Mark's Musings - March 11

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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CBD oil: Miracle cure or junk science? (822 views)

Yahoo lives up to their "360" name in the conversation about the role of CBD (#cannabidiol) in healthcare. From believers ("This isn’t lab science. It’s real life.") and skeptics ("The explosive popularity of CBD is way ahead of any evidence to support its efficacy - or reliable reassurances that it has no serious adverse effects."). There is concern about it not being regulated (“wild West ... You have to know where your products are coming from”) but also about missing an opportunity ("If physicians dismiss this promising, state-sanctioned treatment option, they miss the opportunity to alleviate suffering and improve the quality of life for many patients.”) So which is it? Everybody's opinion on #marijuana is filtered by their biases, so to a large degree it's "in the eye of the beholder." 2019 will be a year of societal wrestling with those disparate views. Sooooo many websites are selling CBD products. You can find bottles and tubes in most retail stores and pharmacies. Not a day goes by without me seeing a story about CBD. Maybe that says more about how Google or Yahoo or Facebook view what's of interest to me but I have noticed the conversation has swung over the past 2-3 years from "marijuana" to specifically "CBD." Based on my interactions with audiences, that's primarily because (1) many are already using it (2) there appear to be no downsides (3) the user cannot get high.

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Did the FDA Ignite the Opioid Epidemic? (11,718 views)

I've heard that FDA approval is the "gold standard" for assessing a drug's efficacy. And they do have a high bar of proof from what can be a laborious clinical trial process. But what if the "FDA ignited this #opioid crisis" by changing the label to support the use of OxyContin for #ChronicPain to "daily, around-the-clock, long-term… treatment" without any evidence to support it? Well ... Do you remember Zohydro? The FDA's advisory committee recommended to NOT approve it and yet the FDA did anyway. Interestingly, it was the MA Governor in 2014 that effectively killed the momentum. Is this interview with a disgruntled industry exec (who shouldn't be believed) or someone offering an insider's perspective (as a public service)? Back to "eye of the beholder." I've long said there are many stakeholders that share the blame, and because I like alliteration they all started with P's - Big Opioid Pharma, prescribers, pharmacists, payers / insurance companies, patients and politicians / policymakers (where the FDA would fit). They - and others - are equally culpable. It will take all of us to #CleanUpTheMess then #PreventTheMess.

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The tip of the iatrogenic benzodiazepine iceberg (891 views)

Just in case you haven't picked up on my not-so-subtle hints over the past seven years in the public eye (and overall since 2003), #benzodiazepines are very dangerous. Not only when you're taking them but when you're trying not to take them. As I've said multiple times along with the #opioid epidemic we also have a #benzo epidemic. Not that they should never be used - but like with opioids, their overuse has created consequences. Check out this quote: "Physicians have been unprepared for these withdrawal disorders and are unable to treat or even guide patients through complicated withdrawal from these substances ... Laypeople and sufferers themselves are unfairly left shouldering the burden of this systematic failure of health care.” That's accurate ... and scary. Especially if you or someone you know uses benzos over an extended time, which can be defined as a very short time period - "misprescribing (> 2-4 weeks, without informed consent about the real risks for physical dependence and withdrawal)." Take note. Be careful. The best way to manage benzos is to not start them in the first place.

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Suicide, addiction deaths surge (290 views)

I read this article on USA Today during breakfast on March 6 - "Suicide, addiction deaths surge." Sad, bad news for every American. But one clarification and one observation. 

• "Deaths from synthetic opioids, including the narcotic pain reliever fentanyl, rose 45 percent." Wrong. The #fentanyl that's the primary source of #opioid overdose deaths is not Rx but the analogues manufactured in China and shipped to the U.S. I blogged about it twice ("Fentanyl Folly" on 7/5/16 and "Overseas Opioids" on 11/15/16). It's important to not be confused about that point.
• In the paper copy I read, underneath the second part of this article is a half-page ad "Good News for Americans, Bad News for Pain Drugs" that advertises a new immune modulation drug. Is it a good drug? I don't know because "these statements have not been evaluated by the FDA" (in small print). A marketing coincidence? Likely not.

Unfortunately this surge is having a macro effect ... "U.S. life expectancy declines again, a dismal trend not seen since World War I." Bottom line? "Life expectancy is improving in many places in the world. It shouldn’t be declining in the United States." But it is.

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FDA takes fresh look at whether opioids are effective for chronic pain (354 views)

Some might say this approach to validating long-term efficacy of #opioids is several thousand lives too late. Some might say the evidence does not (and has never) support their chronic use while others might say the evidence is "inconclusive." Maybe there are even some that say the evidence is clear. There certainly are a number of individuals using them for #ChronicPain with varying results. I prefer to be optimistic and say this will be helpful additional input to make good clinical decisions. Some time in the future. Because it's going to take awhile for these studies to be done. There is little motivation for Big Opioid Pharma to move quickly on this initiative (there is no deadline for compliance that I can see). What we as a society are struggling to identify is .. how to determine "Appropriate, Not Zero, Opioids." It was irresponsible to prescribe so many long-term opioids without proper evidence. It is likewise irresponsible to say all opioids are bad and force people off opioids without proper tapering and equipping them with coping skills. We have to find the delicate balance between appropriate and inappropriate use. Quick.

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March in Like a Lion (256 views)

Thanks to Greg McKenna and Cari Miller for their usual great job with Gallagher Bassett's "The Way." In today's issue they mention a new #opioid weaning pilot program launched in New Hampshire. According to Greg and Cari : "The New Hampshire Department of Labor will launch an Opioid Pilot Mediation Program to voluntarily transition some injured workers away from opioids and into treatment. The goal is to bring together injured workers using opioids and insurance carriers through a mediation process to find covered options for non-narcotic pain relief and recovery. New Hampshire ranks among the top five states affected by opioid addiction. Under the pilot program, a meeting between the administrative judge and the parties is held within 30 days and a nurse is assigned to the case to help the injured worker find pain relief beyond addictive narcotics." The NH program is modeled after the "Opioid Alternative Treatment Pathway" launched by Massachusetts in 2017 (that also uses nurses). Another iteration can be found in New York's weaning hearing process (a legal process) launched in October 2016. While each are unique, both MA and NY have had success. As far as I know this approach has not progressed beyond the northeast and I'm not really sure why. Here's a heads-up to the Work Comp regulators in the other 47 states ... Try it.

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At Sloan, NBA commissioner Adam Silver talks candidly about players’ mental health (917 views)

So, truly, money doesn’t buy you happiness. Nor does fame. Isolation, in whatever form, is dangerous to mental health. As I’ve gotten to know many people in #ChronicPain, isolation is often their largest problem. Some times it's self-imposed. With my frequent travel I am that "lonely guy eating dinner all by himself." That is typically offset by networking during the day with friends and colleagues with lots of great conversations, deep and humorous. According to the National Basketball Association (NBA) Commissioner many players choose to isolate themselves from their teammates which exacerbates the depression and anxiety some of them feel. When you're going through difficult times is NOT the time to be alone but to be in relationship. Two sets of correspondence on LinkedIn add helpful nuance:

• Linda Breads: "Alone and lonely, to me, are different. I chose, at times, to be alone but I am rarely lonely which is a key in solid mental health. We have become a less interactive society on an in person basis and people retreat to a comfort zone of being alone. Today many are socially awkward as those skill you do not gain from a google search. We cannot read body language as hard to see that on FB or Twitter. We are all victims of fair game as we have no foundation anymore by which to build a solid social rock. Social media allows us to be deceitful, mean, hateful and yet it can also share good, if we choose. We are still quick to label, heck we all act out and need to at times vent but if you choose to do so something is wrong. It starts with loving who you are, finding who you are and being truthful to who YOU are not by anyone else standards but your own. We must empower those who look to a pill, drink and another person to validate themselves, they need a way to validate themselves as that is what separates alone from lonely and a mental illness label." My response: 100% agree, Linda. You, like me, believe in eyeball to eyeball communication. To some, that's a lost art. And you can absolutely be alone but not lonely. The former is helpful introspective time - the latter can be dangerous.
• Dr. Pamela Zink: "My experience in working with clients is the separation and loneliness in the recovery process. Pain management is much more than medication, surgery and rehabilitation. Unfortunately most insurance companies do not provide for the mental health aspects of injury in the recovery process." My response: I've seen a transition towards a willingness in Workers' Compensation to pay for the full #BioPsychoSocialSpiritual (whole person that includes mental health) treatment model. But it's not as pervasive as needed yet. Progress but incremental. Until then, we need to keep talking about it until it is standard practice for all stakeholders.

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Cowboys' David Irving appears to smoke weed while blasting NFL's drug policy on streaming video (1,063 views)

The points he is making are not unique - I've heard them / read them from around the country. They resonate with some, don't with others. But it's a dialogue that will continue to play out across dinner tables, in doctor's offices, in state capitals and in the news into the foreseeable future. “Arguing that the league should support him treating pain and mental illness with marijuana in place of #opioids ... 'If I’m going to be addicted to something, I’d rather it be #marijuana, which is #medical,' Irving continued. 'I do not consider it a drug, rather than the Xanax bars or the hydro[codone] or the Seroquel and all that crazy (expletive) that they feed you. Like I said, it ain’t about smoking weed.'" Smoking marijuana in a public way when his (ex)employer has a very specific drug policy that disallows that drug (and has been suspended three times for not adhering to those workplace policies) is probably not the best way to win an argument. However, the points that he makes are indeed not novel.

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In addition, I published one blogpost:

• "Mark's Musings - March 4" on March 5

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

#PreventTheMess + #CleanUpTheMess = The Answer.