opioids

The Unforeseen Opioid Issue

/ Thomas Cohn, MD

overdose pain pillsThis week, another issue of opioid use to control pain came to light in the news. In a suburb of Minneapolis, a patient was in a nursing home type facility. Along with whatever issues brought them to the facility, apparently they had pain and were receiving opioid medications. At the nighttime dose, a staff nurse, probably in a hurry, gave a huge dose of the medication instead of the proper dose without noticing the mistake. By morning the patient was dead from an overdose. All opioids can cause breathing problems especially in those who are sick, and too much medication can easily be deadly.

The overdose of anyone by a person administering medications is unfortunate and should never happen. Two lessons are clearly evident. First, always double check to make sure you are taking the right medication and dose, and second, be aware that these medications are dangerous. When prescribing opioids, medical personnel should always be careful on how much medication is being prescribed and try to avoid giving excessive dosages.

If there are no alternatives, then be careful. Evaluate for medications that may interact with the opioids, such as sleep medications that may suppress breathing or anxiety medications. Check the person’s history for other medical conditions that affect breathing, like lung disease and sleep apnea, since opioids may disrupts breathing patterns. Make sure the person is mentally capable of taking the medication correctly, and that they are not suicidal, depressed, or  dealing with dementia, because this too can also lead to an opioid overdose.

Narcan’s Role In Preventing Overdose Deaths

Besides the above and a bit of common sense, preventing opioid overdose deaths is important. Many providers are adding a prescription of Narcan nasal spray when writing scrips for opioid medications. This is a medication that can block the effects of opioids and reverse its medical effects completely in the body. Narcan can block the respiratory or breathing problems from an opioid, but it will also reverse any pain relief. It is easy to deliver, it is shot as spray up the nose and will quickly reverse only the opioid-induced problems. However, for the new synthetic opioids like fentanyl or carfentanyl that are being abused with heroin, multiple doses may be needed in treatment.

Now, anyone receiving any significant amount of opioid for pain should receive Narcan nasal spray. The person who is normally taking the opioid may not need the Narcan unless they accidentally take to much medication. Otherwise, if someone else in the home of the opioid user takes the medication on purpose or by accident, the Narcan can be used to reverse the opioid and prevent death. As always noted, opioids are not ideal pain medications and can be easily deadly. Having and using Narcan in cases of emergency can prevent an untimely death.

The Gender Disparity of the Opioid Crisis

/ Thomas Cohn, MD

chronic pain pills womenA recent opinion piece in the Star Tribune shined a light on the problem different genders face in the opioid crisis, particularly the challenges faced by women.

One of the main talking points is that deaths from opioid overdoses have increased much faster for women than for men. Female deaths from opioid overdoses have increased 400 percent in recent years compared to 265 percent for men. Both of these numbers are very problematic, but it helps to show that the opioid crisis is affecting each gender differently.

When opioids affect women, it can oftentimes have a bigger trickle down affect than when it affects men. As the article states, in most American families the woman is the primary caregiver, and the woman’s well-being is often closely tied to the health and future of the children. Opioid abuse by the primary caregiver can often lead to problems down the road for the children, and it increases their likelihood of having their own battles with substance abuse. When opioids negatively affect women, it rarely impacts just one person.

Fixing The Problem

The article went on to suggest some ways to reduce opioid disparity and the larger problem of gender-based health disparities in the United States. Some of the proposed solutions include:

  • Addiction risk education for doctors and patients
  • More education has led to fewer opioid prescriptions and in some places, a downturn in overdose deaths
  • Better emergency room treatment
  • Education campaigns to change dosage standards for women
  • Increased doctor education in states where women disproportionately suffer from conditions like obesity, high blood pressure, diabetes, chronic pain and heart problems
  • Stop cutting insurance coverage for certain programs like Medicaid and Medicare

It’s clear that there’s no one-size-fits-all answer for fixing the opioid crisis and gender-based healthcare disparities throughout the country, but the first step is to help spread awareness that a problem exists. Then we need to put a plan of action in place and stop making the bottom line a higher priority than the health of the patient in our office.

Opioids certainly have a place to help patients when properly assigned and administered, but far too often they are being blindly prescribed and without safety measures in place if abuse begins. The Star Tribune article is a step in the right direction by calling attention to the problem, but now we need doctors, patients and our legislatures to follow through. For the sake of women and families across the country, I hope we can work towards a solution.

Minnesota Getting $16.6 Million To Fight Opioid Epidemic

/ Thomas Cohn, MD

opioids chronic pain minnesotaMinnesota is set to receive $16.6 million in federal grants that will be given to foundations and organizations committed to fighting the opioid epidemic.

More than 30 different agencies will receive grants from the federal fund, and the goal is to reach and help more than 110,000 Minnesotans who are seeking treatment for opioid dependency. Most of the money will go to existing programs to launch new efforts or expand current efforts in combating the opioid crisis.

“These grants are designed to build on what we are doing,” said Minnesota Human Services Commissioner Emily Piper.

The Opioid Problem In Minnesota

According to health data, there were nearly 2,500 opioid-related overdoses last year, and 376 of those overdoses were fatal. There were more than 3.5 million prescriptions written for opioid painkillers in Minnesota in 2016.

The federal grant will go to a number of specific places and programs, including:

  • More widespread availability of naloxone, a key substance in helping save people who have overdosed on painkillers.
  • Expanding medication-assisted treatment.
  • Increasing aid and resources on American Indian reservations.
  • Adding opioid-specific care providers throughout the state.
  • Establishing a program to help unborn and newborn babies of mothers with opioid dependencies.

There has also been a push for more regulation at the national level from Minnesota lawmakers. A presidential opioid crisis commission recommended that President Trump support two bills proposal by Minnesota Senator Amy Klobuchar. The first would require more monitoring of drug prescriptions and the second would attempt to reduce the number of opioids that are being illegally distributed through the US mail system.

The Landscape of Addiction in 2017

/ Thomas Cohn, MD

addiction opioidsOne of my favorite activities is reading. I read a wide variety of things, some of the most interesting things come from magazines that are not medical. Time magazine regularly has interesting stories of health.  Science, a bi-weekly publication, routinely has articles on a wide range of subjects that challenge the core of what one thought was fact. National Geographic regularly throws in medical stories. A couple years ago they had a great summary on marijuana, and recently now they had a great article on addiction. Medical journals are often a somewhat dry and boring read, but they do allow one to keep up-to-date with current research. Sometimes these other magazines have extremely valuable information as well.

The September 2017 National Geographic lead story is on The Science of Addiction. The problem is more than just opioids, it is a vast variety of problems from smoking to gambling and including all kinds of drugs. Addiction is a very complex process in the brain, and is definitely a disease and not a moral failing. Different types of addictions may affect a variety of brain regions. The processes involve disruptions in pathways responsible for learning, emotion, desire, regulation, and cognition among many neural events. It can change chemical, hormonal, and electrical paths in the brain. Addiction becomes abnormal learning in the brain with the reward being the addictive activity.

Addiction And Our Brains

All addiction has its roots in the primitive regions of the brain. They have to do with our need to survive, and they all involve our senses like sight, smell and taste. Critical in addiction is the neurotransmitter dopamine and that stimulates brain motivation. Those lacking dopamine often are depressed. Further, Parkinson’s disease has a lack of dopamine, and when given to some patients, it causes problems with an addiction like gambling. When something is addictive, it stimulates the dopamine pathways in the brain and is a very positive reward. The dopamine reward is so strong in the brain, people lose the control of impulses and the ability to inhibit behavior even if it is self-destructive.  

Since there are many things that are now considered true addictions, it is likely there are many different strategies to treat them. For drugs, often there are medications that can block the pleasure from the drug and prevent withdrawals. For alcohol, there are drugs that make drinking nauseating. There are also numerous counseling strategies and psychological-type interventions to deal with the behavioral components of addiction. There are also some new novel strategies including electrical and magnetic stimulation of specific areas of the brain to treat addiction.

The problem of drug addiction or any type of addictive behavior is caused by abnormal function and rewards in the brain. Pain and the problems associated with the medications taken can cause addiction, but this isn’t always the case. Taking opioid medications does lead to dependence and tolerance of the drugs that cause them to lose effectiveness. Opioids can also change a person’s sensitivity to pain and make a person perceive pain sensations more intensively. Therefore, in general, opioid medications have many downsides.

Lastly, opioids can be addictive and cause typical addiction issues in pain patients, but it is in only in a small percentage, somewhere between 5-20%. In most chronic pain patients, addiction and problems with opioids are generally not a typical problem. Treatment in pain patients is the same as with any other person who has opioid problems, and is often best handled by a pain care specialist.  If you are a pain patient on opioids, and taking your medication has become the focus of your life, then it is probably time for one to be treated for addiction and be off of these medications.

Let’s Focus On The Pain Epidemic, Not The Opioid Epidemic

/ Thomas Cohn, MD

pain opioid epidemicA recent article in the Star-Tribune noted that every three weeks, the death toll from opioid overdoses matches the death toll from the attacks on the World Trade Center on September 11, 2001. Not only is this a concerning number, but trends show that the death toll from opioid overdoses is continuing to skyrocket. The government and even President Trump have stated that the opioid epidemic is a problem that needs to be solved, but are they looking at the problem in the right way?

The opioid crisis is a huge issue, but it’s only a symptom of a larger problem, which is the pain epidemic in America. More people are turning to opioids in the United States because more of them are fighting a losing battle against pain. We need to be finding solutions to the pain problem, because the opioid crisis is a symptom of the problem of pain.

Stopping Pain

Think of it this way. Let’s say you’re in your house and you see smoke. You run to the kitchen and notice a fire behind the stove. You quickly fill up some water from the sink and douse the flames with water, stopping the fire in its tracks. It’s great that you stopped the fire, but you wouldn’t just go back into your living room without investigating what caused the fire to start in the first place. If you don’t fix the faulty wiring that caused the fire, you’re prone to another fire in the future.

In the above instance, throwing water on the fire is like trying to treat the opioid epidemic. It is a problem that needs to be addressed, but unless we also focus on the root problem, which is pain (or faulty wiring in this case), then the problem is only going to continue to be cyclical. Eliminating opioids may reduce the number of overdose deaths, but it will also hurt patients who use them responsibly to manage their pain, and severely cutting back on opioids will do NOTHING to solve the pain problem.

What We Need To Do

Enough about what’s wrong with the current system – here’s a definitive list of what we as a nation need to do in order to fix the opioid crisis and the pain problem in America.

  • We need to educate both patients and doctors about how opioids work in conjunction with a multi-faceted approach to pain management.
  • Opioids can play a role in pain care, but they can’t be the only treatment option. They can help manage pain, but they are not a long term solution to treat pain. Anybody who is only taking pain medications for their condition is at a high risk for dependency and has a low chance of ever recovering from their pain.
  • We need to open up insurance coverage to other non-traditional methods of pain management. Let’s get creative with pain management, because what works for some will not work for others.
  • We have to pound home the message that there is no magic pill for pain, but tangible solutions are within your reach.
  • Doctors need to do a better job of pushing people towards tangible solutions instead of quick fixes. Things like physical therapy, aqua therapy, cognitive behavioral therapy, yoga, etc. over writing a quick prescription.
  • We need to invest research funding into pain treatments, whether it’s medical marijuana or new diagnostic tools, we need to spend money on solving the problem of pain. Invest in pain solutions like we’re investing in treating cancer or diabetes.

If we can check off all the items on this list, I’m confident we can find new ways to treat pain, and in turn combat the opioid crisis in America.