The Unforeseen Opioid Issue

February 5, 2018 / Thomas Cohn, MD

This 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.

Minnesota Getting $16.6 Million To Fight Opioid Epidemic

November 10, 2017 / Thomas Cohn, MD

Minnesota 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.

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.

Does Chronic Pain Increase Likelihood Of Cognitive Decline?

June 6, 2017 / Thomas Cohn, MD

Recently, a new report published in the Journal of the American Medical Association suggests that there may be a link between chronic pain and the eventual onset of cognitive issues. But do these findings really suggest that chronic pain leads to an increased risk of cognitive decline, or is there something bigger going on? We take a closer look in today’s blog.

For their study, researchers at the University of California at San Francisco decided to look at how chronic pain impacted a person’s mental health. They began by examining data collected on more than 10,000 individuals over the age of 60 who were taking part in a different nationwide study. Patients in that study were surveyed about their pain scores and cognition in 1998 and 2000. Patients were then monitored over the next decade.

Chronic Pain and Brain Health

After looking at the data at the end of the study, researchers found that individuals who said they were persistently bothered by moderate or severe pain declined 9.2 percent faster in cognitive and memory tests over the next 10 years compared to those who said they were not in pain. Moreover, patients who complained about persistent pain exhibited a 7.7 percent greater chance of developing dementia than patients who did not experience regular pain.

“A persistent report of moderate to severe pain, which may reflect chronic pain, is associated with accelerated cognitive decline and increased dementia probability in a large population-representative data set of elders,” wrote first author Elizabeth Whitlock, MD, a postdoctoral fellow in the UCSF Department of Anesthesia and Perioperative Care. “Clinicians should be aware of this association, which persisted after extensive statistical adjustment for confounding health and demographic factors. Patients reporting ongoing pain may be at higher risk for current and incident cognitive impairment and physical debility.”

Pain Can Compound Mental Health Issues

The authors go on to make another key point about the problems associated with persistent pain and the onset of cognitive problems like dementia. Since individuals with pain oftentimes take opioids or other painkillers, cognitive decline can make it difficult for the patient to remember to take their pills or to get the correct dosage, which can be downright dangerous.

“Elderly people need to maintain their cognition to stay independent,” said Whitlock. “Up to one in three older people suffer from chronic pain, so understanding the relationship between pain and cognitive decline is an important first step toward finding ways to help this population.”

However, the study says the results don’t paint a perfect picture of the link between chronic pain and cognitive decline. Since a good deal of patients are on a variety of different pain medications to help control their pain, researchers said that the pills could be contributing to dementia and other cognitive problems, and pain may not play a role.

Hopefully future studies will look closer at the role opioids may play in cognitive decline. Regardless, this study is just more proof that we need to be investing more time and energy into seriously working to find solutions to the myriad of chronic pain problems in the US and throughout the world.

Opioids and a Healthy Mindset For Managing Pain

May 4, 2017 / Thomas Cohn, MD

The most common treatment option in America for individuals suffering from chronic pain is opioids or pain medications. According to statistics, the US is home to 5% of the world’s population yet we consume 80% of the world’s opiates. Our pain isn’t any different than pain felt by someone in Africa or Asia, so why do we rely so heavily on opioids?

According to Dr. Aneesh Singla, it’s because we have the wrong mindset when it comes to setting expectations for opioid effectiveness.

The Myth of Zero Pain

The Centers for Disease Control and Prevention states that the number of prescription opioids sold in the US since 1999 has quadrupled, yet the number of Americans reporting pain hasn’t changed. That’s because opioids are viewed as a solution, not as an aid to simply decrease pain while other treatments are performed. Opioids will never cure a chronic pain condition on their own, yet we expect them to rid us of all our pain. In a recent article, Dr. Singla said this problem can sometimes be traced back to the physician, who fails to explain that a chronic pain situation is not a zero sum game.

“I believe that pain is protective to us and that opiates will never cure pain 100%; so we set expectations for perhaps 50% pain relief from opiates, so that opioids are not overused in search of 100% pain relief,” said Dr. Singla. “I tell my patients that a 50% reduction in pain is a reasonable goal when treating chronic pain, and we seek this with multiple treatment options, not simply through opiates.”

There are two key takeaways from that quote. First, that the main goal of pain care treatment needs to be a reduction in pain, not its elimination. If you’ve been dealing with chronic back pain for years, it’s unreasonable to think that treatment will completely cure the problem and leave you with zero pain or discomfort, so the focus needs to be on making every day or every week less painful than the previous. The second point is that opiates alone will never solve this problem.

Opioids and Pain Expectations

We talk about pain medications on this blog and on our social channels a lot, and it’s interesting because the topic often brings out a knee-jerk response from different people. When we write articles about painkiller abuse or that pain will never be solved by a pill alone, many people are quick to defend their responsible opiate use and feel that we are attacking individuals who truly need pain pills to help them get through their day. The problem is that knee-jerk reaction couldn’t be farther from the message we’re trying to convey when talking about addiction, abuse or painkillers in general.

Opioids can be a key component to effectively managing chronic pain. We aren’t against opioids at all. What we’re trying to show in these articles is that our current views on them are misguided and that they need to be re-evaluated. It starts with the pharmaceutical companies who only care about their bottom line; It trickles down to the doctors who over-prescribe or under-educate patients on what they should expect from the opioids and how they can be used in conjunction with other treatment modalities, and it ends with the patient who decides to take an extra pill because their back is more painful than normal because they’ve skipped their last three physical therapy sessions.

Managing pain is not easy, and opioids play a vital role, but we need to do a better job of setting expectations and pairing pills with active rehab options to ensure the best results for our patients.