Mark's Musings - June 3

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.

=============================

Coloradans can soon get medical marijuana in place of opioids (415 views)

ICYMI - On May 23 the CO governor signed into law an explicit connection between prescription #opioids and medical #marijuana. "The new law adds to that list (of qualifying medical conditions) all conditions for which opioids could be prescribed to treat." As has usually been the case, it was anecdote (a 13-year old with epilepsy) that won support. Colorado now joins several other states that have similarly tied the two substances together (see my Jan 24 blogpost "Marijuana & Opioids"). Interestingly, a May 21 study concluded cannabidiol (CBD) "significantly reduced both craving and anxiety" (compared to placebo) for people with #heroin use disorder so science may be starting to substantiate the connection. Like I've been saying for awhile, #cannabis and opioids are linked and that connection will continue to drive the discourse. The new law goes into effect on August 2. I'm sure everyone will be watching prescription opioid trends to see how many prescribers and patients adopt this new approach.

=============================

NFL and players’ union to study potential use of marijuana for pain management (1,226 views)

And another article from Denver but this is on potentially an even more influential scenario - the National Football League (NFL) and Players Association has finally decided to move forward with a clinical study on the use of medical #marijuana for pain management by players. I've brought up this possibility as long as three years ago when they started talking about it. As an employer (teams) with a zero-tolerance policy on marijuana but with reportedly a majority of employees (players) using it, there needed to be some sort of reckoning. In my discussions around the country, most people currently not in support of medical #cannabis want clinical studies to prove/disprove the claims - and they might even change their mind based on the results. Granted, the two committees aren't exclusively focused on marijuana but it will definitely be in the mix for review of pain management options (which is telling in itself). When the US' preeminent sports league starts taking it seriously, their conclusions will be watched carefully. Just to be clear - this isn't only about marijuana. "The two committees being formed are a joint pain management committee and a comprehensive mental health and wellness committee ... Its members will study a variety of pain-management issues and strategies for players." Opening up treatment options beyond prescription painkillers is a good thing. Check out my 9/25/14 published article entitled "The Problem of Playing Through the Pain" about the Rx opioid problem the NFL has had for awhile.

=============================

How do our emotions affect our immune response? (696 views)

The evidence continues to pile up ... Chronic exposure to stress, anxiety, and negativity impacts - negatively - our health, #resilience and ability to manage life's difficulties (like #ChronicPain). "Graham-Engeland and team noticed that individuals who experienced negative moods several times per day for extended periods of time tended to have higher levels of inflammation biomarkers in their blood." Can emotions really have biological impacts on our body? You mean the mind is connected to the body? Yes and Yes. So what you're really saying is that a positive outlook on life, enabled by supporters that encourage you with positivity, can have a positive effect on health? And that the reverse - negativity surrounded by negativity - can have a negative effect on health? Yes and Yes. Of course, thinking positively doesn't create good health by itself - you still have to make good choices (exercise, nutrition, sleep, hydration, etc.) But thinking negatively has massive repercussions beyond just your thoughts. Think about it. Then do something about it. Getting out of an emotionally toxic situation - of your own doing or being in the wrong place at the wrong time - is difficult. But doing so is the best (only?) way to break the chain.

=============================

Millions Take Gabapentin for Pain. But There’s Scant Evidence It Works (986 views)

Gabapentin (name brand = Neurontin) "is being taken by millions of patients despite little or no evidence that it can relieve their pain." It, and Lyrica, have only been approved by the FDA to treat "postherpetic neuralgia, diabetic neuropathy, fibromyalgia and spinal cord injury." Using them for anything else is considered off-label, meaning that the FDA did not explicitly approve those uses (maybe because the manufacturer did not request the FDA review it or the clinical evidence submitted was not sufficient for the FDA to approve it). Off-label does not necessarily mean it's inappropriate. But this editorial outlines some of the reasons why these drugs might not be the most effective choice. And potentially even cause harm (read my 4/19/19 blogpost "Guidance on Dangerous Medications" for more information). Bottom line - If you or someone you know uses Neurontin or Lyrica, make sure the benefits exceed the risks and that less potentially dangerous options have been explored. And if you find a better option, do NOT discontinue them suddenly. To underscore the point that potential dangers do not always mean inappropriateness, Amanda Wiggin provided her own personal story: "I take Lyrica for peripheral neuropathy. Unfortunately due too having Idiopathic Intracranial Hypertension a med I need called Diamox (otherwise known as Acetazolamide) has a side effect of tingling of hands, feet, mouth and more.  My Lyrica has worked wonders controlling my peripheral neuropathy and the side effect tingling of the diamox. Lyrica has literally been a game changer for me." The way that Amanda outlines the rationale for use makes a strong case that her benefits exceed her risks. That's what I call making an informed decision.

=============================

Digital Health Intervention Associated with Less Need for Opioids After Surgery (159 views)

Integrating behavioral medicine into surgical events (i.e. #BioPsychoSocialSpiritual) has a new avenue thru Stanford University's “My Surgical Success," a digital (online, on-demand) resource. The question they asked during their RCT was "Will patients engage with an online intervention that is designed to help them have a better recovery after surgery?" The answer was Yes with half of the breast cancer surgery patients taking them up on the offer. The results showed an 86 percent increase in odds of Rx #opioid cessation within 12 weeks and discontinuance occurring five days sooner -- with (importantly) "no significant differences in pre-post treatment pain." Thanks to Dr. Beth Darnall for continuing to lead in finding ways to use less opioids with better clinical results. Interestingly, this study did not attempt to limit access to Rx opioids. Instead, they provided this online tool (with no human-to-human interaction) to educate the patients on ways for them to "effectively self-manage symptoms and enhance recovery after surgery." So the discontinuance of opioids was an organic decision made by an informed patient. Knowledge is power. The goal - for all of us - is to increase the knowledge (via education) so patients can make the best (informed) choice for them.

=============================

How Evidence-Based Recommendations May Direct Policy Decisions Regarding Appropriate Selection and Use of Dietary Ingredients for Improving Pain (590 views)

If a whole-person/holistic approach to manage acute and chronic musculoskeletal pain (including proper nutrition) is considered best practice for USSOCOM (Army Special Forces and Rangers, Navy SEALs, Air Force Special Tactics, and Marine Critical Skills Operators) then it should be for the rest of us as well. They are combating regular use of Motrin (which has a series of negative side effects if used long enough) by embedding "Physical Therapists, Athletic Trainers, Strength Coaches, Sports Psychologists, and Performance Dietitians" into tactical units. While they haven't found enough evidence-based guidance on how strategic nutrition choices affects pain, they're working on it. They published three articles on April 15 - "Research recommendations & priorities", "Specific dietary ingredients" and "No recommendations." Worth a read if you have musculoskeletal pain. Here is some excellent advice from Jason Parker (a Canadian friend that really understands the inverse of disability):

"I agree that treating the person as a whole/holistically is an excellent approach and will only add that a person-centric approach will only enhance the outcomes. What I mean by person-centric is that they HAVE to be at the center, involved in decisions and choices. Too often people-centered care translates to stakeholders playing leading roles rather that supporting roles. And too often people-centered also translates to 'how much value as a stakeholder can I deliver' and usually ends up focusing on customer service versus engagement. That is why I like the term centric vs centered. Motivation to do anything requires a sense of control. We can be motivated by fear for sure, we can be motivated into compliance. However, those require tremendous oversite and conditions of compliance. I agree with you that true motivation requires ownership. As it turns out having a sense of control is a biological/neurological imperative to motivation (see: Work by Columbia university) - 'Motivation is triggered by making choices that demonstrate to ourselves that we are in control. The specific choice we make matters less than the assertion of control. It’s this feeling of self-determination that gets us going…' We have a sense of ownership when we are allowed to make decisions and choices. The Work Comp industry has missed this mark IMHO. We often put the Provider in the decision making role which tends to sideline the worker. We also pretend that good customer service provides a sense of control. Customer service is not a proxy for engagement and we have some data that supports this."

=============================

Easier Access to Naloxone Linked to Fewer Opioid Deaths (319 views)

"Do state laws to improve #naloxone access lead to reductions in fatal overdoses involving #opioids? The answer appears to be 'yes,' but success seems to hinge on the details of those laws." The difference appears to be when pharmacists are allowed by law to dispense Naloxone to anyone (without requiring a prescription) that per a NIH study has shown a much greater reduction in opioid-related deaths. So if your state does not have a NAL (naloxone access law), advocate for it. If your state has a NAL but does not give pharmacists the flexibility to dispense to anyone that asks for it, advocate for it. While society is trying to reduce supply of these drugs (Rx and illicit) and demand (mental health, recovery), saving someone from an overdose is something that happens on a daily basis. And the more Naloxone there is available at those specific moments, the more lives can be saved. To state the obvious, you can't save someone that's dead.

=============================

Association between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study (1,418 views)

Yes, it's me talking about nutrition again. This time, it's a clinical study that validated "ultra-processed foods and drink products" (carbonated drinks, sausages, biscuits (cookies), candy (confectionery), fruit yogurts, instant packaged soups and noodles, sweet or savoury packaged snacks, and sugared milk and fruit drinks) create a "62% relatively increased hazard for all cause mortality." Be careful what you put in your mouth - it could be hazardous to your health and negatively impact your ability to manage #ChronicPain. Hat tip to Kimberly George for sharing this on Twitter. This prompted some interesting comments:

• Jennifer Johnson: "'Let food be thy medicine and medicine be thy food.' -- Hippocrates"
• Kimberly George: "Thanks for sharing the study, Mark. When afforded a food choice, the healthy decision is to avoid ultra-processed foods. Nutrition is a significant factor in health and wellbeing, frequently minimized or all together omitted from treatment plans and patient education programs."
• Michael Stack: "My wife started beating the drum roughly 6 or 7 years ago to make changes in our family diet, which we have significantly to mostly whole foods, plant-based. It makes me laugh how many times I've said: 'yes, she was right about that.'"
• Linda Breads: "Many people seem to choose less healthy options as many times it comes down to cost. Healthy costs more at the register." And my response -- Yes, it does. Organic costs more than processed. McDonalds costs less than Panera. Kale costs more than iceberg lettuce. I understand some socioeconomic circumstances don't provide the capacity or availability for healthier choices. However, if you look at it as an investment into potentially a longer, higher quality of life then maybe at least some of those people can find a way to make that healthier choice.

=============================

Public Speaking Is No Longer a 'Soft Skill.' It's Your Key to Success in Any Field (303 views)

Just so you know ... Persuasion is not a "soft skill" ... It's a required skill. Talent is innate. Skill is practice.

=============================

TheNNT (607 views)

Hey Linda Van Dillen - I know how passionate you are about taking Number Needed to Treat (NNT) into account when comparing treatment options. I ran across this website - TheNNT - that fits that approach. Interestingly, their inclusion of #opioids (they use "opiates") is focused only on abdominal pain. They also include opioid withdrawal and NSAIDs (post-partum). That leaves a lot uncovered. But I loved how they made it simply green, yellow, red, or "harms > benefits" while giving the full clinical study to read. Do you have some other resources you could suggest for people with #ChronicPain? And here is Linda's response: "Thanks for sharing, and I will keep my eye out for any very simple graphics like this. In regards to what works for chronic pain I did a recent three part series of articles on the Ethics of Pain Management and included all of the most recent Evidence Based approaches to managing pain and the findings on their efficacy in Part 3.  Here is a link to the third part of the series that discusses this evidence."

=============================

In addition, I published two blogposts:

• "Mark's Musings - May 20" on May 21
• "The Road to Resiliency" on May 24 by WorkCompWire

=============================

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

#PreventTheMess + #CleanUpTheMess = The Answer.