Doctor Killed For Not Prescribing Pain Pills To Patient

August 7, 2017 / Thomas Cohn, MD

Last week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated. Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.

Cutting Back On Opioids Could Reduce Pain

July 18, 2017 / Thomas Cohn, MD

It may sound counterintuitive, but new research suggests that reducing long-term opioid intake could actually lead to lower pain levels in patients with chronic pain.

More than 10 million Americans are currently prescribed a long-term opioid to deal with a chronic pain condition. The number of people who get these prescriptions continues to grow, and not surprisingly so too do opioid overdose deaths. Used correctly, opioids can work wonders for individuals who have been struggling to find a way to take control of their chronic pain, but far too often they are overprescribed and knowingly or unknowingly abused.

Long-term opioids should only continue to be used if you’re still seeking active treatment options to address the painful condition. Since opioids are a passive treatment option, they are only masking the pain, and they aren’t actively working to correct the problem. They can work wonders when paired with active solutions like physical therapy or exercise because it can lessen pain during these crucial strengthening times, but if you’re not actively working towards a solution, long-term opioids are just dulling the pain while your body begins to crave larger doses of the drug to be effective, which can lead patients down the path of addiction.

Reducing Long-Term Opioid Intake

Researchers conducted a systematic review of 67 published studies in order to determine the effects of discontinuing long-term opioid therapy for patients with chronic pain conditions. Although they admit that the overall quality of evidence was not superb, they found an association between long-term opioid dose reduction and improvements in pain, function and quality of life.

“It’s counterintuitive that pain and well-being could be improved when you decrease pain medication…but patients felt better when dosages were reduced,” said Dr. Erin Krebs, medical director of the Women Veterans Comprehensive Health Center, part of the Minneapolis Veterans Affairs Health Care System, and an author of the study.

However, study authors echoed what we’ve been saying in this blog, that long-term opioid reduction shouldn’t be done by itself. It should be reduced with the oversight of a licensed physician and paired with other multidisciplinary approaches and behavioral interventions to continue actively pursuing pain reduction and function improvement. Hopefully future studies can take a closer look at this idea and provide some clearer solutions with stronger evidence so we can continue doing everything in our power to help patients fight back against their chronic pain conditions.

Overprescribing Opioids Is A Problem In Our Own Backyard

July 13, 2017 / Thomas Cohn, MD

New findings published in the Annals of Surgery suggests that clinicians at the Mayo Clinic in Rochester were routinely writing opioid prescriptions for surgical patients that exceeded regulatory guidelines currently being drafted by the state of Minnesota. The findings also uncovered significant differences in opioid prescribing among the Mayo clinics in Rochester, Arizona and Florida, as well as within surgical procedures.

Study senior author Elizabeth Habermann, who also serves as the scientific director of surgical outcomes research at Mayo, said the findings help highlight where improvements can be made.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Opioid Overdoses In America

According to the Centers for Disease Control and Prevention, the number of deaths involving prescription opioid overdoses have nearly quadrupled since 2000. In fact, more than 90 people died each day from either a prescription opioid or heroin overdose in 2015 alone.

Study co-author Dr. Robert Cima said doctors have been so focused on ensuring patients have their pain minimized as much as possible after surgery that they often don’t consider the possible long-term side effects of the prescriptions they’re filling.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said Dr. Cima, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

I have no doubt that the Mayo Clinic will adhere to the new guidelines being drafted at the state level in short order, but this story speaks to the larger issue of just how unregulated opioids are at some of the nation’s best hospitals. And if it’s happening there, you can bet it’s happening to a larger degree at lesser care centers.

However, these findings do cast light on the problem and should help push us towards a solution, but it’s not necessarily going to come from the top down. It needs to start with doctors. We need take time with each patient and push them towards active treatment techniques instead of passive treatments like opioids. Opioids certainly have their role in pain management, but they shouldn’t be over-relied on, as it appears they are.

Understanding Opioids, Addiction and Naloxone

April 17, 2017 / Thomas Cohn, MD

Chronic pain patients have a multitude of possible treatments available for the management of symptoms. Strategies often include exercise, physical therapy, chiropractic care, massage, injections and medications. One of the more frowned upon treatments is opioids, but sometimes they are used successfully. With the current opioid crisis, many pain patients fear using them and want to be safe if they have them in their possession.

Opioid Safety

The most important rule with regards to use of any medication, especially opioids, is to never take more than what has been prescribed. Opioids can build up in the body and suddenly become deadly if too much is taken. Running out early can cause opioid withdrawal syndrome and while it is uncomfortable, it is not dangerous to your health. If you are taking opioids, expect your doctor to closely monitor your medication and behavior while taking these drugs. Since they are highly addictive and abused, most doctors will tightly control prescriptions and refills. Drug testing, opioid contracts, behavior screenings, depression screenings and monitoring of other medications are standard. Mixing of medications like sedatives, anti-anxiety treatments like benzodiazepines, and using any street drugs often will lead to ending a prescriptions for opioids, and often there is zero tolerance of any safety rules due to the extreme danger inherent with opioid misuse.

Mixing Street Drugs and Opioids

The latest step in opioid safety is the prescribing of naloxone in addition to the opioid. Naloxone is a drug that can block the opioid receptors for most opioid-type drugs, and it can prevent an accidental or purposeful overdose. In Minnesota it can be obtained at most pharmacies even without a prescription, and can be given effectively as either an injection or as an intranasal spray. Anyone who is routinely taking an opioid or has opioid medications in the home should likely have naloxone too, in case they accidentally or purposefully take too much, or someone else takes their medications. If you are on these medications, ask your doctor about having a safety prescription for naloxone.

Using street drugs for an addiction to opioids or for pain is high-risk behavior. The singer Prince was using Percocet obtained from street sources to control his hip joint pain. The Percocet he obtained had allegedly been mixed with fentanyl, which is an extremely potent opioid and caused his overdose death. If you are addicted to opioids, are using them to get high, use heroin, or have family or friends that is misusing opioids, you can obtain naloxone and this may save someone from an overdose death.

Successful Opioid Treatment

Opioids can be helpful in treating pain, but they are extremely difficult to use due their limited safety. More physicians are very reluctant to prescribe these medications and their long-term efficacy and safety is limited. More information has become available on how opioids actually tend to increase pain over time versus being helpful. Pain management specialists will work with patients to find alternative strategies to these dangerous medications.

One last issue with regards to all medications, especially opioids, is how to dispose of unused or outdated prescriptions. In the past, medications were often flushed down the toilet or thrown out in the trash. The environment does not do well with those methods, and it tends to lead to contamination of our waterways and ground water. Freshwater fish are starting to show significant levels of some commonly disposed medications. The best way to get rid of unwanted medications is to bring them to your local police or sheriff’s department where they have disposal lock boxes. These medications then are handled as hazardous waste and usually incinerated at high temperatures to completely destroy them and turn it to relatively safe ash.

If you’re struggling with an opioid addiction or want a doctor to help get to the bottom of your pain, contact Dr. Cohn today.

How Unregulated Opioid Use Can Lead To Heroin Addiction

April 12, 2017 / Thomas Cohn, MD

In the 1960s, the drug culture was known for psychedelics, LSD and marijuana. Eventually, some of those users sought a stronger high, and that led them down the path to heroin. At least that was the message pushed by the government in its fight against drugs.

Heroin was actually not that common and it was often a drug of addiction found in Vietnam veterans due to its availability in that region. Intense drug programs and interventions to rid production significantly reduced heroin use in the U.S. from the 1970’s through about 2000. In the 1990’s, the era of everyone needing opioid pain management began and along came Oxycontin. The quick and easy option for most doctors to treat pain was to write a prescription for the magical opioid pill. For the last ten years, we now have discovered the rising tide of opioid addiction and now deaths from overdoses is catching up to the number from auto accidents.

Link Between Pills and Heroin

Oxycontin first came on the market in the 1990’s and was extensively marketed as a safe drug for management of pain. The manufacturer would fly physicians to resorts, wine and dine them, and then try to hire them to lecture other doctors on the wonder of their drug. By about 2005, some of the problems with addiction were becoming evident. The government convinced the manufacturer to develop a formulation that would deter abuse by making anti-crush pills, and these came on the market around 2010. It was still a potent drug, but it was not as fun to take and the pills became expensive on the black market. However, the damage had been done and now the main way to treat pain was with opioids, any many people had become addicted to the powerful medication.

A study recently done by the University of Pennsylvania and the Rand Corporation explains why heroin has now become a problem. The development of the new formulation of Oxycontin made this drug more expensive and harder to abuse. Heroin has become cheap, more pure, and once you’re hooked on opioids, it is now easier and less expensive to obtain. So once a person is addicted to pain pills, the cheaper route to get high and prevent drug withdrawal is to use heroin.

Now the latest trick for those with an opioid addiction to get high is to use heroin or oxycodone that is mixed with another synthetic opioid like fentanyl or cor-fentanyl which are a hundred to over a thousand times stronger. These drugs are often been manufactured in China or India, and they can be easily mailed anonymously without much suspicion into the U.S. If mixed wrong, these newer synthetic opioids are often deadly.

Takeaway Points

The message from the opioid crisis is that pain has many ways to be treated, and left unregulated the use of opioids is often more dangerous then helpful. Addiction is a disease; without treatment, some resort to the use of heroin since it is cheap, and many cut that drug with other potent drugs that are deadly.

Stopping the opioid crisis will take time and effort. Treating pain is not just about taking opioids – that has led to the addiction crisis. Money needs to be spent on pain research and the development of better pain management strategies. A third of the population has issues with pain, making it more prevalent than heart disease, cancer and diabetes combined. To solve the problem of pain and drug abuse, a concerted government investment into pain research and better medical management is needed.