Naloxone for Narcotic Overdoses

April 7, 2014December 11, 2015 / Thomas Cohn, MD

Opioid and narcotic abuse is rampant, and overdoses killed over 16,500 people in 2010 and the numbers are rising. The death toll is about one person every 30 minutes. The awareness of the problem has been rising with the deaths of prominent celebrities, but the problem strikes at all levels of society and all ages.

The FDA recently approved a new treatment for narcotic/opioid overdose called the Evzio auto-injector. The new medication is Evzio, a form of naloxone, which has been available for medical use since 1971. The drug reverses the opioids’s effectiveness and prevents the drug from binding to its normal receptors on a short-term basis. Opioids at too high of a dose cause people to have impaired ability to breathe, and this difficulty breathing is the major cause of death from an overdose. Naloxone can only be given by injection into a vein for best results, therefore it has been difficult for anyone but trained medical personnel to administer. Programs have been established in some areas to authorize some first responders to give the medications. This has saved over 200 lives in Philadelphia in one year.

Evzio’s Effectiveness

Evzio won FDA approval in record time, most likely due to its need and safety. The medication is in an auto-injector; all one has to do is press the unit against the leg and trigger the mechanism. The set dose will help most overdose victims. The initial unit comes with a training sample injector that has voice prompts to walk a person through the correct use. The dose of naloxone delivered by Evzio will likely reverse breathing problems for 1-3 hours, enough time to obtain full medical support and treatment.

There are many people at risk for accidental overdose. Many people using opioids for chronic pain also have anxiety and may be receiving benzodiazepines that potentiate drug effects and poor breathing. Combining sleep medications, alcohol and other drugs can have a similar effect with opioids. The ability to have the new Evzio auto-injector available to reduce the chance of an accidental overdose is wonderful.

The biggest challenge ahead is to have laws that allow easy access for family, friends and first responders to obtain and use this new medication. Currently the status is a bit unclear. Every state regulates these medications differently, and there is an urgent need to save lives versus argue about the morality of the issues. Hopefully, the availability and use will become common in the near future and lives will be saved.

The Devastating Consequences of Addiction

April 2, 2014December 11, 2015 / Thomas Cohn, MD

Addiction is one of the leading concerns for physicians in the field of pain medicine. Pain management is a broad and complex field with a range of treatments crossing many different disciplines of medicine. When pain is chronic, there is often not a magical single solution or pill. Pain is managed – it may not be cured – and the patient will have to do a significant amount of individual work and treatment to keep the pain under control.

What is Addiction?

Addiction is a disease of the brain. It is often described in terms of the “4 C’s” of behaviors that are seen. The four C’s are:

Loss of Control
Continued Use Despite Harmful Consequences
Compulsion
Craving

The first C is for loss of control over use. One pill is not enough, and the person will take more and more until they pass out. The behavior does not stop at one episode; it continues multiple times. The second C is continuing use despite harmful consequences. An addict may be hospitalized for repeated overdoses of medication. Some people steal medications of others, or sell their medications in order to be able to afford more drugs in the future. The third C is a compulsion to use a drug. One may not have any pain, but continues to use the drugs because they want the “high”. The fourth C is a physical craving for the substance. If they stop the drug, they will go into a withdrawal. They will physically shake, become nauseated and have other symptoms.

Addiction is a bio-psycho-social issue. There are multiple circumstances that surround addiction, but a big influence is a person’s environment, which may stimulate addiction. If the people you associate with and the activities they participate in promote addiction, for instance hanging out at the bar drinking every evening, addiction can occur.

If a person has family members that have an addiction issue, genetically they are also prone to the same problem. Certain chemicals to the brain also stimulate addiction. Compounds that increase dopamine levels in the brain can cause a prone person to have problems. Opioids and some antidepressants affect dopamine and taking these medications can promote problems in an at-risk individual.

Addiction Prevention

Pain medicine physicians have many solutions to pain. Pain physicians are trained to recognize which medications may lead a person towards addiction, and to spot addiction symptoms at early stages. A physician will shy away from certain medications if they see that a patient has had a problem with medication abuse in the past. Prescribing drugs that are less likely to lead to addiction is one way to prevent addiction, but there are a lot of related prevention techniques that should be discussed and implemented by your physician.

If you have ever had a problem with addiction, a wise pain physician will help you find a solution to your problem and try to avoid a new issue. Pain is difficult to treat and it will take significant effort on the part of the patient and treatment team to develop a reasonable solution over time. New discoveries will also improve management. There is hope on the horizon.

New Pain Medication Issues: The Zohydro Case

March 31, 2014December 11, 2015 / Thomas Cohn, MD

Zohydro A new pain medication has debuted and has set off major controversy. The new medication is called Zohydro, and it is a long-acting form of hydrocodone. This is the same medication as Vicodin or Norco, without the acetaminophen. Vicodin and Norco are the most abused short acting opioid/narcotic medication. Despite knowing this, the FDA recently reversed its stance and approved the high potency long-acting drug. Zohyrdro will certainly help some people who deal with chronic pain, but it will also undoubtedly be abused by others. This begs the question, will Zohydro cause more harm than good?

The answer to question is up in the air, but it certainly looks like it will cause significant harm. It will cause problems, especially since some physicians will ignore the risks and prescribe the drug because it will do a great job relieving pain. This new drug can be easily abused, and has no abuse-deterrent properties. Many potent opioids have abuse-deterrent properties like smaller doses and pills that are designed so the user can’t alter the contents to snort or inject the substance, but Zohydro has no such properties. It will be abused.

Physician Care

Pain physicians, at their annual meeting last week, came to the understanding that opioids are important, but the most potent medications need to be abuse-deterrent. Opioids have a tendency to be abused, and therefore pain physicians have an obligation to help reduce abuse. This new medication adds very little to our treatment regimen, but it opens up more opportunities for abuse.

There are many abuse-deterrent formulations that can be used to treat pain. As far as pain physicians are concerned, there are just to many medications available that are being abused. In reality, it is unlikely we really need this medication.

Pain physicians would like to see more pain medications designed with abuse-deterrent properties. These are medications that have properties which do not stimulate a “high”. These tend to be slower acting, or have specific properties that do not stimulate the brain areas that give a rush. The future in pain care is developing more medications that treat pain but do not lead to abuse. Opioid/narcotic abuse is rampant in the United States, and physicians can play a key role in reducing this problem. Aggressively prescribing Zohydro is not one of those ways.

Hand Pain & Carpal Tunnel Syndrome

March 24, 2014December 11, 2015 / Thomas Cohn, MD

Hand pain can be caused by a number of different ailments. There are a huge number of structures in the hand that allow it to have its functional ability. The bones, joints, muscles, ligaments, tendons, and nerves all may be sources of pain. Trauma can easily damage any of these specific structures. However, one of the most common syndromes to affect the hands is carpal tunnel syndrome.

Pressure on the median nerve in the wrist may cause pain, numbness, tingling and weakness in the hand. The median nerve and several tendons of the hand travel through a narrow space in the wrist called the carpal tunnel. The median nerve provides sensation and motor function to the thumb and first two fingers. Difficulty with pain, tingling and weakness in these fingers is often from median nerve injury in the carpal tunnel region.

Causes

The cause of carpal tunnel syndrome is pressure on the median nerve in that confined space. Swelling in the region of the wrist can cause pressure. Medical conditions such as diabetes, hypothyroid, and rheumatoid arthritis may also be causes. Obesity, hypertension, and pregnancy with fluid retention can also bring about symptoms. Even more commonly, repetitive motions of the hands and wrists, such as typing or the use of a keyboard or mouse, can cause the injury.

The diagnosis can be made by a physician exam with several tests that may reproduce pressure on the nerve and symptoms in the distribution of the median nerve. Confirmation of the diagnosis is made with electrodiagnostic testing of the median nerve and comparing it to other nerves in the hand. If the study is abnormal, the diagnosis is confirmed.

Treatment Options

Treatment of carpal tunnel syndrome depends on the severity of symptoms. Mild symptoms and changes to the median nerve are treated by reducing the repetitive activities and causes. Rest and splints are great at alleviating mild CTS cases. Moderate cases may be helped by anti-inflammatory medications and steroids with hand physical therapy. Severe cases, where significant damage has occurred to the median nerve, usually require surgery to resolve damage or prevent further damage.

Genetic Testing and Pain

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

Genetic testing is a new area of pain management in which enzymes are studied to help better define what medications may be helpful in treatment. Many physicians assume that if a drug is not working, the patient is probably not taking the medication correctly, or somehow is abusing the drug.

As technology and science has improved, so has our understanding of how various drugs are processed in the body, including many drugs used for pain. We now know what enzymes control the metabolization of drugs into a person’s system, and not all people have the same enzymes in their bodies.

A case in point is my own family. I likely have a missing CYP2D6 enzyme and have passed it on to at least two of my children. Several years ago, one of my sons had knee surgery for a torn muscle. Post-operatively he was given Vicodin. After the surgical anesthesia wore off, in the middle of the night, he was screaming in pain despite taking his medication. We ended up in the ER and changed his medication to Oxycodone. This resolved the problem and he was off the medication within several days. My daughter had a similar issue after surgery, and we again found that Oxycodone worked best to help control the pain. In the past, after surgery, I’ve noticed that Vicodin has done virtually nothing for me, but I just dealt with it. In retrospect, this is not a coincidence, but a genetic variation that now can be tested.

Enzyme Trials

Today, most medication is prescribed on a trial basis and we just see if it works. If it does not, we just look for another treatment. In cancer treatment, genetic testing has become essential; We are learning that medication effectiveness for various tumors can be determined at least partly by various genetic markers. The lessons that we are learning from cancer are now being applied to other areas of medicine. The enzymes responsible for the metabolization and processing of various drugs is starting to be understood. The interactions of various drugs with each other are also being better understood as this chemistry is being determined.

Genetic testing is done for several reasons. There are many drugs that interact; If you are on multiple medications for any number of reasons, testing may help clarify possible interactions and allow for more informed decisions to be made if medications need to be adjusted. The most important reason may be if a person is having trouble with medication effectiveness of treatment. Genetic testing may reveal interactions or enzymes that prevent a medication working properly. If the treatment you are receiving is working, there probably is no reason to undergo genetic testing.

Science and technology are moving forward quickly. The changes in the future may guide us to better tailored treatments for the individual. At this time we are just scratching the surface of understanding these higher levels of information. The future appears bright, but patience is necessary since new treatments take time to safely make it to the market.