Archive for 'pain medication'

What To Do When Back Pain Causes Overdose?

“We don’t appreciate what we have until it’s gone.” If only we had a dime for every time we heard this. Perhaps the reason it is such a common expression is the simple truth in it. This certainly applies to our health, but specifically our backs. We probably all take our good health in vain, until something goes wrong. By the time we are in our forties over twenty percent of us experience some form of back pain. And what do we do when we experience pain? Well, unfortunately many people will turn to strong painkillers. This means opioids, morphine-like painkillers. And, while we have written about this topic in the past, there is something new on the horizon. Evzio, the brand name of injectable Naloxone, is a prescription medicine that can block the effects of morphine and related painkillers. Approved by the FDA in April 2014, it allows a patient to quickly treat themselves or be treated by a family member if the patient has overdosed on opioids.Evzio

In the past, Evzio was difficult to obtain due to its high cost. However, recently The Clinton Foundation announced that it has negotiated a lower price for Evzio (see NYT article). This will allow municipalities to more easily purchase this medication, making it more available to those who need it.

It is a sad reality that many people will turn, in desperation, to painkillers as an answer to their aching backs. We, at the Norman Marcus Pain Institute, only use opioids as a last resort. Our method of finding the source of the pain and treating it has eliminated back pain for thousands of patients.. Nevertheless, with the rise of overdoses each year, the increased availability of naloxone to non-medical personnel will allow lives to be saved.

 

 

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Because of the growing problem of addiction, misuse, and diversion, 49 states have now adopted a state prescription drug database.  You may have read an article recently in The New York Times about Missouri being the only state that has not adopted such a database. In New York, as a prescriber of controlled substances, each time a patient is prescribed any type of controlled substance, I must log into the NYS website to confirm that a patient is not receiving other medications from other doctors.

prescriptionsI found a few patients who had not been honest with me and had received medications from other doctors. Unfortunately, the small occurrence of dishonest behavior has obliged all doctors to be alert for the possible misuse of medication.  At the Norman Marcus Pain Institute, I implement several rules for patients receiving any type of controlled substance from me. Here are a few of them:

•             Only one physician can prescribe all pain medications.

•             Only one pharmacy should be used to obtain all pain related medications.

•             All medications, including herbal remedies and over the counter medications, need to be reported since all medications can interact with one another.

•             Medications must be kept in a safe and secure place, such as a locked cabinet or safe.

 

Following these simple rules will help protect my patients and their families from improper use of pain medication.

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From 1991 to 2009, the number of prescriptions written for the strongest pain medications tripled. These medications are collectively named opioids and include morphine, oxycodone, and hydrocodone.Opioids are a type of pain drug that may cause serious side effects. From 2005 to 2009, the number of emergency room visits for nonmedical use of prescribed pain medication doubled. Therefore, the states and federal governments are acting to try to limit the amount of pain medication being prescribed.

At NMPI, we focus on finding the most effective treatment to relieve our patients’ pain – without surgery, steroid injections, or heavy painkillers. However, when a patient complains of severe pain and is not responding well to other pain medications, stronger, prescription opioids will be given.

 
Pain pills blog-Norman Marcus Pain Institute-blogSome opioids, such as oxycodone, are often combined with Tylenol (acetaminophen) in one pill. Some examples of these combination drugs are Lorcet, Lortab, Norco, Vicodin (are all hydrocodone and acetaminophen), and Percocet (oxycodone and acetaminophen). Most often, severe pain is related to a condition that will improve over time. Ideally, all prescription pain medications should be given only while severe pain persists. Like any medication, there are risks and side effects:

 

• Opioids can make you drowsy – which raises the risk of falling and severe injury
• Opioids when mixed with alcohol, anti-anxiety medication, seizure medication, muscle relaxants, or sleep-aids can be deadly.
• Opioids cause constipation and can lower sex drive.
• Patients can become physically and psychologically dependent on opioids.
• Overtime a patient with chronic pain can develop a tolerance for the opioid and need a higher dosage.

Keep in mind that not all pain requires such strong medication, and most patients with pain can be managed with drugs such as acetaminophen (Tylenol) and aspirin-like drugs, called non-steroidal anti-inflammatory drugs (such as ibuprofen and Naproxen). When taken as directed, these less powerful drugs may be all that you need. (There are potential serious side effects with acetaminophen and NSAIDs, which I will discuss in a future blog.) For certain pains, some drugs are better than others. Sometimes we find that a drug we have been using may not actually be effective. A New York Times article on July 23, 2014 reported that for treating low back pain, acetaminophen was no better than a placebo.

Physicians have a responsibility to properly care for patients in pain. Some of these patients may appear to be at a higher risk to abuse opioids. Occasionally, patients complain of non-existent pain to obtain opioids for its mood-altering affect, called a “high.” The fact is that physicians who had been writing too many prescriptions for pain medication are now wary of prescribing any potentially habit-forming pain drugs. This has resulted in a decrease in emergency room visits for drug overdose and deaths from overdose, but it has also resulted in depriving many patients of medication they legitimately need to function normally.

At NMPI, when we treat patients in pain who have a history of drug abuse or who test positive on a written test to determine the risk of abuse, I believe that these two basic American traditions should be the guiding principles:

1. Innocent until proven guilty; and

2. In the words of Ronald Reagan, Trust but verify. Those patients who have problems or are at risk to not properly use pain medication need extra attention, not condemnation. They may be more difficult to treat, but that is why there are specialists to deal with complex pain problems.

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Morphine: Friend or Enemy?

You may have read several articles in the news lately about opioids and pain medications. Earlier in July, The New York Times printed two separate articles on the dangers and abuse of prescriptions drugs in the States. On July 1st, Sabrina Tavernise’s Prescription Overdose Deaths in Florida Plunge After Tough Measures, Report Says, appeared in the Health section and on July 3rd, The Op-Ed editors wrote a piece entitled States and Painkiller Overdoses.

Obviously, the media is very concerned regarding the large number of pain medications being prescribed, the amount of medications being misused and/or diverted, and the adverse effects of the medication, particularly addiction.Pills

Back in the day, alcohol was used as anesthesia for surgeries – patients were given a bottle of bourbon and told to bite the bullet.  Modern medicine introduced Ether and chloroform for surgical procedures and morphine to control the pain after the surgery. Morphine was thought to only be effective by injection, but then we found that morphine tablets and liquid taken by mouth could be just as effective in relieving pain. Morphine was then used for patients with terminal cancer pain. Why not make a dying patient comfortable?

The availability of oral instead of injectable morphine allowed doctors caring for cancer patients to more easily relieve the suffering that many dying cancer patients experienced. If it was good for cancer pain, why not use it for back pain and neck pain? Short acting and long acting morphine-like drugs were developed and a new approach to pain control became the standard of care. Use morphine and other related drugs, such as oxycodone, Oxycontin, Dilaudid, and hydrocodone, and if the patient has more pain, raise the dose of pain medication.

Although overdose could interfere with breathing and cause death, the most troublesome side effect with careful use was thought to be constipation. Other adverse effects of these medications began to be observed, such as addiction and opioid-induced hyperalgesia (when the morphine-like pain medication actually causes more pain).

In addition, people who had been using mind-altering drugs like heroin recognized that they could get the same effect from prescribed medications, which could be cleaner and cheaper. The illicit use of prescription pain drugs is a growing problem in the USA, and are actually the preferred street drug after marijuana.

At NMPI, we only use prescription drugs like oxycodone, Oxycontin, Dilaudid, and hydrocodone to relieve severe pain when patients are unresponsive to our usual therapies. We take a holistic approach to the treatment of pain. Our treatments include:

  • Exercises
  • Muscle/tendon injections (no cortisone or any other steroids are ever injected into the muscle tissue)
  • Low-level laser therapy, which can aide in the healing of damaged muscle tissue and sensitized fibers found in the muscle attachments.
  • Traditional and novel medications, relaxation therapy, and counseling

In the next few blogs, I will discuss the problems arising with prescription drugs for pain relief and what steps are being taken to try to manage this problem.

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NSAIDs for pain relief

The next series of blogs is a brief discussion of different types of medications used for pain.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are generally one of the first line of medications used in the initial treatment of pain. They are exactly what their name means – they are not steroid medications (like cortisone or prednisone) and they reduce inflammation which is the body’s response to any damage from any cause. When inflammation occurs there is pain along with redness, swelling and heat, which are collectively known as the cardinal signs of inflammation. Examples of NSAIDs are ibuprofen (Advil/Motrin), naproxen (Naprosyn), meloxicam (Mobic), and diclofenac (Voltaren). Aspirin is similar to the NSAIDs in almost every way but curiously it helps prevent heart attacks whereas NSAIDs may cause them (see below).

PillsAlthough NSAIDs have a number of side effects, the two most common are stomach irritation and an increased tendency to bleed. That’s why you are advised to eat when taking NSAIDs and why you have to stop taking NSAIDS before any type of intervention that may cause bleeding (such as injections or surgery).  In order to decrease the side effect of stomach irritation, many have switched to a topical NSAID, most commonly diclofenac which is offered as a patch (Flector-patch) or gel (such as diclofenac or Voltaren gel). Other potentially serious side effects include kidney failure – if your kidneys are not working properly the NSAID can cause them to stop functioning, asthmatic episodes if you are prone to having asthma, and heart attacks if you have cardiovascular disease (heart disease, high blood pressure, history of stroke).

 

 

Image courtesy of anekoho/FreeDigitalPhotos.net

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A discussion about back pain

Back PainWhere to begin? In the first two chapters of my book, End Back Pain Forever,  I explore a variety of issues related to the difficulties in evaluating and treating patients with back pain. I am posting these chapters as a means to share my perspective which developed over more than 40 years as a pain medicine physician in the US and the UK. I encourage the members of my LinkedIn Group, Let’s Talk About Pain to agree, disagree, or share your own experience as a patient, family member of a patient, or clinician.

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The cost of evaluating and treating lower back pain and neck pain is rising. From 1997-2005 it went up from $54 to $86 billion/year. Unfortunately, advances in spine surgery techniques, nerve blocks, and pain medication have not translated into more successful treatment – from 1997-2005, 25% more patients reported difficulties functioning because of neck pain or back pain.

Although 70-80% of back pain is diagnosed as non-specific lower back pain, referring to sprains and strains of muscles, ligaments and tendons, the current guidelines do not mention muscle as a possible source of persistent back pain. This leads to an overemphasis on the spine and the nerves leaving the spine.

We need a treatment model (step-care) that addresses the most common reason for back pain first. Protocols that provide soft tissue treatments that are least costly with minimal chance of harm, should produce better, more cost-effective outcomes.

Spending more money to do the same kinds of treatment is not working. This discussion group will explore possible reasons for sub-optimal pain treatment outcomes. How can we change the way we evaluate and treat persistent pain to improve our results and lower the costs of care?

A search for back pain on the internet finds almost 600 million sites. With so many different ideas on how to address this problem, we will attempt to narrow the discussion to concepts that have been studied and published in scientific journals. One obvious issue is the absence of a muscle evaluation and treatment protocol.

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Opioid misuse

“Thank you for treating me as someone struggling with pain and not as a former drug addict who could not be trusted with strong pain medication”  – a note I recently received from one of my patients.

A patient with a history of drug abuse may be fearful that their past will prevent adequate treatment for a serious painful condition. My patient imagined that I would not be respectful of his suffering and his commitment to sober living. He received the pain medication that allowed him to go through a series of medical and dental procedures without suffering. He was grateful.

Concerns about opioid misuse have made physicians wary of  prescribing potentially habit-forming pain medication. Illicit prescription drug use is a growing problem in the USA and is actually the preferred street drug aside from marijuana. However in treating patients in pain, two basic American traditions should be the guiding principles with patients who have a history, or who test positive on a written test to determine the risk, of drug abuse:

1. Innocent until proven guilty; and

2. in the words of Ronald Reagan, Trust but verify. Those patients who have problems properly using pain medication need extra attention, not condemnation. They may be more difficult to treat, but that is why there are specialists to deal with complex pain problems.

 

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Chapter 2 of End Back Pain Forever delves into the ever-increasing problem of the back pain epidemic. Please review this blog for Chapters 1 and 2 from my book.

Chapter 2

You Are Not Alone: The Back Pain Epidemic

     If you suffer from back pain, you are not alone. The widespread failure by doctors to recognize muscles as the primary source of back pain is helping to fuel an epidemic. Back pain is now the most common disability in the United States. Every year twelve million Americans make new-patient visits to physicians for back pain and a reported one hundred million visits to chiropractors. At the current rate, eight out of ten Americans will experience back pain sometime during their lives.

In addition to the human suffering, medical costs are soaring. The cost of back pain, together with related neck pain, came to $86 billion in 2005, the most recent year for which figures were available. That was an increase of $34 billion from 1997. More amazingly, 25 percent of patients reported being significantly impaired, compared with 20 percent eight years earlier. Spending on back pain now equals the amount spent on cancer and is largely the result of failed surgeries, various nerve block procedures, and the cost of pain medications. We are spending more and getting worse results.

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Why do we over-prescribe strong pain medication?

The NY Times on 4/9/2012 ran a story about the overuse and unintended negative consequences of strong (opioid) pain medication. They mentioned opposing views concerning the liberal use of opioids. I participated in a debate in 1995 about the inappropriate use of the diagnosis “Chronic Pain Syndrome”(CPS) in patients whose muscles had not been assessed as a cause of their persistent pain, which resulted in the justification to put some of these patients on opioids for the rest of their lives.   

Since then one of the largest growth industries in medicine is the evaluation and treatment of back and neck pain, currently accounting for ~$100 billion in direct medical costs. The pain juggernaut is fueled in part by ignoring muscles which are the most common reason for pain complaints. Addressing the incorrect causes of pain leads to inappropriate, expensive and potentially harmful treatments with poor outcomes, persisitent pain, and overuse of opioids. CPS is a license to prescribe life-long medication. Chronic use of opioids has not been studied for its overall impact on patients with CPS but neither have any of the other medications that we are now using. Does the marginal reduction in pain in many of the patients taking these medications justify their costs and side effects? As the Times reports, for some patients the treatment is actually making them worse.

Imagine if some of these patients had pain that could be eliminated. Many do; it’s from muscles that are not evaluated or treated in a systematic way.  My new book, End Back Pain Forever, to be released by Atria on June 5, 2012 is a wakeup call to change the way we are treating common pain problems.

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Strong pain medication after surgery – is there a downside?

A recent article  revealed that 2/3 of patients who received opioids (drugs like morphine) for 90 days following surgery were still taking them one year later. It doesn’t make sense that there still is pain from the surgery one year later. Did these patients become dependent or addicted to the drugs?  Did they really need the medication for pain in the first place?

It was suggested that patients who undergo minimally painful surgeries should perhaps never receive opioids for pain. This thinking is consistent with the current discussion in the USA about the dangers of overuse and abuse of opioids. Annual emergency room visits and unintentional deaths from opioids have dramatically increased in the past five years. Widespread, persistent use of opioids is increasing without a clear understanding of the benefits or of all the associated risks. Making it harder to get the medication and limiting its availability is one way to reduce the unwanted effects.

Many physicians have been alarmed over the misuse of opioids and will not prescribe them at all or will often provide less than adequate doses to effectively treat their patient’s pain. I recently saw a young man who, despite severe back pain that would require surgery, was denied opioid pain medication because he had a high score on a test that measured risk for its misuse. Since I understood the risk, I was able to successfully provide opioids while staying in close contact with the patient and his mother before and after surgery.

Indiscriminate provision of opioids is potentially harmful but so are overly restrictive attitudes and rules governing its availability. Each patient deserves to be evaluated as an individual so that compassionate and rational pain care can be provided.

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Darvon banned by FDA- Methadone spared

The painkilling drug Darvon (propoxyphene) was banned this week by the FDA because it can cause potentially fatal arrhythmias (abnormal heart rhythms). But other pain medications, like methadone, can also cause dangerous arrhythmias. I have been asked a few times why was Darvon banned, but not methadone?
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Pain Medications in the News

Back pain that never goes away completely can undermine your quality of life. It can prevent you from participating in activities that bring you pleasure and security. The medications that we use to deal with the pain, while being life-savers in terms of providing relief from the suffering, expose us to potential harm.

Tylenol (acetaminophen) has been found to result in more than 40,000 cases of liver damge each year in the US. Some of these patients have died. Because of the misuse of this generally well tolerated drug, the FDA will limit its availability in combination drug products such as Percocet and Vicodin. The recommended upper limit has been 4000 mgms but will probably be reduced in the near future . A regular dose Tylenol tablet is 325 mgms, making twelve the maximum number of tablets/day. When you take the combinaton drug you may not be aware that you are ingesting the same drug as in Tylenol and inadvertently take a harmful overdose.
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NORMAN MARCUS PAIN INSTITUTE
30 East 40th Street - New York, NY 10016
Tel 212-532-7999 Fax 212-532-5957
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