Opioid Dependency and Prescription Length

April 10, 2017 / Thomas Cohn, MD

A new study conducted by the University of Arkansas on opioid use has been recently published by the Centers for Disease Control. It is somewhat of a curious study since it was based on record analysis of prescription records for opioids. The results will likely be twisted by the press soon to announce how bad these drugs are and how addictive they can be.

The question the study sought to answer was – “If a patient gets a certain amount of drug prescribed on a first visit, will they still be taking that drug a year later?” The numbers are somewhat surprising, but in reality it does not really say anything about opioids, addiction or pain. All it really says is that for some people there may be limited options to treat pain, and maybe it is very effective for some people.

Continued Opioid Use

The patients studied were all 18 and over, cancer free, studied June 2006 through September 2015 and did not have a history of opioid abuse. Here’s a look at the results:

A person who received 1-day supply of medication had a 6% chance of being on opioids for a year or longer.

With a 5-day supply, they had a 10% chance of being on opioids in a year.

With a 10-day supply the odds go to a 20% that they will be still using opioids in a year.

A 30-day supply had about 30% chance of being on the medications a year later.

So if you start on opioids, and have it for over 10 days, 1 in 5 of those people may still be on those medications. However, it also means that 80 percent will not still be on those drugs.

Interpreting The Results

Several messages can be inferred from this data. First, acute pain should be treated with the least amount of medication for the shortest length of time. If at all possible, avoid the use of opioids for acute pain and find other less addictive and dependency causing medications. Second, many people do not use these medications long-term and can use them responsibly. Lastly, pain is very complex, and since some medications are highly addictive, try to avoid them and use the multiple other ways to treat pain including everything from chiropractors, to physical therapy, to exercise, and to injections.

The study also may be an analysis of the treatments available for severe pain. Some of the most effective treatments sometimes are the least healthy and can cause dependency. Opioids have been around for hundreds of years. Our knowledge of pain is limited, as are the solutions. Since it is such a huge medical problem, we really need to spend more on research and solutions. We know there is an opioid crisis with addiction. We need research solutions and new treatments. Now is the time to spend on research, as it may provide better solutions for more people than some of the recent government spending recommendations.

Minnesota Medical Marijuana System Tough On Chronic Pain Patients

April 7, 2017 / Thomas Cohn, MD

One of the approved conditions for medical marijuana in the state of Minnesota is intractable pain. Intractable pain is pain that can’t easily be tracked to a specific source and treated successfully, and many patients with chronic pain are deemed to have intractable pain. So you’d think the medical marijuana program in Minnesota would be beneficial for chronic pain sufferers? Well, according to a recent article in the Star-Tribune, it’s anything but easy.

Jumping Through Hoops

Minnesota is at least moderately progressive in that it allows medical marijuana as a treatment option for some conditions, but there are still a number of issues with the current state of the program. For starters, the majority of doctors in Minnesota – including those who specialize in treating chronic pain – are not approved to certify patients for the medical marijuana program. The reason being is that the health care system employers prohibit these doctors from prescribing it. Some doctors who treat rare and severe illnesses can prescribe the treatment, but the vast majority cannot.

So, most doctors are unable to prescribe it. You’d think the state would compile a list of doctors that could prescribe medical marijuana to those who qualify, but no state-provided list exists. Instead, patients need to search the web, call clinics and try to track down a doctor who can prescribe the treatment on their own.

Footing The Bill

Once you’ve tracked down a doctor and had your medical records faxed over to the clinic, you finally get to meet with a specialist who can prescribe medical marijuana. But, according to the Star-Tribune columnist who sought medical marijuana for her pain, since the appointment was for medical marijuana certification, her insurance wouldn’t cover it. So the $844 bill for the 90-minute session would come out of her pocket.

If she would be approved by the state, she’d have to pay a certification fee. That runs $200, and it needs to be renewed each and every year. Moreover, after you pay your certification fee, your treatment needs to be approved by the state. If you are approved, you then have to fill out a Patient Self-Evaluation Form. Finally, after that is approved, you can visit a Cannabis Patient Center, where any purchases once again aren’t covered by insurance, so you’re paying out of pocket. Oh, and forget writing it off as a medical expense, as medical marijuana is not legal under federal law, so the expenses can’t be written off.

The author detailed how she would need to return to the clinic four weeks after receiving the medical marijuana for a follow-up appointment that again would not be covered by insurance (and again at six months). In all, she estimated that her start up costs would fall just short of $2,000 just to get into the program – and that’s without purchasing any medical marijuana.

There are good intentions behind the legalization of medical marijuana in Minnesota, but the program currently has many faults. These patients who are in incredible pain are repeatedly being asked to jump through hoops and open their wallets just with the hope that they can get in the program and find a solution for their pain. The current system is broken, and while we’d like to see more money being poured into medical marijuana research to ensure we increase treatment effectiveness, we can’t expect the solutions to happen on their own. We need to revamp the process for getting medical marijuana for patients with intractable pain.

Why Chronic Pain Patients Feel Targeted By Opioid Crackdowns

March 28, 2017 / Thomas Cohn, MD

As opioid overdoses continue to rise in the US, the government, lawmakers and medical personnel are all trying to figure out the best way to reduce these unnecessary deaths. Obviously restricting access to opioids would reduce the number of people who can get their hands on them, and in turn reduce overdose deaths, but it would also unfairly target people who need the pills. People like those suffering from chronic pain. So it’s understandable to see why when lawmakers propose strict rules for who can access these medications that chronic pain sufferers feel like they are being targeted and singled out.

It’s a tough balance to strike, and unfortunately it seems that as a nation we are more focused on what is easy and cheap instead of what will really address the root problem. Putting a band-aid over a large gash might stop some bleeding, but the wound won’t close correctly without stitches. Simply restricting access opioids and painkillers might stop some abusers from getting the pills, but it won’t solve the whole problem. We need to put some stitches in place.

Solving The Opioid Crisis

We’re not going to sit here and pretend we have all the answers for solving the problem of opioid addiction and overdose, but like we said above, simply restricting access is not going to solve the problem, and many innocent people who rely on those medications may no longer be able to access them. Instead, here are some steps that will help address the root problem.

1. Doctor Education – The vast majority of doctors understand that opioids do not address the root problem, but sometimes they are confused by a diagnosis or have seen other treatments fail and they fall back on them. Other doctors cut corners and prescribe pills freely and dangerously. We need to provide better understanding at the top level of how these drugs should be used, how to spot signs of abuse and how to ensure patients are safely taking their medications so that overdoses don’t occur.

2. Systemic Pressure – This problem will be harder to solve, but in many cases doctors are told to see as many patients as possible. If a doctor is feeling overwhelmed or rushed to see a number of patients, they can sometimes fall back on easy solutions like opioids. Doctors need to take their time with each and every patient and ensure they are giving them the best care possible. It’s possible the best care will involve opioids, but it should also involve therapy, exercise and regular abuse checks.

3. Patient Education – Patients also lack understanding of opioids and their abuse potential. Opioids are not a magic pill that will cure your pain, but they can provide temporary relief so other rehab techniques like exercise, swimming or physical therapy are more bearable. Opioids are a passive treatment, and they need to be paired with an active treatment option for best results. Patients also need to learn the warning signs of abuse for themselves and for loved ones who may have access to their pills.

4. Pill Technology – Medical researchers are looking into new abuse-deterrent opioids. They are creating pills that can’t be crushed or that become gooey if a user tries to extract the solution for injection. Other pills come in an extended release form and can’t be manipulated to give an elevated or intense high. More research into abuse deterrent options could prove useful.

Simply saying we need to restrict access to opioids will not solve the problem, and many chronic pain sufferers will be affected instead of those who are actually abusing the pills. That’s why so many patients feel targeted by these proposals. It won’t be easy to reverse this trend, but if we put in the time and money, it can be done.

Do Daith Piercings Work? Let’s Hear What Patients Have To Say

March 23, 2017 / Thomas Cohn, MD

The daith piercing is without a doubt the most talked about subject on my site, which is ironic because I do not perform the procedure myself. My goal as a pain management specialist is to analyze a person’s pain and come up with a variety of solutions to help manage and treat that pain.

I referenced how some people have experienced headache relief by having their daith pierced and, although I’ve mentioned that there is no hard science behind the piercing, I’ve explained how some of the pain pathways may be affected by stimulation.

We’ve been referenced, praised and lambasted on other sites for talking up the piercing, but people continue to ask us questions about the daith piercing. So instead of giving some general answers about why it may or may not work, we though we’d let people who have already undergone the piercing speak about their experience. We’ve collected a bunch of comments from people who have shared their story on our site, and we want to put them in one easy to read place. So below, you can read what people who have undergone the piercing are saying about their experience. We hope you find it enlightening.

People Who Have Had The Daith Piercing

Here is a sample of some of the most recent comments we’ve received about the daith piercing.

I had a daith piercing done (left side) on 9/30/2016. I have not had a migraine since getting this done. I used to have one every day, with several trips to the ER a month. I had tried every medication possible they could prescribe me for them and the only thing that ever really worked for me was going to the ER and doing the IV cocktail thing, which unfortunately there is no script that can be given that works like it. When I got my piercing done I was experiencing a migraine almost to the point of debilitation, the second he preformed the piercing the pressure was relieved, similar effect to pushing the pin in the stem of a tire to let the air out and my vision was no where near as blurry. the next day it was gone with no meds at all. I do still get small headaches but OTC meds knock them right out. My only caution for it is please strictly follow the after care instructions and do your research on the shops that are doing them. Be 100% comfortable with the person doing it for you. Many shops say “oh yes I can do that for you, I have done tons of them” but just because they have done them does not mean they have done them correctly. – D.A.

I just recently had this piercing. I had researched this for several months before deciding and talked to several people that had it done and have had great success. It was really not as painful as everyone makes it sound and took less than 60 seconds. I am very hopeful about this helping with my migraines. – C.S.

I’ve had headaches all day everyday for a long time, so I heard about this piercing and I went and got it done right away, went in with a headache and left pain free, literally! It’s been 3 days now still no pain or headache The piercing site bled a little because I slept on it. Cleaned it up and it’s healing, so very thankful I had it done, I love being pain free. – S. W.

I’ve had headaches for over 20 yrs. Its hurt pretty much every day for years now. Most days its a dull ache but other days they can become quite unbearable. Meds don’t help. I just got my daith piercing today. Before doing it I spent a few weeks massaging the general area so I know that pressure seemed to help, but only while pressure was being applied. I can say this much, I had a pretty bad headache before getting it done, my headache went away, but my ear is quite sore right now. It was quite painful for me, but everyone is different. – R.T.

I had the piercing in both ears it’s been a week now. I’ve not had the headaches but the pain I’m experiencing in my jaw is really bad what did you suggest that I do for the pain. I’m think of taking them out. – B. P.

I suffered chronic migraines and was in my 11th headache day when going in to get this piercing. Immediately upon the needle going through there was a HUGE release. I was getting migraines regularly during my menstral cycle my last cycle passed with NO migraine for the FIRST time in YEARS! I have only had one migraine since the piercing and it could hardly be called a migraine compared to what I was used to. I get them if I eat eggs or chocolate on an empty stomach.. if I skip meals or stay up too late. The last migraine I had was triggered by eggs and the pain was 50% less to 70% less than what i was used to and it only lasted a day and a half compared to the usual 3 days. This piercing helps tremendously and perhaps the acupuncture community could learn something. Also acupuncture does not pierce all the way through the skin.. there are a bundle of nerves penetrated that are deeper into the skin than acupuncture goes. Acupuncture may help some for me it stimulated my headaches and made them worse. The Daith was so helpful and so healing. There are SO many people being helped by this and Thank GOD for whoever noticed the correlation. Hope this helped! Bless! – K.E.

So as you can see, the piercing has worked for some, and not for others. There’s no guarantee that it will work for you, but for individuals who have failed to experience relief from other treatments, it may be an option worth exploring.

The Benefits and Drawbacks Of Medical Marijuana

March 20, 2017March 20, 2017 / Thomas Cohn, MD

Recently, the National Academies of Sciences, Engineering, and Medicine did a comprehensive review of the information available on the use of marijuana. The study looked at research published since 1999, and they came up with a number of conclusions. One of the most important findings is the current lack of good scientific information on marijuana. There is a clear need for good scientific research to guide healthcare professionals on the risks and benefits associated with marijuana use. Currently, to study marijuana or any of its derivatives, the federal bureaucratic hoops one must go through makes it extremely difficult to perform. The information available and the quality of the research at this point are limited. The conclusions are based mostly upon case report studies with limited controls.

The Complexity of THC and Marijuana

In Minnesota, medical marijuana is available to treat several specific conditions, and this year chronic pain was added to the list of approved conditions. The recent study also supports the idea that marijuana may be helpful to treat some people with chronic pain. For some it seems the non-THC (THC is the component that is responsible for the “high”) may help for pain. Since there are multiple causes of pain, it definitely is not indicated for everyone. Further, no studies have been done to determine what types of pain may be helped by components of marijuana, and it is not clear which of the 80 or more different compounds in marijuana are helpful. It is also known to be helpful for nausea from chemotherapy, and spasticity in multiple sclerosis. Marijuana may help in appetite with HIV, and there is limited evidence for help with bowel disorders, epilepsy, and Parkinson’s disease.

Potential Drawbacks

There are multiple potential harms that may be caused by marijuana. There is strong evidence that its use can lead to schizophrenia and psychosis, especially among young and frequent users. It may also lead to depressive disorders. The claim that it can make you a better driver is simply false, as statistics have shown that it leads to inattentive driving, a main contributor to traffic accidents. In pregnancy, use can lead to low birth weight in infants. Smoking pot can also cause and worsen any respiratory condition. There is weak evidence that smoking marijuana can increase the risk of heart attacks. One can also develop an addiction to marijuana. Conclusions cannot be drawn with regards to school achievement, unemployment, or social function and marijuana use.

Understanding It All

The overall scientific conclusion so far is that marijuana may have some reasonable medical uses. However, the scientific research on the compound is extremely limited at the moment. In the United States, it has been classified as a compound with no medical value and harmful to society. What needs to happen is that national legislation is needed to reclassify marijuana as a controlled substance, then good medical research can be done to determine what compounds in this plant are helpful or harmful. Once good research is done, then the use of compounds can occur with everyone understanding appropriate risks and benefits like with any other drug now available.