Tag Archives: medication

How Cancer Hides Pain

How Cancer Hides Pain | Pain Research Forum – by Matthew Soleiman – Jul 2017

Cancer is often painful, but some types, such as melanomas and glioblastomas, are notably pain-free. Now, Ru-Rong Ji, Duke University, Durham, US, and colleagues might have found one reason why.

The researchers show that in melanoma-bearing mice, programmed cell death ligand-1 (PD-L1), a protein tumor cells produce to suppress immunity, binds to its receptor, PD-1, on sensory neurons.

That renders the neurons less excitable, ultimately masking the pain that would otherwise arise.  Continue reading

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Oxytocin to Manage Chronic Pain

Oxytocin, an Opioid Alternative, Ready for Regular Clinical Use to Manage Chronic Pain

Editor’s Memo November 2017: Dr. Tennant opens an overdue discussion on the history and future of pain medication alternatives.

From a purely pharmacologic and physiologic perspective, we really have not had a relatively safe, potent alternative to opioids since the 1890s.

In those early days, doctors at Brompton Hospital in London described the use of opioids, morphine, and heroin, as well as a stimulant known as cocaine, which when combined (aka the Brompton cocktail) was prescribed to lessen the pain associated with a terminal illness.   Continue reading

Anti-inflammatory drugs can inhibit muscle growth

Anti-inflammatory drugs can inhibit muscle growth – 30 August 2017

The long-term use of over-the-counter (OTC) anti-inflammatory drugs can inhibit muscle growth in young, healthy individuals engaging in weight training, according to a new study from Karolinska Institutet, reporting on the effects of ibuprofen on the skeletal muscles and published in Acta Physiologica.

Most mild analgesic and antipyretic OTC drugs, apart from paracetamol, are of the NSAID (non steroidal anti-inflammatory drugs) kind. These drugs are some of the most widely consumed in the world, and they all inhibit the so-called COX enzymes.   Continue reading

Genetic Testing for Opioid Pain Mgmt: A Primer

Genetic Testing for Opioid Pain Management: A Primer – free full-text /PMC5447546/

Patients see their primary care physicians (PCPs) for a variety of medical conditions, chronic pain being one of the most common. An increased use of prescription medications (especially opioids) has led to an increase in adverse drug reactions and has heightened our awareness of the variability in response to medications.

Pharmacogenetics has improved our understanding of drug efficacy and response, opened doors to individual tailoring of medical management, and created a series of ethical and economic considerations.

Since it is a relatively new field, genetic testing has not been fully integrated into the primary care setting.

The purpose of this paper is to review the metabolism of commonly prescribed opioids, discuss the economic and ethical issues, and provide PCPs with an understanding of how to incorporate genetic testing into routine use to improve clinical practice and patient management.

Introduction

With a rapidly aging population, primary care physicians (PCPs) are seeing a higher incidence of chronic pain conditions.

These patients are often plagued with multiple medical problems, which make their medication management more challenging. Pain medications are some of the most commonly prescribed drugs in the United States, with opioids continuing to be the mainstay of chronic pain management.

Adjuvant therapies such as antidepressants, benzodiazepines, anti-inflammatory agents, or anticonvulsants can also be useful in managing pain, and many (if not most) pain patients may be treated with a combination of these medications. Therefore, PCPs must be increasingly aware of the potential risk for drug-to-drug interactions

Fatal adverse drug reactions have been reported to be the fourth leading cause of death in the USA.

In addition, the “trial-and-error” approach to prescribing medicine is costly and causes delays in effective care.

As personalized medicine becomes more prevalent, these costly approaches to medical care will eventually become obsolete, and streamlined methods guiding therapeutic decisions will prevail.

One of the tools available for implementing a more personalized approach, with greater optimization of patient outcomes, is pharmacogenetic testing.

Pharmacogenetics is a type of genetic test that assesses a patient’s risk of an adverse response or likelihood of responding to a given drug, thereby informing drug selection and dosing

As the personalized medicine movement gains momentum, pharmacogenetic testing will be important across all medical specialties, with an emphasis in primary care, since a majority of all prescription drugs are written in this setting

Pharmacogenetics is a relatively new field, and as yet it is only slowly being integrated into the primary care setting. Many PCPs are still not familiar with how to test, interpret, or apply this technology in clinical practice.

This paper serves as a primer for PCPs to enhance their understanding of pharmacogenetics, with a focus on opioid pain medications.

Opioid Metabolism

To understand how opiates are metabolized, it is necessary to start with related terminology.

  • Pharmacokinetics is the process by which the body absorbs, distributes, metabolizes, and excretes drugs, while
  • pharmacodynamics describes the drug’s effects on the body at the cellular or receptor level.

Genetic polymorphism is the term for variations in the structure of genes, which includes structural changes such as deletion, duplication, and translocation.

Each of these gene alterations is called an allele of the original gene (wild-type).

Having two copies of the same allele is called a homozygous genotype, while having any combination of two different alleles is called a heterozygous genotype.

A single-nucleotide polymorphism (SNP) is the most common altered gene form.

Other Receptors and Enzymes Associated with Opioids and Analgesics

Polymorphisms in the mu opioid receptor itself may cause reduced potency of opioid medications.

For example, the mu receptor subtype OPRM1 is the primary site of action of most opioid medications as well as endogenous endorphins.

This receptor also controls the rewarding effects of nicotine and alcohol.

Whether the patient possesses the wild-type (two normal copies), heterozygous (one normal, one altered) or homozygous (two altered copies) alleles of this gene has been shown to influence postoperative opioid requirement after abdominal surgery.

One of the best-studied OPRM1 SNPs is 118A/G, with the G variant seen in 10–48% of tested patients, depending on the study. Reynolds et al. found that patients carrying the GG genotype required much higher opioid doses to achieve pain relief.

Other receptors such as catechol-o-methyl transferase (COMT) have known variants (i.e. Val/Val, Met/Met) that are associated with increased opioid requirements, fibromyalgia, and a higher risk of addictive behaviors such as gambling and drinking

Conclusion

Chronic pain is one of the most prevalent medical conditions, and pain medications are some of the most commonly prescribed drugs in the United States today.

Unfortunately, there is wide variability in patient response to pain and to pain medications, which may be related to

  • pain origin,
  • pain sensitivity,
  • cultural differences,
  • weight,
  • age, and
  • prior use of opiates,
  • as well as genetic polymorphisms.

The risks of long-term opioid use include death from overdose and drug interactions; the use of more objective measures (e.g. urine levels, genetic testing) rather than subjective measures (pain scores) should aid in determining efficacy, identifying diversion, ensuring patient compliance with therapy, and guiding the management of complex patients.

Over time, genetic testing has become more accessible and less expensive.

However, there are very serious and complex ethical and financial concerns regarding its use that must be addressed prior to widespread implementation of this tool.

And, while the current data are intriguing, there is still no clear evidence that genetic testing—at least for the general population—is effective.

…with the knowledge of a patient’s potential for positive response to a given pain medicine, a physician is armed with critical information that can guide therapeutic decisions in real time.

The incorporation of pharmacogenetic biomarkers holds promise as a means of assessing a patient’s risk of adverse events or likelihood of drug efficacy.

Incorporation of such biomarkers is emerging at the forefront of personalized medicine, and has the potential to improve the utility and efficacy of current strategies and to guide the development of new approaches to pain management.

You can read the full article at /PMC5447546/

Over-the-counter pain relievers and your heart

Over-the-counter pain relievers and your heart – Harvard Health Blog – Harvard Health Publishing – May 15, 2017 –Monique Tello, MD, MPH,

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen are and have been the go-to “benign” pain medication for doctors and patients alike. Why?

They aren’t addictive, and it’s not easy to overdose.

But multiple studies suggest a clear link between all NSAIDs and heart attacks, strokes, and heart failure.   Continue reading

Heroin, Hydrocodone, Bupe & PROP-aganda

Heroin, Hydrocodone, Buprenorphine & PROP-aganda | Dr. Jeffrey Fudin | Feb 2013

According to US News Health, PROP’s President, Dr. Andrew Kolodny is quoted to say “There is very little difference between a heroin molecule and a hydrocodone molecule.”

This could be misleading to the layperson, media, politicians, and perhaps many healthcare providers.

Let’s dissect this a bit further.  While it is true that there is some similarity between heroin and hydrocodone, there are very significant differences. 

Heck, there’s cyanide in vitamin B12 (cyanocobalamin), but we require this vitamin even though B12 chemically contains cyanide.   Continue reading

Acid Reflux Meds Promote Chronic Liver Disease

Common Acid Reflux Medications Promote Chronic Liver Disease – Oct 12017

Approximately 10 percent of the general population take a proton pump inhibitor (PPI) drug to block stomach acid secretions and relieve symptoms of frequent heartburn, acid reflux and gastroesophageal reflux disease.

Researchers at University of California San Diego School of Medicine have discovered evidence in mice and humans that stomach (gastric) acid suppression alters specific gut bacteria in a way that promotes liver injury and progression of three types of chronic liver disease.

This is what I expected and what made me decide not to use PPIs even though they were prescribed for me. I’d rather deal with the discomfort of too much acid than deal with the unknown long-term implications of altering my gut biome.  Continue reading

Insurers Restrict Pricey, Less Addictive Painkillers

Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers – The New York Times  By KATIE THOMAS and CHARLES ORNSTEINSEPT. 17, 2017

ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year.

Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.

In contrast, almost every plan covered common opioids and very few required any prior approval.   Continue reading

Gabapentin Dosing for Neuropathic Pain

Ask the Expert: Gabapentin Dosing for Neuropathic Pain – Dec 2016

Neuropathic pain can be diverse in nature, encompassing a wide range of pain types, including post-herpetic neuralgia (PHN), painful diabetic peripheral neuropathy (DPN), and painful cancer-related neuropathies.

the mechanism of action by which gabapentin exerts its analgesic effect is still unknown. 

It is suggested that gabapentin may block the calcium channel alpha(2)delta (a2d)-1 receptor in the brain. This protein-modulated receptor is involved in excitatory synapse formation. Therefore, the therapeutic effects of gabapentin may be attributed to prevention of new synapse formations

It may be therapeutic, but It can’t be good to prevent the formation of new synapses in our brain – that’s how we adapt to new situations.   Continue reading

Inflammation’s role in many diseases

Clues point to inflammation’s role in many diseases. Will treatments follow? By MEGHANA KESHAVAN @megkesh – Aug 2017

inflammation has become one of the hottest buzzwords in medical science, pointed to as a culprit in causing or aggravating conditions ranging from allergy to autism to Alzheimer’s disease.

The latest evidence of inflammation’s broad role in disease came this past week, when a global clinical trial of 10,000 patients who had previous heart attacks showed that an anti-inflammatory drug from Novartis reduced their risk of further heart attacks or strokes.

A surprise side effect: The drug also sharply cut the risk of lung cancer Continue reading