Mark's Musings - April 22

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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Luck Is What Happens When Preparation Meets Opportunity (317 views)

This is the way I've tried to live my life and I've been (not randomly) "lucky." Do you need better "luck"? Then maybe you need to do more preparation and be more sensitive to opportunities. You've heard it said "I would rather be lucky than good." If you're not good, you might not be lucky. So why not be both?

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Low-impact exercises for pain (681 views)

For those in #ChronicPain who can't take on medium-high impact exercises, here are some ideas ... because "Motion is Lotion"! The four suggestions are:

1. Walking (and for those with balance issues, "nordic" walking)
2. Yoga and Pilates (since it's less intensive it might be better for #ChronicPain than Yoga)
3. Qi Gong and Tai Chi (the more vigorous of the two)
4. Pool exercises (when ground-based aerobics aren't an option)

"It is important for patients to be strategic about exercise, & invest the limited time & energy on sustainable, beneficial forms of exercises." If you can't do it by yourself / for yourself, you'll likely not be as successful long-term. The key is figuring out what works best for you, your condition and your circumstances.

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Positive Drug Test Rate Among Workers is Way Up, Quest Says (262 views)

ICYMI on Friday, this article by Nancy Grover quotes me on the implications of drug testing results just published by Quest Diagnostics. There are the obvious takeaways and then the not-so-obvious (which are the ones I focused on). Here are my observations:

• The decline in positive results for prescription opioids makes sense given the decline in prescriptions that started in 2012 (per the CDC, "Prescribing Practices") and began to be documented by Work Comp in 2014. So the trend of declining positives will likely continue.
• It was likewise not a surprise that positive tests for heroin also declined. However, there is a hole in the statistics because they did not mention test results for the fentanyl and it's analogues that largely replaced heroin and prescription opioids as the primary killer by 2016 (what is known as the "third wave" of the opioid epidemic). So this analysis is incomplete.
• It was not a surprise that positive marijuana tests increased since medical and recreational use has been NORMLized (in case that pun is too subtle, NORML = National Organization for the Reform of Marijuana Laws) across the country. However, to reiterate what I've been saying/writing since 2014, presence does not necessarily mean impairment when it comes to marijuana.
• The implications of these trends in drug test results mean that individual companies are making individual decisions. Some are required to have zero tolerance policies because they receive federal funding and/or have employees with commercial drivers licenses. Others have made a corporate cultural decision to disallow presence of any type. Others have decided to have different rules for different jobs. And others have decided to either forego testing completely or just remove some drugs (like THC) from the panel. In other words, how employers are managing drug testing mirrors how our country is handling marijuana - piecemeal and local. Did you know there are "dry" cities and counties in Colorado and California that don't consider the state's recreational legalization applicable? In one word - it's complicated.

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One in five deaths worldwide linked to unhealthy diet (477 views)

“Poor diet is responsible for more deaths than any other risk factor in the world ... Our assessment suggests the leading dietary risk factors are high intake of sodium, or low intake of healthy foods, such as whole grains, fruit, nuts and seeds and vegetables ... Diets high in sugar, salt and bad fats are known risk factors for heart disease, stroke, diabetes and many types of cancer.” Like I said last week, you don't need a prescription from a doctor to eat more "fruits and veggies." You just need to make a decision at every meal and snack to choose wisely. And for those in #ChronicPain it becomes even more important (e.g. if your pain is coming from inflammation then adopt an anti-inflammatory diet). If you can't completely change your diet overnight (don't worry ... nobody can) then do one thing - Replace Sodas (regular or "diet") With Water. That would be a great start.

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Multidisciplinary "Prehab" Prior to Spine Surgery for Patients with Opioid Addiction and Chronic Pain Syndrome is Efficacious (979 views)

The combination of spinal surgery and #WorkersComp means the patient is twice as likely to have a negative outcome (injured worker's health and payer's financial costs). Check out these studies:

• "Workers’ Compensation Status: Does It Affect Orthopaedic Surgery Outcomes? A Meta-Analysis" on 12/5/12
• "Two-fold Increased Risk for Unsatisfactory Spine Surgery Outcome Found in Workers’ Compensation Patients" on 2/22/19

That heightens the importance of the "prehab" mentioned in this article: 1) transition from opioids to non-opioid medications, 2) cardiovascular exercise program, 3) smoking cessation, 4) alcohol cessation, and 5) psychotherapy to treat mood and maladaptive pain behavior. Comments from two friends were incredibly enlightening:

• Virginia Johnson: "I had my low back surgery at 21 years old, and was also fortunate to have a good outcome. Good to see that cardiovascular exercise is mentioned here, but would think that adding resistance training to strengthen the surrounding muscles would be equally important. Cardiovascular exercise does not necessarily equal resistance training. Although an anecdote, strength training was key to my recovery and minimizing chronic pain."
• Jay Garrard: "Having been in the industry for 20 years and seeing so many bad spinal surgery outcomes for injured workers it was a frightening prospect to have my wife facing a lumbar fusion. Not quite one year later, and she is a prime example of when everything goes right. It would be interesting to dissect all the factors that led to her great outcome, versus the poor outcomes in Work Comp ... The weight training and core strengthening that my wife focused on for several months prior to surgery is definitely one of the things that gave her a good foundation for a positive outcome."
• And my response: "Thanks Virginia for that helpful addition to the "prehab" (and Jay's affirmation). I totally agree that resistance training and core strengthening - anything attached to your spine that could help aid it's stability and strength - is a key component. You both may have touched on why outcomes are so much poorer in Work Comp because you obviously had the motivation and discipline to do your part (and you did it). That's obviously true of many injured workers (or else the failure rate would be 100%) but there's many that have a passive, entitled approach where the hard work before and after surgery is not adequate. Determining up-front those that have the self-discipline and motivation to do the hard stuff and those that don't is the key to ultimate success - and those that don't will require an extra focus to help them achieve optimal outcomes. I don't like broad stroke comments, but when the statistics show Work Comp is 2x more likely for negative outcomes, it's difficult to not draw some big-picture conclusions."

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The Sackler Gallery (164 views)

Thanks to John Oliver's "Last Week Tonight" for these artistic interpretations of actual court depositions and e-Mails from Richard Sackler (Purdue Pharma, manufacturer of #OxyContin). Bryan Cranston, Michael Keaton, Richard Kind and Michael K. Williams each have their own style but the words are not theirs. Key phrases to watch for are "I don't know", "blizzard" and "reckless criminals" (amazingly directed at #opioid patients). My guess is that even more details will be coming out as the various lawsuits continue to play out. My other guess is that Oliver will continue to ensure those details don't get overlooked.

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In the age of legal marijuana, many employers drop ‘zero tolerance’ drug tests (461 views)

This article reiterates what I've been saying to audiences around the country since 2014 about #marijuana and the workplace. The concept of zero-tolerance drug policies are increasingly a subjective (and pragmatic) decision by individual employers. I incorporate multiple stories from employers I've spoken with (CA, CO, NM, IL, NC, GA, NY, etc.) that (1) confirm a zero-tolerance policy (2) do drug tests but remove THC from the panel (3) don't do drug tests at all. This article from the Sacramento Bee is a great overview of each angle and the reasons behind them. If you want more info about the Quest Diagnostics study see the "Positive Drug Test Rate Among Workers is Way Up, Quest Says" story above. The job of a business owner, H/R manager, supervisor and Medical Review Officer continues to get more difficult by the day. The primary question - How do you balance a safe workplace and full employment? For some, that means a compromise on potential impairment. More good back-n-forth comments on this article:

• J. Stephen Monahan: "We should instead have policies focusing on impaired performance regardless of cause. That doesn’t mean fire the person, but it does mean remove them from the work environment where the person poses a danger to himself and co-workers, and the bottom line. It means observation supervision and coaching which all to often are under valued."
• And my response: "Spot on! It comes down to whether they can do the job they were hired to do. If they can't, regardless of the impairing chemical, then they need help (to either proactively confront their need for impairment or find a different job). All of that is management - true management - of not just the task but the person performing the task. The "observation, supervision, coaching" that you mention is indeed a key component to that and often overlooked / under-utilized."

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4 ways employers can address the opioid crisis (221 views)

Great advice to employers about how to manage the #opioid crisis with their team members. It involves accurate and honest communication along with maybe some workplace culture changes. If you're on the management team, please read the entire article for yourself. Here are the four items the author felt important to reinforce:

1. Get rid of unused or expired medication
2. Facilitate treatment
3. Amend plan design
4. Lead from the top

While all are very worthwhile (e.g. the semi-annual DEA takeback day is Saturday April 27, focusing on vetted evidence-based treatment options), I especially like #4. Being honest, transparent and even vulnerable throughout the organization on how everybody has difficulties in life (whether you are the CEO or the janitor). "Employers must strive to provide a workplace culture that destigmatizes substance use disorders and encourages employees to get help." Amen. If you're a business owner or a member of the management team, you are on the front lines of the opioid epidemic. Grasp hold of that responsibility and do your part.

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The truth about planks (538 views)

I'm a "plank" person. What I had not considered was a "reverse plank." If you want to skip past his rationale why the plank is maybe too easy and not doing everything it's been promised, at the 6 minute mark he talks about "flipping it over." He makes it look easy - believe me, it's not. But when you feel it that means it's probably doing something. So if you're a "plank" person, try both sides. It's all about your core.

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Making Treatment Guidelines Matter (127 views)

Thanks for sharing, Jeffrey Austin White! Indeed, great conclusions from your research that Peter Rousmaniere concisely stated. "Its research shows that non-compliance is not necessarily wrong, only that in certain circumstances it might be wrong ... It is not surprising that Gallagher does not, at least for today, use guideline adherence to profile the overall performance of a provider, over many cases, to create a provider score ... Compliance with medical treatment guidelines matters. Significant departures from the guidelines leads to longer disability durations and higher medical costs." Not doing the wrong thing is as important as doing the right thing and treatment guidelines help clinicians and payers determine the difference. But don't ever view treatment guidelines as inviolable. Notice the word ... "guidelines."

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Doctors, pharmacists in 5 states charged in prescription pain pill bust totaling 32 million pills (1,026 views)

"Federal prosecutors charged 60 physicians and pharmacists Wednesday with illegally handing out opioid prescriptions ... the illegal prescriptions put as many as 32 million pain pills in the hands of (about 28,000) patients ... the list of indicted medical professionals includes podiatrists, orthopedic specialists, dentists, general practitioners and nurse practitioners ... "if so-called medical professionals are going to behave like drug dealers, we're going to treat them like drug dealers" ... they gave out about 350,000 improper prescriptions in Alabama, Kentucky, Ohio, Tennessee and West Virginia." Even now, with what we know about the #opioid epidemic, at "ground zero" for it's genesis (Appalachia), we have "clinicians" acting like this? I know they're just allegations at this point (here's their names) but it's shameful. A silver lining? "The hope is 'when these facilities are taken down, there are resources in place to give the best possible chance for those victims to get proper treatment,' Glassman said." Unbelievable. Except it's happened over and over and over again ... so, unfortunately, it's believable.

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Guidance on Dangerous Medications (224 views)

Thanks to Stephen Sullivan and WorkCompWire for publishing my blogpost today entitled "Guidance on Dangerous Medications." Included is some information on a very promising study on the use of #opioids for acute spinal pain underway in Australia. And what the UK's rescheduling of pregabalin and gabapentin (also a trend here in the US) means for "safer" but not "safe" medications potentially used as an #opioid substitute. If you've missed my previous blogposts on WorkCompWire you can catch up on them at my own homepage.

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20 Habits For a Healthier, Happier Life (813 views)

If you're not familiar with the "Blue Zones" it's important to get up-to-speed. They are five geographic areas on the planet - Ikaria Greece, Okinawa Japan, Ogliastra Region Sardinia, Loma Linda California, Nicoya Peninsula Costa Rica - that "not only had high concentrations of individuals over 100 years old, but also clusters of people who had grown old without health problems like heart disease, obesity, cancer, or diabetes." So the interesting part is - what do they do differently to live so healthily? Well, here's 20 tips discovered during that research journey. You'll recognize some of the items based on what I've been "preaching" about but there's also some new ones that are simple to say but more difficult to do (e.g. "Create Downshifting, Stress-Relieving Habits"). How many of these do you already do? How many more do you NEED to do? I have my work cut out for me since I have only 10 of the 20 ... ;)

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In addition, I published one blogpost:

• "Mark's Musings - April 15" on April 16

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

#PreventTheMess + #CleanUpTheMess = The Answer.