Mark's Musings - April 1

Below is an aggregation of the stories I posted on LinkedIn since my last edition. I curate them through the prism of an "intersection of chronic pain and appropriate treatment" and so they come attached with my opinion.

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Novel Program Improves Chronic Pain, Stops Opioid Use (412 views)

Thanks to Linda Van Dillen for sharing this article on Twitter last week. Very positive outcomes for these 53 patients. However, I'm not sure that "novel" is the right term for this method of treating #ChronicPain. Many interdisciplinary functional restoration programs (FRP) across the country utilize similar whole-person tactics and "focus on function." I've visited many of them in-person since 2011. They've all had great success when the patient is ready for change. "In our interdisciplinary model, patients not only work with strength training and physical therapy, but also psychology, nutrition, and other modalities to help them get more ownership of their pain and increase their understanding of pain. We thought this would help reduce the central pain, and this is what our study shows." Great description - the very definition of #BioPsychoSocialSpiritual. But this approach is not new (hence my disagreement with the term "novel" to describe it, which was probably coined by the article's author and not the research clinicians). I've been a proponent of the FRP model for several years. If you're not, get to know it. Two great comments were posted that helps further underscore the point that FRP's can be very useful but are definitely not "new":

Thomas Heitkemper Ph.D.: Mark, I helped run interdisciplinary pain management programs (a step above "multidisciplinary" programs...the difference is that interdisciplinary programs coordinate and communicate among all treatment components) from 1986 through 1996... We called it the "full court press" approach with simultaneous physical, psychological, social, and vocational reactivation. So indeed, everything old is new again. And we had great outcomes (reduced med use, lower health care utilization and continued vocational goal attainment) at 2-month, 6-month and 1-year follow-up. Many of my psych sessions were done during PT and OT sessions to make sure we were addressing the "hurt versus harm" issue that can lead to pain-avoidant behavior and overall activity intolerance. Our program director, Dr. Peter Vicente (past president of the American Pain Society and one of the most brilliant and passionate persons I've ever met) helped develop this model in the early '80s. Unfortunately, these programs nearly became extinct in part due to the proliferation of modality-specific pain centers and, of course, the siren call of opiates as an answer to dealing with chronic pain.

Geralyn Datz Ph.D.: 100% on point Mark. These programs are not at all new but were very popular about 3 to 4 decades ago when the healthcare landscape was much different than now. Thankfully there is wisdom in history and indeed, as printed out above, what’s old is new and there is renewed interest in these programs which address both the mind and body and promote self empowerment and physical movement and strength despite pain. We have seen similar amazing results and also presented our findings at this meeting! So glad to see this getting publicity. More people need to know about these programs.

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Purdue Pharma to pay $270 million to settle historic Oklahoma opioid lawsuit (278 views)

Thanks to Jeff Rush for sharing this article on Twitter today. My comments:

• $270M sounds like a lot money but when you count up the past/present/future implications of the #opioid epidemic, not so much. If this is the Purdue strategy - settle before the openness of court - lots more checks to come.
• Often the only stakeholders that win in settlements are attorney fees so let's hope the #Oklahoma AG uses ALL of the $270m to help pay to #CleanUpTheMess of the #opioid epidemic.

BTW ... In case you didn't know, all of these Big Opioid Pharma lawsuits are being managed by U.S. District Judge Dan Polster in Cleveland. Expect constant news throughout 2019. Good news in a subsequent article about my second point above: "The settlement will establish a nearly $200 million endowment at Oklahoma State University's Center for Wellness and Recovery that will go toward treating addiction, Hunter announced. It will also provide an annual $15 million payment to the center over a 5-year period and ongoing contributions of addiction treatment medicine." That means this money will go directly towards finding ways to help people.

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To Save Lives, Empower the Addiction Treatment Workforce (202 views)

From the president of the American Society of Addiction Medicine (ASAM), Kelly Clark, MD, MBA:

• One scary statement - "Even with skyrocketing numbers of drug-related deaths, there are too few physicians and other clinicians with the requisite knowledge and training to prevent, diagnose and treat #addiction."
• One scary statistic - "In 2017, an estimated 20.7 million Americans needed treatment for SUD (substance use disorder), but only 4 million reported receiving any form of treatment."

We cannot #CleanUpTheMess of the #opioid epidemic unless treatment is available and utilized. Dr. Clark offers two intriguing options to help narrow the gap: "Fund a new student loan repayment program for SUD (substance use disorder) treatment professionals who serve in high-need communities ... Bolster existing efforts to expand opportunities for medical professionals to obtain specialized training in the prevention and treatment of addiction." I'm sure there are many other ideas out there of merit, but when the ASAM President speaks the rest of us should listen.

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Opioid Tapering Tips 1: Reducing Opioids without Withdrawal (435 views)

"Among the studies countering this notion (that patients who have been on long-term opioids will not want them discontinued regardless of the resolution or improvement of a painful condition or the possibility of alternative therapies) was one that found 75% of 110 patients in a clinic with chronic non-cancer pain on long-term opioid treatment agreed to taper their dosage, if they could receive help from the clinic to do so. 'This suggests that patients may be hopeful to decrease or discontinue opioid therapy, providing there is a validated plan in place and they have extensive support as they moved forward,' Joseph Pergolizzi Jr, MD observed." Another important quote: "Patients often require supportive care in this vulnerable time and may need help with pain control, tactics to manage withdrawal symptoms, and psychological or emotional comfort." Read page 2 for his tips on #tapering. Obviously they only address #opioids. Those typically aren't the only medications part of the regimen due to the cascading side effects and many of those other drugs also require careful tapering. In a word, tapering is complex. To address that it needs to be an individualized, strategic process. Here are the tips (but I suggest you read the full article anyway):

1. "The daily dose of opioids needed to prevent acute withdrawal symptoms is approximately 25% of the previous day's dose. MP NOTE: The 2016 CDC opioid guidelines recommend "A decrease of 10% of the original dose per week is a reasonable starting point. Some patients who have taken opioids for a long time might find even slower tapers (e.g. 10% per month) easier." The takeaway is that tapering needs to be methodical, strategic and individualized.
2. If a patient is receiving opioids through different routes of administration, such as transdermal and oral, it may be advisable to convert to a single, extended-release oral product before tapering.
3. If different opioid products are being used, conversion to a single product should be at roughly the equivalent dose over 24 hours, often expressed in morphine milligram equivalents (MME).
4. The highest daily morphine equivalent dose (MED) recommended by the CDC is 90mg. Although many patients take higher doses due to tolerance, it is noted that both high dose and extended duration of use are risk factors for OUD.
5. Short-acting opioids may be helpful at both the initiation and end of tapering the extended-release product, to avoid withdrawal."

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6 Speed Walking Tips to Help You Burn as Many Calories as You Would Running (244 views)

If you've been engaged with me for any amount of time, you know I try to provide as many self-management techniques as possible for managing #ChronicPain. Here's a "treatment" that doesn't cost you a single penny - "speed" walking at 4.5-5 mph. Obviously not everybody can walk that fast, but if you can it's almost as good as running (with less wear & tear). However, keep in mind that your speed is less important than your desire. Because, as I often say, Motion is Lotion. It's all about an #ActiveLifestyle. Sometimes we look for (and maybe even prefer) complex answers to complex situations. Sometimes the simplest answers actually work best.

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Purple heroin laced with carfentanil prompts warning from Vancouver health officials (57 views)

ALERT: A mixture of heroin and carfentanil in Vancouver. Even "testing" at "supervised injection sites" (wrap your head around that concept) isn't able to detect the tainted product. Just a reminder for those that haven't heard about it yet ... Carfentanil is 10,000 times more potent than morphine (Oxycontin is "only" 1.5 times more potent than morphine; fentanyl is "only" 100 times more potent than morphine). Outrageously dangerous. It should go without saying but any illicit drug purchased on the street is definitely "buyer beware" whether it's heroin (with carfentanil), "xanax" pills (that are actually pure fentanyl), cocaine (mixed with fentanyl), or synthetic marijuana (laced with fentanyl). These drugs (regardless of what may be mixed in that the user doesn't know about) aren't good for you. And the people that sell it don't care about you. The "filler" of fentanyl (or, in this case, carfentanil) is a killer.

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Childbirth, burns and missing teeth: Meet the woman who feels no pain and could open door for new generation of medicines (281 views)

I used to say #pain is part of the human condition. For this 71 year old woman who lives near Loch Ness Scotland (yeah, that place) apparently it's not. In some ways, not feeling any pain certainly is liberating. But in other ways it's very dangerous ("often the first she knows about it (burning herself while cooking) is the smell of her own burning flesh"). Another interesting aspect of this article was their focus on a "gene known to play a role in #endocannabinoid signalling." It is a biological system every human being has to regulate a "variety of physiological and cognitive processes" that includes both CB1 and CB2 receptors. If "cannabinoid" sounds familiar, it should ... #cannabis.

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In addition, I published one blogpost:

• "Mark's Musings - March 25" on March 26

And I was the guest on a Healthcare Solutions Podcast published by Cristy Gupton of Custom Benefit Solutions (this is part 2 of 2 from our discussion - you can listen to part 1 of 2 here):

• "How Real Leadership is Solving the Opioid Crisis" on March 25

And I was a guest of Brian Chu of EPIC as part of his "Q&A" video series on LinkedIn:

• View the Video from March 28

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"It's Never the Wrong Time to do the Right Thing" - Martin Luther King, Jr.

#PreventTheMess + #CleanUpTheMess = The Answer.