump is more complex. These pumps deliver medication directly into the spinal fluid. The drugs need to be specially compounded by a pharmacy, and only a limited number of drugs have been used in this fashion. Pumps can deliver medications to receptors that are only accessible by being present in the spinal fluid, and often these same medications do not transfer from the blood to the spine or brain. A lot can go seriously wrong with medication delivery directly to the spine. These are also only effective in highly selective and very motivated patients. Once implanted, the patient is married to the pain clinic and there may be significant additional limitations especially on travel and freedom to be away from the clinic that fills the pump.

Pain is a very complex problem. If your pain is not well controlled, working with an experienced pain physician to develop the correct strategy is necessary. Implantable devices are tools to help control symptoms, but they are complex and not magical solutions. There are new developments in pain control being researched now. A good pain specialist will help find a pathway to a better solution.

Tarlov Cysts and Back Pain

/ Thomas Cohn, MD

Tarlov Cysts back painTarlov cysts are fluid filled sacs in the spinal cord region along the nerve, usually close to where it enters the region to leave the spinal canal. The cysts are usually small, and not in a position that would cause symptoms. They became better known once we developed advanced imaging like MRI and CT scans. Their cause is not known, and usually they do not need to be treated, although occasionally they have been associated with connective tissue disorders including Marfans and Ehlers-Danlos syndrome.

Symptoms and Diagnosis

Tarlov cysts are sometimes larger than 0.5 inches in diameter, and at that size they may become symptomatic. The larger size may cause them to put pressure on a nerve root or even the spinal cord. Symptoms are related to the location; most likely in the sacrum. Problems include tailbone pain, pain in the groin region, sexual dysfunction, bladder dysfunction, and lower extremity numbness and weakness. Over time, without treatment, they do have a tendency to enlarge, meaning the cysts may start without symptoms and later develop into problems.

The diagnosis now is usually made by MRI scan, but may also be noted on CT scan. Tarlov cysts are usually found incidentally when scans are done looking for causes of back pain symptoms. Since most of these cysts are small, they usually are not correlated to symptoms being investigated.

Causes and Treatments

The cause of Tarlov cysts is unknown. There are many theories, but none appear to be definitively correlated to their development. Since there is no known cause, there is no known method to prevent their formation.

Treatment of Tarlov cysts is only necessary if they are definitely linked to symptoms or bone/neurologic compromise. Depending on the exact location, sometimes they can be ruptured by a radiologically guided needle under CT scan. Otherwise, they may need surgical management to drain. Unfortunately, they do have a propensity to re-occur and may need retreatment.

In summary, most Tarlov cysts are found by accident on an MRI scan for another issue. They are often small and usually cause no problems.  If they are large, sometimes they do need treatment and your physician can help determine possible options that would relieve the problems.

Visculosupplements for Knee Pain

/ Thomas Cohn, MD

Visculosupplements for Knee PainDegeneration of the knee is a common condition that occurs as we age. Early problems are often minor injuries to the ligaments and meniscus, and they usually heal with conservative or surgical care. Over the age of forty, we start getting deterioration of the joint space and cartilage. Pain then becomes more consistent, and the knee moves less well and becomes swollen and stiff. Ignoring the knees becomes difficult and walking hurts, so many individuals seek medical attention.

When the simple treatments for degeneration/osteoarthritis do not work, one of the next levels of management is injectable medication. At this point in treatment, a Physical Medicine Pain expert can guide you through the best comprehensive program with the least additional pain. Usually the first level of injection is a cortisone type of injection, best done either with ultrasound or fluoroscopy. Long-acting cortisones include methylprednisolone and triamenacelone, which help control inflammation in the knee for three to six months.

The Benefits of Visculosupplements

Visculosupplements may be beneficial if steroids are not helping. These are injections of buffered hyaluronic acid that promote normal joint fluid production and lubrication. The first compound approved by the FDA was about 20 years ago – Synvisc – and is still used but has significant problems with allergic reactions. Now there are many three-dose regimens that work very well and are very purified without any issues with allergic reactions. The three-dose process may be the best to actually stimulate joint fluid production. In February a single dose regimen, Monovisc, was approved. Whether this will work well remains to be seen. Previous single dose regimens have not been quite as effective.

With all osteoarthritis and degeneration of the knee treatments, conservative measures with injections are necessary. Lifestyle changes including weight loss, exercise, and sometimes using adaptive equipment like braces or canes can be helpful. Using anti-inflammatory medications including creams may also help.

In the United States these visculosupplements are only approved for the use in the knee. In other countries they are used successfully in many different joints. They can be used safely in other joints, but the medication cost would be the responsibility of the patient. They have been used in the hip, pelvis, elbows, and hands.  As a safe conservative treatment especially for the knee, these injections are a time-tested success.