Dealing with Pain Physicians Should not be so Painful

The State of Florida is trying to eliminate medical practitioners and facilities which prescribe narcotics freely without doing the proper evaluations. These pill mills sell drugs for cash and the resulting overprescribing of oral narcotics has flooded the streets of Florida and nearby states with oral pills leading to increased opioid related deaths and trips to the emergency departments for drug overdoses. The frenzy has been fueled by “blue ribbon physician panels” discouraging the use of nonsteroidal anti-inflammatory drugs for pain in favor of narcotics. The Florida Legislature responded by passing draconian legislation that separated opioid pain prescribing into acute prescriptions which all physicians may prescribe and chronic prescribing. For chronic prescribing health care providers must take a course and check a special box on their licensing reapplication form every two years. Pharmacies are coming under scrutiny for providing refills of short acting narcotics for pain when they have been refilled well past the 8 week suggested limit on these medications, even if the prescription is appropriately written by a legitimate physician. The pressure on the pharmacies by the state and law enforcement has led to a policy of not stocking narcotics or filling narcotic prescriptions at many Florida pharmacies. Sick patients with well documented sources of pain and legal prescriptions search endlessly for a pharmacy to fill their pain medications.

The Florida pain law encouraged the growth of pain specialist doctors especially anesthesiologists, rheumatologists and psychiatrists. I treat an elderly population of chronically ill patients many with severe long term chronic back, hip and joint problems. They arrive at my practice with a history of long term use of nonsteroidal anti-inflammatory medications for pain relief and many are using opioid narcotics for years. When referred to many of the pain specialists they are integrated into a conveyor belt type operation using injections of medications into joints, physical therapy with very little attention paid to the patient’s medical history. Most of the pain doctors prefer using injection techniques rather than working with oral or injectable medications, physical therapy, counseling or any of the alternative therapies.. The patients receive their series usually of three shots into an area of the body and then are expected to be able to tolerate their pain. The problem is that during the series of injections and after the series of injections, if the pain relief has been incomplete or inadequate, there is little time set aside to discuss what to do when it really still hurts. The result is that the patients call a doctor who actually answers the phones and returns calls promptly even if that physician does not have a degree in pain management or a large volume practice injecting joints for pain relief. That doctor is left with the option of prescribing the very oral medications we are being advised not to use, or chasing down the pain doctor to discuss exactly how they wish to address the problem? Usually the pain doctors are very willing to take ownership of the situation and they make suggestions of oral medications for that particular instance. The problem then usually recurs before the next round of injections or shortly after. There are very few pain practices actually talking to patients, examining them and working with oral medications or transdermal medications to relieve pain. They just do not have the time to discuss the situation especially with the procedures being so much more profitable. It is much like the situation in psychiatry where so many of the practitioners see patients briefly to adjust or regulate medications but spend little time engaging in counseling or psychotherapy any more.

There are however, several local pain doctors, who have answered my calls for assistance regarding patients having multiple cognitive and behavioral problems due to chronic use of opioid medications for legitimate pain. They have spent time analyzing the situation and helped the patients successfully withdraw from ineffective treatment regimens and resume a productive life. These clinicians are few and overwhelmed with chronic pain patients. The solution to the problem is an updating or retraining of our health care provider population so that more practitioners are comfortable treating chronic pain. At the same time our elected officials and law enforcement need to establish a system which prevents prescribers of pain medications from profiting from the dispensing or distribution of these products. Until that occurs I will continue to get phone calls from patients saying, “I had my third shot three days ago and I am still in excruciating pain. I cannot reach my pain doctor but their PA says I cannot get another shot for another three months. What should I do about the terrible pain?”

Aspirin Use for Targeted Breast Cancer

The indication to take aspirin to prevent various diseases has certainly been confusing over the last few years. A Veterans Administration (VA) study in the 1950’s noted that men over 45 years of age who took an aspirin per day had fewer heart attacks and strokes. The exact dosage of aspirin to take to prevent heart attacks and strokes has been the subject of many studies and much disagreement. In more recent times researchers have questioned whether aspirin should only be taken by those individuals who already have survived a heart attack or stroke for secondary prevention.

Taking aspirin is not risk free with users having a higher risk of gastrointestinal bleeding and cerebral hemorrhage especially if head trauma was involved. Recent studies have made it even more confusing with some experts not wanting patients to take aspirin for primary prevention of a first heart attack or stroke unless their 10 year risk of an event was 6% or greater. Others thought 6% was too high a figure and suggested 3%. The guidelines and suggestions for aspirin use to prevent cardiovascular disease have certainly become more confusing and have made the decision to use it far more complicated.

As a result of the use of aspirin in prevention of vascular and heart disease, researchers noted that people who took aspirin had fewer pre-cancerous adenomatous colon polyps and less skin cancer. In a 2010 study in the Journal of Clinical Oncology, Drs. Michelle Holmes and Wendy Chen of the Harvard Medical School noticed that women with breast cancer who took one aspirin per week had a 50% lower chance of dying from breast cancer. This observational study required a more detailed sophisticated double blind study to prove the point but the authors did not receive the necessary funding to begin the research study. This left the relationship between aspirin use and breast cancer development very unclear.

In the December 22, 2015 edition of the Mayo Clinic Proceedings, Bardia A, Keenan TE, and Ebbert JO and associates published data hinting that aspirin use was associated with a lower incidence of breast cancer for women with a history of breast cancer and those with a personal history of benign breast disease. This study of 26,580 postmenopausal women followed the study participants for three years. In the online journal Internal Medicine News, Neil Skolnik, MD talked about the exciting possibility of decreasing breast cancer in this specific group of women by 30 – 40% by taking a daily aspirin.

There is no question that aspirin therapy increases the risk of bleeding especially in the GI tract and the brain. Trauma and cuts will lead to increased bleeding and blood loss. Individuals will need to discuss with their physician the pros and cons of preventive aspirin therapy for heart disease prevention, skin cancer prevention, colon cancer prevention and now breast cancer prevention based on their personal and family medical history and balance it with the risk of bleeding.

High Disability and Death Rates in Bleeds Associated with New Oral Anticoagulants

In the trailer for the movie Jaws 2 they show a swimmer in the ocean with a deep voice saying, “Just when you thought it was safe to go back into the water…” followed by the classic music associated with a shark attack and a big fin approaching the unsuspecting swimmer. I feel much the same way upon reading a Medpage Today online journal review of an article in JAMA Neurology published on December 14, 2015. Jan C. Purrucker, MD and colleagues looked at 61 consecutive patients with non-trauma related cerebral hemorrhages due to the newer oral anticoagulants Pradaxa, Xarelto and Eliquis. Overall there was a death rate of 28% at three months and “two out of 3 survivors had an unfavorable outcome.”

In October of 2015 the FDA approved the use of the antibody fragment idarucizumab (Praxbind) to reverse anticoagulation in patients bleeding from the administration of the oral anticoagulant Pradaxa. There are currently no medications to reverse the bleeding from the drugs Xarelto or Eliquis but we are promised that new products are in development. The article goes on to discuss how physicians have been forced to improvise when patients on these medications show up bleeding. They have tried fresh frozen plasma, 3-factor, 4-factor and activated prothrombin complex concentrates prothrombin complex concentrates, recombinant factor VIIa and cryoprecipitate alone or in combination with marginal success at best.

Despite there being no antidote to these blood thinners, the massive direct to consumer advertising continues on television prime time and magazines as if the products are no more dangerous than an antacid for heartburn. Coumadin or warfarin is the prototype anticoagulant working by inhibiting vitamin K dependent clotting factors. Its effects are reversible with administration of Vitamin K and clotting factors if bleeding occurs. Coumadin requires periodic blood tests (INR) to check on its efficacy and there is a long list of medications and foods that need to be avoided or adjusted while taking it. It is less convenient but safer in the sense that its effects can be reversed with medication.

The newer oral anticoagulants were championed by several studies that suggested that they were more effective in preventing embolic strokes in patients with the heart rhythm atrial fibrillation. Many experts in the field felt that those conclusions were flawed because the Coumadin group was not tightly regulated to keep their INR in a therapeutic non-clotting range thus unfairly biasing the results in favor of the newer agents.

There is no question that the newer agents are more convenient than warfarin treatment, but until there are readily available antidotes, complications seem to be more difficult to limit and control.

Does Not Testing the PSA Lead to More Advanced Prostate Cancer?

Mortality from prostate cancer has diminished by almost 40% since the introduction of the PSA test in the late 1980’s. Much of this is due to the use of the PSA blood test for screening purposes. In 2011 The US Preventive Screening Task Force strongly condemned the use of PSA screening. They felt that we were finding too many inconsequential early malignancies that would not lead to death and were being over treated. In their eyes, prostate cancer treatment with surgery and or radiation carried a high price tag with multiple long term complications and the benefit of screening was not worth the risk. Prior to the USPSTF”s 2011 recommendation against screening for prostate cancer with a PSA there were 9000 – 12,000 new cases of prostate cancer diagnosed per month. In the month following the USPSTF recommendation not to screen with PSA the number of new cases dropped by almost 1400 a month or over 12%. Over the next year the decline in prostate cancer diagnosis was 37.9 % for low-risk prostate cancer, 28.1% for intermediate risk, 23.1 5 for high risk and 1.1% for non-localized cancer. Clearly if you do not look for a disease you will not find it.

In the December issue of the Journal of Urology, Daniel Barocas, MD, of Vanderbilt University and colleagues discussed the PSA testing controversy. They too noted that the consequences of not screening for intermediate and high risk prostate cancer by performing the PSA test may lead to individuals presenting with far more advanced disease that is more difficult to treat, has more complications and ultimately leads to disease related deaths. His position was debated by two major urologists in the editorial section of the journal with no firm conclusion being reached.

In an unrelated article, the Center for Medicare Services or CMS announced that it is considering penalizing physicians who test the PSA for screening in Medicare patients beginning in 2018 as part of their paying for value and quality. They said that physicians need to present their patients with an ABN (advanced beneficiary notice) stating that Medicare will not pay for this test, before the blood is drawn or face fines and penalties.

Men in their forties and older have been put in an uncomfortable and inappropriate position by health policy leaders. The truth is we are currently unsure how and when to test for prostate cancer in men with a normal digital rectal exam (DRE). The consequences of not paying for screening will not be known or understood for easily ten to fifteen years. It is clear that early stage disease has the option to be observed for progression with minimal consequences in the short term. Not enough time has elapsed for anyone to know the long term effects of this policy change. Unfortunately, men in this age group are all guinea pigs in the public health policy laboratory while the data to reach a firm scientific conclusion is assembled. The predominant policy today is spending less and doing less. With this in mind, it is best for men to see their doctor, have an annual digital rectal exam, discuss their family history of prostate disease and reach an individual decision on PSA screening appropriate for their unique situation rather than one based on large population policy.

Blood Pressure Control in the Elderly Needs Common Sense and Individualization

The recent SPRINT study pointed out the benefits of lowering blood pressure to < 120 mm Hg rather than 140 mm Hg in patients’ high risk for cardiovascular events because this reduced all-cause mortality by 25% and cardiovascular events by 35%. The SPRINT study is ongoing and will hopefully one day answer the question of does this data apply to the older elderly or our increasing population of 80 and 90 year olds. Previous studies looking at presumed dementia including pathological autopsy review of brains hinted at aggressive blood pressure lowering causing low perfusion or blood supply to the brain resulting in dementia type symptoms. In lay terms the anatomic findings did not support the diagnosis of dementia but the behavior which was dementia like may have been due to over aggressive lowering of blood pressure preventing elderly brains from receiving enough blood.

Nanette Wenger MD, a professor Emeritus of Cardiology at the Emory University School of Medicine and one of the most common sense teachers of clinical medicine cited the need for individuality in treating this patient group. She reviewed the many existing blood pressure guidelines and suggested keeping the systolic blood pressure of people over 80 to < 150/90 while shooting for < 140/90 in younger adults. Her clinical talk at the American Heart Association meeting recently contrasted the treatment of an 80 year old active vibrant individual managing all his or her affairs , in contrast to a wheelchair bound mildly cognitively impaired person living in a skilled nursing facility. She talked about starting slow with a low dose of medication and gradually titrating the dosage to control the pressure while checking to see if the blood pressure abruptly drops upon standing up or sitting up from a supine position. In most cases it requires at least 2-3 medications at low dosage to control blood pressure without producing adverse effects. It is still unclear if both younger adults and certainly older adults will tolerate and take higher dosages and more medications to achieve the suggested outcomes that the SPRINT study is encouraging. This fact makes it increasingly clear that patients will need a physician who has the time and takes the time to learn of their lifestyle and how taking the medication impacts it. In today’s medical world of conveyor belt template driven care encouraged by employers and insurers, finding that type of individual attention and access is a challenge in itself.

“There really is no template for the oldest old,” Dr Wenger advised. For this reason geriatricians and primary care physicians who are accessible and take the time to determine the entire clinical picture are necessary to tailor individual care.

There is No Hope for Ending Medicare Fraud

South Florida is apparently a hotbed for criminal Medicare fraud. It is easy theft with crime rings accessing Medicare numbers of the elderly in Dade County and Broward and setting up durable medical equipment companies that bill our local Medicare subsidiary for equipment that doesn’t exist. Having said that, yesterday I received a Medicare Summary of Benefits letter for my mother at my home. She is almost 90 years old and my brother and I are her legal guardians and handle all her financial affairs while she resides in a skilled nursing facility in northern Palm Beach County, Florida. We moved her to this excellent campus in May of 2015 from a facility in Broward County and by submitting a change of address notice to the US Post Office, all her mail now comes to me. The official Medicare Benefits Summary stated that on September 11, 2015 a claim had been received for a wheelchair for my mom for $280 from a durable medical equipment company in Miami, Florida. The ordering physician was her former physician at her former Broward County skilled nursing facility. I thought it was strange that a bill would be submitted for a wheelchair four months after she was gone from that facility so I tried to reach the doctor. I was told that he was no longer at that facility. I next called my mom and asked her if she had received a new wheelchair in the last few months and she just did not remember if she had or not. I had no knowledge of it but the move from one facility to another accompanied by closing down her apartment in the assisted living section had been tumultuous and disorderly.

I then called the Medicare Fraud number listed on the piece of mail, 1-800- Medicare. The call was answered by an automated attendant who did not list “Fraud Report” as one of the choices so I pressed 5 for “other.” I was placed on hold for five minutes and a pleasant gentleman asked me why I was calling. I explained and he politely asked me to please hold on. Another five minutes elapsed before he got back on the line and apologized for the delay. He started asking me personal questions about my mother for security purposes such as her address, phone number, date of birth, Medicare number. He then asked me to hold on while he prepared a report and another seven minutes elapsed. He told me he would be transferring my call to a supervisory claims officer and I held on again.

It took five or more minutes before a woman got on the phone and repeated the same questions I had already been asked and answered. I tried to explain the purpose of the call and my relationship to my mother but she politely silenced me and told me that she had the original agent’s summary and knew the reason for the call. She asked me to hold on while she looked up the claim and another ten minutes elapsed. When she returned she told me that Medicare paid durable medical equipment claims monthly for up to twelve months and possibly this was a late claim for a 13th month. I then asked her what type of non-motorized wheelchair could possibly cost 12 X $280. I explained to her that all I was interested in was reporting a suspicious claim. She told me that without me forwarding her a copy of my Power of Attorney form she would not be able to reveal any claims history information to me. I told her I wasn’t asking for her to reveal any information but was just trying to report a suspicious Medicare claim. She responded that the claim had been denied and not paid so why was I making such a fuss in the first place. Having invested almost an hour trying to be a responsible citizen I gave up. If this is the type of system we as citizens put in place and tolerate then we deserve to be ripped off!

Two Handoffs with Different Outcomes

My 66 year old professional athletic patient had a history of a scar tissue related small bowel obstruction seven years ago related to a previous appendectomy. He now had similar symptoms with cramping, lower abdominal pain, and some nausea. Since his office was next door to his longtime friend and gastroenterologist he called over there. He was given an appointment with the junior partner since his buddy was out of town. Thirty years earlier I had referred him to that practice. The junior partner examined him, thought it was a self-limited viral illness and sent him home. The next day the two met in the Emergency Department for similar symptoms and once again the patient was sent home. The symptoms continued for 48 hours, and at the end of one of his long workdays he again saw the junior partner. This time the gastroenterologist sent him over to the hospital for a CT scan at about 6PM. Two hours later he received a phone call that the patient had a small bowel obstruction and the radiologist inquired of the GI specialist; “What should I do with him?” He was told to send him to the Emergency Department. When the physician in the ED called the GI doctor for admitting orders, he responded,” call his PCP (primary care physician) I am a consultant and I do not admit patients. “Forty five minutes later I received a call from the emergency department informing me for the first time of my patient’s problem and asking me to come in and admit the patient to the hospital. I asked him why the GI doctor was not taking ownership of the problem. I was told that the gastroenterologist said he was a specialist and did consulting not admissions. When I called the gastroenterologist directly I reached one of the covering partners who told me, “We are only gastroenterologists and we have not kept up our certification in internal medicine so we are really not qualified to admit a patient with a bowel obstruction or provide the day to day medical care.”

Another patient, 67 Hispanic and female was being treated for depression. She was under the care of a psychiatrist and in the middle of a medication adjustment. Her husband brought her to me because she was hallucinating, talking to her deceased father, acting violent and sexually inappropriate. I called her psychiatrist and then her neurologist who both answered the phone call immediately and suggested we schedule a CT scan of the brain. It showed a large brain frontal lobe tumor with much swelling around it and a hint of hemorrhage. I met with the patient and informed her of the problem and called the local university medical center to speak to the director of their brain tumor department. The university center is traditionally difficult to communicate with and receive information from. This time the young new department chair took my phone call, reviewed the clinical scans and data sent to him by fax and said, “She seems like she needs our help. If she can come down now I will have our team meet her and begin her evaluation. Later that night she clinically deteriorated. I text messaged the surgeon. He responded within minutes and said, “Send her down now; my team will meet her in the Emergency Department. “ I received daily clinical updates from this department chairman and prior to discharge he called me with a complete review, medication list, things to look for and emergency contact numbers if the patient had a problem. The professionalism, thoroughness and collegial communication was outstanding and far safer for the patient than for my local patient with a bowel obstruction. I was treated as a professional colleague asking for help with a patient rather than a generalist medical doctor expected to whatever the procedural specialist did not want to do.

I thought the gastroenterologist was both rude and dismissive of primary care physicians. I believe he abandoned his patient and created a safety issue by not calling me directly if he wanted me to assume the patient’s care. I was so upset that I brought the matter to the attention of the Chairperson of the hospital department of medicine and the associate chair of our medical executive committee. Both told me that similar things had happened to them. One told me of a nephrologist performing dialysis on a mutual patient who sent a patient unannounced to the Emergency Department because his vascular access was amiss and never called him about it but expected him to admit the patient and obtain appropriate specialty help to deal with the infection. The other doctor told of a cardiology patient who saw a cardiologist in an office that was across the street from the hospital. The patient was in dire straits with florid pulmonary edema and great distress so he sent him by ambulance to the Emergency Department. When he got there and the Emergency Department called him he said, “I don’t admit. Call his PCP for that.” He never called the patient’s PCP either to tell him he was sending this mutual patient who was critically ill to the hospital. Both medical staff officers told me that I could not hope to change a national culture which dumps on the PCPs and the patients. They told me it was not a hospital staff problem but one I needed to solve with the individual consulting groups.

Failure to communicate and take responsibility for care you have begun especially when the problem is in your area of expertise is a safety issue. It will come back to harm a patient someday. When these same gentlemen are sitting in court testifying in that medical malpractice case they will say the system is not fair rather than recognize that their inactions contributed to the problem. Hospital administrators and hospital boards using physicians they now employ and a limited number of local private physicians they can control have created a culture of poor communication between caregivers at a time when the technology exists to make communication far simpler and easy. They choose physicians for committee positions that are easy to influence. Community and public input into the policies of local hospitals and health care delivery systems has been eliminated or limited so that the driving force for policy is profits whether you are dealing with a for profit or nonprofit facility. In this setting the probability of errors occurring and patients’ being harmed because of lack of communication is greatly increased. There is institutional indifference to this problem and the safety organizations responsible for inspecting hospitals have not addressed it yet.

SPRINT Study Supports More Aggressive Blood Pressure Targets

For several years now there has been a growing controversy over how low to lower blood pressure to reduce health risks. The most recent recommendations were to lower systolic BP to 140 or lower in men and women less than 60 years old, with a higher systolic blood pressure of 150 in those over 60 years older. There has been much recent concern that if we lower systolic blood pressure too much in senior citizens we fail to perfuse the brain with needed blood supply carrying oxygen and nutrients. The end result is a clinical appearance of dementia or cognitive impairment. Researchers recognize that to achieve a systolic blood pressure of less than 140 most patients need to take at least two blood pressure pills. There has been a great deal of difficulty convincing patients to consistently take those two blood pressure pills so the thought of adding a third medication to achieve a systolic BP of 120 or less is quite challenging.

To answer the question of how low to optimally lower blood pressure, the National Heart and Lung Institute instituted the SPRINT study looking at 9300 men and women over age 50 that had high blood pressure. One group was attempting to lower systolic blood pressure to 120 or less. The other to 140 or less. The study was scheduled to run through 2016 and conclude in 2017. The goal was to see if the lower blood pressure reduced the number of heart attacks and strokes. Last week the Federal government announced that the reduction in heart attacks and strokes in the aggressively treated group was so pronounced that they were stopping the study early. With the lower systolic BP the heart attack and stroke risk was reduced by nearly a third and the death risk by 25%. To achieve the desired systolic blood pressure of 120 or less required the daily use of three distinct blood pressure medications per patient.

In the process of cutting the study short to announce the results for the public’s benefit, the researchers were not able to answer the question of whether senior citizens would suffer more falls from getting dizzy with the lower pressure or if the lower pressure resulted in more cognitive impairment and dementia due to hypoperfusion of the brain. The only question they answered is that a lower target blood pressure will result in less death due to heart attacks and strokes. They did not address the issue of whether lower blood pressures would result in less chronic kidney disease either.

There are many academic researchers who hail the SPRINT study as cutting edge in further reducing cardiovascular injury and death. Other researchers are peeved at the failure to look at the effects on dizziness, falls, dementia like symptoms and kidney function with the lower blood pressure in our elderly population. As a practicing clinician I will look at each patient situation individually. I will suggest maximizing lifestyle issues such as smoking cessation, weight reduction, lipid control and sensible exercise before adding additional medications to lower blood pressure even more. We will recognize that many of you are already on two blood pressure medicines, an antiplatelet agent, a lipid lowering agent plus other medications before we add a third class of blood pressure medicine to get your systolic blood pressure even lower. With the side effect profile of most blood pressure medications including electrolyte imbalances, fatigue, effects on frequency of urination and sexual function, we must consider the individual pros and cons of further lowering BP by additional medication very carefully.

Fish Oils in Osteoarthritis – Low Dose vs. High Dose

Using the common sense approach that if a little bit is good then more is better in the treatment of “rheumatism” Catherine Hill, M.D., of the University of Adelaide in Australia and colleagues looked at the effect of taking low dose fish oil supplements versus high dose fish oil supplements. When one looks at the adult population of Australia, one third of them take fish oil supplements and had within a month of this study. The typical dose is one ml of fish oil per day. Experts say the dose for anti-inflammatory effect for arthritis is considerably higher at 2.7 gram or 10 ml per day. Dr Hill’s theory was that high dose fish oil for symptomatic and structural outcomes in people with knee osteoarthritis was better.

She enrolled 202 symptomatic patients in a double blind study. High dose group patients received 4.5 g EPA/HPA per day. The low dose group were given a blended of fish oil containing 0.45 g EPA /DHA per day in combination with Sunola oil. Both supplements were flavored with citrus oil.

All patients received a baseline MRI of the knee at inception of the study and at two years. The patients mean age was 61 years and body mass index was 29kg/meter squared. Both groups showed x-ray evidence of arthritis in the knee at inception and both groups were allowed to take non-steroidal anti-inflammatory medications and acetaminophen for arthritic pain during the course of the study.

At two years there was no difference in the MRI findings or cartilage volume loss between the high dose and low dose groups. Each group took similar amounts of NSAIDs and acetaminophen for pain on a regular basis. The high dose had no benefit over the low dose.

The researchers concluded that there was no benefit in their study to high dose versus low dose fish oil supplementation for arthritis. They reasoned that since patients in the study were permitted to take additional fish oils on their own during the study this may have altered the findings. The researchers additionally had little control over how much fish the participants ate.

In reviewing the data it seems to indicate that fish oil played a minor role in slowing down arthritis in the knee joint. Low dosage had as good of an effect as high dosage but the studies lack of a true control group who did not take fish oil at all made the conclusions hard to accept.

I will suggest to my patients that they continue to eat two fleshy fish meals per week to get their fish oils for arthritis and cardiovascular protection, rather than purchasing and taking low dose or high dose fish oil supplements.

Are Non-Steroidal Anti-inflammatory Drugs Safe?

In recent months patients and physicians have been challenged to find safe medications to relieve pain. Nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen and others were once the mainstay of simple pain relief. We knew that they could irritate the lining of your stomach and possibly cause gastrointestinal bleeding so we suggested that you take them with food in your stomach. We knew they could injure your kidneys so we reduced the dosage and frequency to individuals with kidney issues. When reports came out that these effective pain medications were contributing to acute heart attacks through coronary artery spasm, we grew leery of prescribing them. In recent years after a pharmaceutical industry push to use narcotics for pain relief we are confronted with addiction and all its negative connotations to deal with if we use opioids to relieve pain. What then is available to prescribe for pain?

The SCOT (Standard Care vs Celoxicab Study), championed by, Thomas M MacDonald, MD, of the University of Scotland Dundee helped provide an answer. The study was discussed at the meetings of the European Society of Cardiology this week with results that show that older patients with no heart disease history had no increased risk of heart attack or stroke while using NSAID drugs for extended treatment. They followed 7297 patients 60 years of age or older for three years who were prescribed celecoxib (Celebrex) or another nonsteroidal drug. The endpoint of the study was a heart attack, a stroke or the discovery of new cardiovascular disease. The number of new heart attacks or strokes was actually far lower than predicted proving that these drugs do not cause heart attacks or strokes in cardiovascular disease free individuals. The study did not look at these drugs effect on individuals with documented heart or cardiovascular disease.

In recent months the Food and Drug Administration has insisted that manufacturers of NSAID’s specifically inform and warn consumers of the increased risk of a heart attack within weeks of starting the drug and increasing with time. This study will now allow us to relieve the pain of the young athletic individual with musculoskeletal pain without fearing we are setting them up for a cardiovascular calamity.