The Overdose Issue: Narcotics and Benzodiazepines

/ Thomas Cohn, MD

Pain Pills KillThe recent death of actor Philip Seymour Hoffman has brought to the forefront the issue of narcotic overdose. Many of the famous actors who have died of medication overdose have done so with a whole cocktail of drugs found in their system. Many have overdosed on a combination of multiple prescription medications, street drugs and alcohol. The mixture of drugs is especially lethal, since the effect of the mixture makes many drugs more toxic. A very common mixture found in overdose cases is the combination of opioid/narcotic and benzodiazepine. The source of these medications is most often the primary care provider.

Opioids and Benzodiazepines

Opioids have a very legitimate use for the management of pain. The prescription of these medications for acute pain on a very short-term basis by primary care providers is definitely appropriate. Once pain becomes chronic, pain management becomes much more complex, and the prescription of opioid medications should be in consultation with a trained pain physician. Since there are many advanced treatments for pain, the inclusion of a pain physician will reduce the over-prescribing of opioids. Furthermore, pain physicians will be able to better monitor appropriate medication use and determine early when the medications are not advisable.

Benzodiazepines are medications used for anxiety. Short-term use of these medications for anxiety is reasonable if prescribed by a pain physician. Anxiety and depression are closely related, and if the patient is depressed, treating the condition with an anxiety medication will not help resolve the feeling of depression. Ongoing anxiety is usually a sign that the patient is depressed, and a physician should prescribe a depression medication and not a benzodiazepine.

Pain and Depression

In the brain, the centers for pain and depression are next to each other and they interact with one another. Significant pain will cause stimulation in the area that controls your mood, thus, a patient with chronic pain will often be depressed. A primary care provider will often treat individual symptoms through a combination of opioids and benzodiazepines, which is safe as long as they are taken in the recommended amount. A patient may not realize the danger of these medications and may overdose if they take too much in a short period of time or in combination with other drugs.

The other main issue is that these medications are, for the most part, widely prescribed.  These medications are available in the public, and they are being traded and sold, which opens them up for abuse. A person with an addiction has easy access to these medications either legally or on the street. Better management of patients who actually need these medications will greatly reduce the amount of medication on the street. Better education of all medical providers on pain management will also help. Experts trained in recognizing pain and depression symptoms can help decrease the amount of excessive or unnecessary pills that flood the market.

The more we know, the more we can do to help keep people safe.

Women Feel More Pain Than Men

/ Thomas Cohn, MD

Woman in painPain physicians often see more women than men in practice. Some pain-related diseases have a definitively higher frequency of occurrence in women compared to men. Fibromyalgia, for instance, is at least three times more common in women. Many rheumatologic conditions and headache problems are also more common in women. As science has become more sophisticated, we are beginning to obtain some of the reasons that pain is more frequent in women.

Estrogen and Testosterone

At this time, one of the leading hypotheses is that estrogen in women and testosterone in men impact nerve sensitivity. Research is indicating that estrogen increases the sensitivity of nerves. Women have more estrogen and thus are more sensitive to painful conditions. The connection is especially evident in fibromyalgia, where there appears to be a global increase in pain sensitivity throughout the body.

Testosterone is the opposite of estrogen, and men have much higher levels of it than women. Testosterone appears to be protective and decreases overall pain sensitivity. Young men often appear to endure more severe painful activities. It is common to watch men power through injuries during athletic competition as testosterone attempts to lessen the pain.

As men and women age, estrogen levels and testosterone levels begin to drop, and the difference in levels is less pronounced. As a specialist, I see a more even distribution between men and women with pain as patient age increases.

Hormone Help

The answer of hormone replacement for men or supplements in women is much more complex. As we are studying hormone replacement in both women and men, it appears the side effects and dangers of supplements may be significantly more dangerous. Rates of cancer and other complications tend to increase with hormone adjustments. At this time, it is probably not a great idea to treat most pain with hormone adjustments.

Science is giving us some unique insights into pain. Unfortunately, it is often just making our understanding of pain more complex. In the future, it may lead to better pain treatments, however now we just know that hormones do influence our pain perceptions in some manner.

Tiger Woods Dealing With Back Spasms

/ Thomas Cohn, MD

Tiger WoodsBack pain affects 80% of the population at some point in their life. Tiger Woods has joined the rest of us normal people and now has back pain. Unfortunately, Tiger needs his back to be working correctly to in order to play golf at the highest level. He withdrew from a tournament last weekend, and this past tournament he struggled on Sunday after re-injuring his back. Woods spoke about the pain after the tournament.

“It is back spasms, so we’ve done all the protocols and it’s just a matter of keeping everything aligned so I don’t go into that,” said Woods. “If I feel good, I can actually make a pretty decent swing. You saw it (Saturday). I actually can make some good swings and shoot a good score, but if I’m feeling like this, it’s a little tough. It’s the same thing … it flares up. It’s just a matter of keeping it calm, and we had a quick turnaround from last week. … It will be nice to take this week off and get everything ready for Bay Hill.”

Most likely, Tiger strained some muscles, or possibly irritated a disc or joints in the low back. An irritated back will develop muscle spasms, and these spasms are painful and reduce the ability to move. All of us who have strained our back and have had this problem know how hard it is to move. Walking is difficult, and bending, lifting, and twisting is even harder. Add in the fact that he has to walk the length of the course and swing a golf club – it’s no wonder he had troubles.

Tiger Woods is likely getting the most aggressive treatment to resolve the low back strain causing muscle spasms. Treatment choices are numerous, but most likely include medications that reduce muscle spasms and aggressively influence healing. Likely he is receiving prednisone, a very powerful anti-inflammatory medication that may facilitate more rapid healing. Additionally, medications for muscle spasms and traditional anti-inflammatory medications like Ibuprofen or naproxen may be used. Intense physical therapy is also likely being used to improve movement and decrease the muscle spasms.

Professional golf requires Tiger Woods to be in perfect physical and mental shape to hit the ball adequately. Unless he is at 100%, it is unlikely that he can play at a competitive level. He needs to be mentally alert to judge all variables to make any shot and to concentrate, and many of the medications for spasms have some decrease in mental awareness. Physically, any muscle spasms in his back will change his swing slightly and prevent him from making the shot he wants.

Muscle strains and sprains in the back can resolve quickly if treated correctly and aggressively. Unfortunately, many times it takes a lot of work to control back spasms. Hopefully, Tiger will be lucky and he will heal quickly. He needs to be 100%, especially with The Masters looming next month. Golf’s first major is Tiger’s biggest priority at this point, so I wouldn’t be surprised if he withdrew or skipped other tournaments leading up to The Master in order to put his back in the best possible shape in his quest for another green jacket.

Related source: USA Today

Pain Injection Risks and Safety Procedures

/ Thomas Cohn, MD

Pain InjectionsMany patients with pain can benefit from various types of injections. These pain injections are preformed by interventional pain physicians who specialize in managing pain and reducing chronic aches.

Training of interventional physicians is variable; they include those trained in Anesthesia, Radiology, and Physical Medicine and Rehabilitation. A good interventional pain physician will be board certified in their specialty and have years of experience.

Types of Pain Injections

The appropriate injection will be determined once the problematic area is assessed. Most injections can be performed with minimal discomfort and will take only a few minutes once the procedure begins.

Every injection has the same four risks. They are:

Risk of Infection – The first risk is infection. Cleaning off the skin, and using sterile techniques and medications reduces this risk.

Bleeding Risks – The second risk is bleeding. If the patient does not have a bleeding disorder or is not on anticoagulation medication, then this is not a problem.

Allergic Reaction – The third risk is an allergy to a compound used with the injection. The most common is an allergic reaction to the X-ray contrast, however this risk is very small, less than the risk of being hit by lightning, and can be treated.

Needle Damage –  The largest risk is the possibility of a needle causing damage to the structure that is being treated. Damage during a spine injection to the spinal cord or to a vascular structure that may cause damage to a nerve, spine or the brain is always a concern. Risk is minimized by using real time X-ray guidance known as fluoroscopy, and by having an experienced and knowledgeable physician administer the injection.

Post-Injection Safety

Some pain clinics require all patients to have a driver for any procedure, but it usually depends on which injection you’re receiving. In the vast majority of procedures, the patient will feel the same or better shortly after receiving the injection. If the patient is nervous, I usually recommend they have someone drive them to and from the clinic, as there is little reason to compound the injection with fear. This is also a good piece of advice for anyone who will be receiving an injection for the first time. If you feel fine on the ride home from your first appointment, feel free to drive yourself to any follow-ups.

If you need help to move or drive before the procedure, it is unlikely the injection will give you the ability to do so in the immediate aftermath. In these cases, you absolutely should plan on having a driver. If you are sedated for your procedure, you’ll be required to have a driver since this definitely impairs the ability to make safe decisions behind the wheel.

After the injection is complete, the physician will likely use a local anesthesia to reduce discomfort around the injection site. This will make your drive home more comfortable, especially if you received an injection on your lower back or hips.

A good pain physician should be able to make you comfortable during the procedure. They can answer your questions and describe the procedure so you know what to expect. You should always meet the physician before the procedure so you can ask any questions you might have ahead of time.

Nonsteroidal Anti-inflammatory Drugs And Safety

/ Thomas Cohn, MD

Are NSAIDs safe?The FDA recently ruled that available evidence does not prove that the painkiller Naproxen, often sold under the name Aleve or Naprosyn, is linked to greater reduction in heart disease than other nonsteroidal anti-inflammatory drugs (NSAIDs) on the market. A previous study suggested Naproxen was less dangerous to the heart than NSAIDs like Ibuprofen or Celebrex, but the FDA advisory panel did not find enough evidence to corroborate the statement.

The science of nonsteroidal anti-inflammatory drugs (NSAID) like Ibuprofen, Naproxen, and Celebrex is quite complex. The mechanism and effect on the heart attack risk is not really fully understood. These drugs reduce inflammation in the body by blocking enzymes known as COX-1 and COX-2. The newer drugs in this group were a bit more selective in blocking COX-2 enzymes, which led to a reduction in stomach discomfort. However, the overall effect of all these drugs is that they may disrupt the balance of other enzymes in the inflammatory cycle throughout the body and actually lead to more hardening of the arteries and an increased risk of heart attack and stroke. That said, the increased risk is similar to the risk of a poor diet, smoking, genetics, and diseases like diabetes.

The risk of all NSAID medications seems to be that they may increase the risk of hardening of the arteries and heart attack or stroke. The newer COX-2 drugs like Celebrex, and previous ones Vioxx and Bextra, made this more evident since they became very widely used. Once the effect was found with the more selective COX-2 drugs, further studies have shown all these medications have the same potential risk.

NSAID Use In America

The use of NSAIDs is widespread. The medications can be very helpful in controlling pain related to injury and chronic inflammation due to degeneration of joints and neck and back problems. Many people do take these medications on a long-term basis to control pain levels. These medications can be taken fairly safely, but knowing that they can cause problems, a person should work at reducing all their other risks to prevent heart issues.

The main issue with NSAID medications is not heart attacks with most people, but stomach irritation and bleeding and kidney injury. All these drugs are very well known as significant causes of gastrointestinal bleeding due to the enzyme affects of the COX system on the lining of the stomach. Severe bleeding is a common side effect from these drugs. The COX enzymes and other affected enzymes also can lead to damage to the kidneys. In reality, these drugs have hurt more stomachs and kidneys than caused heart attacks.

The take home message on all medications is that any drug has risks and can have bad side effects on the body. Whenever taking a medication, one has to decide whether the benefit going to outweigh the risk. If you can change your lifestyle such that a drug is not needed, that would be the best option. If changing your lifestyle options is not sufficient, then discussing the risks and benefits with your healthcare provider is the next step with regards to any medication.

Related source: Reuters