Healthcare News and Research

[*Anya*]

Better Pain Control by...Cutting Back on Opioids?
Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York.

Posted: 02/13/2012
I want to talk about a new approach to chronic pain care, based on a recent, exciting study.[1] I certainly see many people with chronic pain in my role as director of a pain center in an academic institution. Many patients do not respond to typically prescribed medications for osteoarthritis and for various neuropathic pain states. I am certain that those of you who are not working at pain centers also see patients who do not respond to available treatments that provide pain relief for other patients.
We are all concerned that sometimes we do not always have a treatment for each individual patient. We need new and improved analgesics and, absent those, at least a more creative way to benefit from what we have.

One approach to this quest has been to try to capitalize on the endocannabinoid system through the use of cannabinoids in various oral pharmacologic tactics. Some cannabinoid agents are available, but with marginal benefit. A second approach has been to develop a better, more effective, and safer way of using opioid analgesics.

The study I want to discuss, "Cannabinoid-Opioid Interaction in Chronic Pain," by Abrams and colleagues,[1] demonstrates how combining the 2 agents may provide promise. I live in New York State, where using marijuana is illegal, medically or otherwise; I am not speaking for or against this. I am merely reporting this particular study.

This study involved individuals with various chronic pain states, including musculoskeletal pain from osteoarthritis and other causes, neuropathic pain, sickle cell disease, and others. These patients were already using long-acting opioids: either time-released oxycodone twice daily at mean doses of 100 mg/day or time-released morphine twice daily at mean doses of about 120 mg/ day. More than 300 individuals were screened, and ultimately 21 of these participated in the study. Participants had to be stable on their opioid regimens before they were enrolled.

The 21 participants were managed as inpatients over 5 days. On the first day, they received 1 evening dose of vaporized cannabis; on days 2-4, they received 3 doses; and on day 5, they received a morning dose, in addition to their typical opioid regimens.

On average, these participants experienced an added 27% reduction in pain with the addition of vaporized cannabis. Pharmacokinetic studies demonstrated that although there was an effect on reducing absorption of morphine by the addition of vaporized cannabis, there was no change in the area under the curve. Therefore, the patients were exposed to a similar amount of morphine, although the peak concentration of morphine was also slightly reduced. Adding vaporized cannabis seemed to independently magnify the response the person was experiencing to the analgesia.

This brings to mind a couple of things. First, this was a limited, 5-day study; the investigators recognized this limitation. However, this shows a new and potentially very helpful combined approach to treatment that comes at an important time when we are searching for improved and novel analgesics that can provide us with additional relief for our patients, and also could spare opioid dosing.

Most important, we're looking for ways to safely treat patients who have chronic pain. This study of vaporized cannabis in addition to long-acting opioid found no significant changes in the plasma opioid level with the combination, even though it proved more effective than the opioid alone. This may be a gateway to future studies using lower doses of opioids in combinations with endocannabinoids or other agents that act on cannabinoid receptors -- or, in certain settings, use of cannabis itself.

Ultimately, this may point to a new way we can effectively treat outpatients.

References

1. Abrams DI, Couey P, Shade SB, Kelly ME, Benowitz NL. Cannabinoid-opioid interaction in chronic pain. Clin Pharmacol Ther. 2011;90:844-851. Abstract
Medscape Neurology © 2012 WebMD, LLC

[Corkey]

Wouldn't mind a pill form, as a reformed smoker just not gonna inhale.

[Rockinonahigh]

I quit smoking nearly a year and ahalf ago,if this came in pill form I could do that just not smokeing it cause I know it will put me on the path to ciggies again.Currently im takeing tramadole and useing flexerill to relax my back,recently ive been up in the amount of tramadols I can take a day but I ony take the extra pill if I really need it.I am so tired of floating thrue most of the day I just dont take anything at all dureing the day,just at bed time.

[Toughy]

There is a pharmaceutical version of cannabinoids. It is FDA approved for treatment of nausea and vomiting during chemotherapy. It was approved in the early 90s. The generic name is 'dronabinol' and the brand name is 'marinol'. There are some other approved versions.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000403/

I tried it. Did not like it at all. Gave me a headache and I had no way to control how much I was taking. I think it came in 2 different doses. With smoked cannabinoids, I had control. I can take 1 or 2 tokes or smoke the whole joint depending on pain severity. I did not get the relaxed 'oh I feel better now' that I got by smoking. It didn't really get me loaded.....just a headache and maybe a tiny bit of pain relief.

Vaporized cannabis is very very different than smoking cannabis. It doesn't feel like smoke going in your lungs. I can't tell if I have actually had a dose. It has none of the problems with smoked cannabis. No tars, none of the evil nasty crap smoking gives you, no apparent risk for developing lung disease down the road.

[*Anya*]

Women at Midlife and Beyond Have Unique Health Needs

An Expert Interview With Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN

"Hot Flashes and More: Midlife Women's Health and Beyond" was presented at the 14th Annual Nurse Practitioners in Women's Healthcare (NPWH) Premier Women's Healthcare Conference. We spoke with one of the presenters, Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN.

Medscape: What percentage of women in midlife is living with symptoms related to menopause?

Dr. Alexander: Every single woman who lives long enough will experience menopause, and all of us will have some kind of symptoms; the biggest question is whether or not it is bothersome to them. All women experience vaginal atrophy over time. There are certain different symptoms that affect everybody; whether or not it is bothersome is a separate question.

Medscape: Do vasomotor symptoms associated with menopause consist only of hot flashes, or are there other symptoms as well?

Dr. Alexander: Some women get sweats and some women get chills. In Europe they call it 'hot flushes' instead of hot flashes, because their faces turn very red.

Medscape: What are some other consequences related to loss of estrogen?

Dr. Alexander: People can have psychosomatic symptoms, like mood swings, or they can have neurological symptoms like formication, where there's a sensation of bugs picking over the skin. Women sometimes have disbalance.

They can have genitourinary symptoms; they can have musculoskeletal symptoms; some women have gastrointestinal symptoms. The receptors for estrogen and progestogen are all over the body, and so symptoms can occur anyplace, in areas where those receptors become unbalanced, during and after menopause.

There are other physiologic changes that aren't so much symptoms as they are physiologic changes like loss of bone mass and increase of cardiovascular disease, although that's not really related directly to loss of estrogen — it's probably more related to estrogen-testosterone balance, or imbalance.

Medscape: What are some of the risks and benefits associated with use of hormone therapy, and which women would be considered the best candidates for it?

Dr. Alexander: We talked a lot during the session about the history of hormone therapy, and how it has swung like a pendulum over time: first it was in favor, then swung out of favor, then swung into favor, and then swung out of favor.

The most recent evidence-based (data) that we are working with include the HERS study and the WHI study. These studies have indicated that contrary to what was suggested in prior population-based observational studies, hormone therapy, estrogen therapy, or estrogen plus progesterone therapy do not confer cardiac protection, especially if taken a chunk of time after menopause.

We don't really have good data yet whether or not there might be any kind of benefit toward that if hormone therapy is started at the time of the woman transitioning towards menopause. It looks like there are a couple of theories that are evolving, if you look at one more data and start to analyze subgroups. That has suggested 2 different theories related to when one should initiate using hormone therapy; one of them was the "gap" theory, which looks at breast cancer risk, and there's some question about whether there might be a decrease in breast cancer risk if a woman holds off on starting hormone therapy for that 5 years post menopause.

The news is starting to suggest that if we start hormone therapy right at the time when a woman becomes postmenopausal, it helps to decrease, delay, or put off their risk of developing cardiovascular disease.

Now, it is very controversial; there's a lot of good data that's available. Some of the results from various different studies are rather controversial and confusing, and so it's important for people to really look hard to make sure they remain abreast of these developments.

The most immediate information that we have is what I've just described, and it's looking more and more like we really need to individualize care…if the greatest risk for her is related to heart disease, you might want to think about hormone care sooner than later if in fact she's a good candidate. If the risk factors are higher for breast cancer, you might want to wait.

Medscape: Are there any alternative therapies that you currently favor, and what are some of the risks and benefits of those, particularly when compared to hormone therapy?

Dr. Alexander: There are some alternative therapies, and nonhormonal prescription medications that can be used to try to allay symptoms related to menopause: selective serotonin reuptake inhibitors (SSRIs), selective neurotonin reuptake inhibitors (SNRIs), and the like.

The good thing is that we really have a lot of choices and we're learning a lot more about potential risks and benefits, and I think that's incredibly important. We do know that hormone therapy, estrogen therapy, or estrogen plus progesterone therapy are the single most effective for menopause-related symptoms, but it's not a good choice for every person, and it's not something that every woman feels comfortable taking because of some of the risk factors that we're learning about.

Some of the things that might be most beneficial [with hormone replacement therapy] are things like: A) when a hot flash is coming on, the woman can try to decrease its intensity, or B) possibly stop it from happening.

There are a couple of different products on the market that are available, and some of them suggest benefits that may not be borne out when we do larger head-to-head clinical trials. The other thing is that there are many different things that can trigger hot flashes, and it is really important for women to recognize that there are triggers, and if something is coming on, that they might be able to stop it…if they start to feel that hot flash, by using paced breathing.

The data [related to acupuncture] is kind of all over the place. I think the most recent meta-analysis suggested that it probably didn't have a very strong effect… The benefit of acupuncture is that it's a very well-known, well-proven, safe alternative therapy and it certainly increases relaxation and decreases pain, so if it helps lower someone's stress level and anxiety, it may help to decrease hot flashes — not so much because it's having an impact on the hot flashes directly, but more because it is decreasing some things that are possibly triggering the hot flashes to begin with.

Medscape: Which women would be considered good candidates for alternative therapies?

Dr. Alexander: Anybody.

Medscape: What screening tests should be done on all women at midlife and beyond, regardless of whether they are experiencing symptoms of menopause?

Dr. Alexander: We recommend colonoscopy for women starting at age 50 or younger if there's a family history of colon cancer that is identified before the age of 50; regular female Pap smears and annual internal exams; clinical breast exams and mammography; blood sugar and lipid screening at least every 5 years or more frequently in women at risk; PSA [prostate-specific antigen] sometime around age 40 or 50; hemoglobin around age 50; flu shots annually, pneumothorax depending on their health risk at 65, herpes zoster vaccine every 10 years; tetanus vaccine, and if there's any travel, they should have appropriate immunizations for that.

Osteoporosis is very important; some women need to be measured on a stadiometer every single year to be sure that you actually have an accurate height. Bone density screening should be done at the age of 65, unless experiencing other risk factors earlier.

For women who are experiencing menopause-related symptoms and for whom various different therapies might be being considered, there are some screenings that we do that are separate from that: clotting factor, blood cancer risk, heart disease risk, and so forth.

Medscape: Do you have any special tips for examining women at midlife and beyond?

Dr. Alexander: It's important that you maintain an open differential because even though a woman is 52 and hasn't had a menstrual period in 8 months, and has symptoms that sound like they are related to menopause, it doesn't behoove the patient or the clinic to just decide, "Those are menopause-related symptoms." You need to really make sure you go through an appropriate history and a complete physical exam and really maintain your open mind to a broad differential and potential basis for the symptoms.

Women who are at midlife are at higher risk for diabetes, just like men are, and the waxing and waning of blood sugar levels can sometimes mimic menopause-related symptoms such as hot flashes, and it's important to make sure that you screen for those other health conditions.

Dr. Alexander disclosed that she is on the speaker's bureau for Amgen.

National Association of Nurse Practitioners in Women's Healthcare (NPWH) 2011 Annual Meeting. October 12-15, 2011.

Medscape Medical News © 2012 WebMD, LLC

[Slowpurr]

Available at: http://www.medscape.com/viewarticle/408896.

Can Exercise Offset Impact of Estrogen Loss?

Physical activity, so vital to good health and well being, takes on even greater importance at menopause; as the ovaries shut down, a woman loses estrogen's protective effects against bone loss. The years surrounding the menopause, which occurs at an average age of 52, when a woman undergoes the transition from a reproductive to a postreproductive state, are termed the climacteric period. Regular exercise can prevent or lessen the impact of many of the changes women experience at this time. Exercise also can decrease morbidity and mortality after menopause by lowering a woman's risk of bone fracture.

Exercise can attenuate some of the effects of aging as well as the physical changes linked to a sedentary lifestyle. Regular physical activity can reduce the symptoms and risks of cardiovascular disease, osteoporosis, obesity, and other chronic diseases such as diabetes, which become more prevalent in the postmenopausal period.[1] There is some evidence that symptoms often associated with the hormonal changes of menopause, such as hot flashes, insomnia, and depression, can also be alleviated by exercise.[2] Despite the growing body of evidence for the benefits of exercise at any age, it is estimated that only 38% of females over the age of 19 exercise regularly.[3] The public health burden of inactivity, with its associations to coronary heart disease (CHD) and all-cause mortality, is high. All women should be encouraged to exercise regularly, and clinicians should reinforce the particular benefits of exercise to patients in their menopausal and postmenopausal years.


Authors and Disclosures

Margaret Burghardt is Staff Physician at the Fowler-Kennedy Sports Medicine Clinic, University of Western Ontario Faculty of Medicine, London, Ontario, Canada. She holds a diploma in sports medicine from the Canadian Academy of Sports Medicine (CASM).

Burghardt M. Exercise at Menopause: A Critical Difference. MedGenMed 1(3), 1999. [formerly published in Medscape Women's Health eJournal 4(1), 1999].

[Greyson]

You know, I am sure there are medical merits to using canabus. Personally, I am tired of the scamming encouraged by greed and for some addiciton in this medical marijuana wars.

Why don't the States that allow the sale of medical marijuana put it in a pharmacy? All of these "dispensarys" popping up under the planning/land use decisions and local (city) ordinances are not working. Make it accountable to the State, legalize it as a medical drug and sell it out of the Pharmacy. This is how it is done with other medical prescriptions.