Mark's Musings - November 12

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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Marijuana Election Roundup (219 views)

The votes are in - #marijuana legalization has expanded in the U.S.:

• Michigan passed Proposal 1 to legalize recreational use, 57.1% - 42.9%
• North Dakota Measure 3 failed to legalize recreational use, 59.2% - 40.8%
• Utah's Proposition 2 legalized medical marijuana, 54% - 46%
• Missouri decided on Amendment 2 (the other options, Amendment 3 and Proposition C, failed) to legalize medical marijuana, 65.3% - 34.7%

The National Conference of State Legislatures has already updated their really "green" map:

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Rethinking “doing well” on chronic opioid therapy (149 views)

"For some patients, the primary benefit of opioids becomes the avoidance of withdrawal. This constitutes harm, but is easily misconstrued as ongoing effectiveness." An interesting dialogue by a physician. Please take two minutes to read the article and provide your feedback as comments. The author is David N. Juurlink, MD, FRCPC, PhD, BPharm (Divisions of General Internal Medicine and of Clinical Pharmacology and Toxicology, Department of Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ont.) - lots of letters after his name - he has the clinical expertise to make these statements. This editorial opines that the anecdotal stories on social media about opioids being the only solution that works for individuals in chronic pain may be less about the efficacy of the medications and more about what happens when they aren't taken. He admits there are some that do receive benefit (that exceed the risks) from the long-term use of opioids. I think his opinion corresponds with mine that it's about "Appropriate, Not Zero, Opioids." However, he draws the following conclusion:

"... patients receiving chronic opioid therapy can easily be harmed more than helped by medications they perceive to be effective or even essential ..."

Whether you agree or disagree with his conclusion, I think it underscores the fact that every individual is an individual and we cannot make broad-brushed assumptions or clinical decisions. There is no such thing as "cookie cutter medicine." And without all of the potential treatment options at their disposal, both providers and patients can make poor decisions.

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I Had No Idea I’d ‘Misused’ Klonopin Until I Tried To Stop Taking It (377 views)

An interesting first-hand account of how Klonopin (clonazepam - a #benzodiazepine) can become dangerous without anyone really noticing. Especially if you stop taking it without a tapering strategy. Can it help manage anxiety? Undoubtedly. But could the risks exceed the benefits? Entirely likely. If you're already taking a benzo or a clinician is advising you to do so, read this helpful info from MedicineNet. This "anxious millennial woman steeped in a high-pressure environment and with privileged access to health care" was legitimately prescribed Klonopin to address anxiety and panic attacks. But a year after her first prescription she said "Everything hurts. I can’t sleep. I can’t be awake. I can’t move. I can’t stop moving. I feel crazy." After finding nothing medically wrong, the doctor asked her a connect-the-dots question - "When was the last time you took any (Klonopin)?” When she answered "one week" it was obvious her need to be in the Emergency Room was because of benzo withdrawal. Read the rest of her story in this article. Then make a personal decision as to whether a benzo is the right drug for you. If not, be very Very VERY careful in how you decide to stop using it.

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Seniors In The Deep South And Rural Western States Prescribed Most Benzodiazepines And Opioids (158 views)

Yes, something else from me this week about #benzodiazepines.

"The study found that some primary care doctors prescribed sedatives at a rate more than six times that of their peers, and that those who were top prescribers tended to also be high-intensity prescribers of opioid painkillers."

I guess these doctors haven't been paying attention. It's not new and it's everywhere. From reputable sources:

• "FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning"
• The CDC's "Workers Using Prescription Opioids and/or Benzodiazepines Can Face Safety and Health Risks"

Benzos by themselves can be dangerous. Mixing benzos and opioids are even worse. I saw this cocktail the very first time I analyzed a drug regimen for chronic pain in 2003. I still see them. What will it take for doctors to understand the danger? What will it take for patients to understand the danger? It's sooooooo frustrating. If doctors can't figure it out then it's up to the patients and their caregivers to take ownership and question their use. Not that this combo is never effective. Sometimes it is. But when it's not, it's deadly.

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Patient satisfaction: Who is rating the ratings? (282 views)

Cookies drive higher student satisfaction scores. Prescribing antibiotics drive higher patient satisfaction scores. Telemedicine doctors spending 20 fewer seconds to issue a prescription helps their "satisfaction". The summation = "Whether doctors want better patient satisfaction scores or to save time, they should not overprescribe antibiotics." Or #opioids. Or #benzodiazepines. Or .... I have consistently tied four things together as the cause / genesis of the opioid epidemic in the mid-1990's:

1. Doctors being accused of (and even sued for) under-treating pain
2. The introduction and (misleading) marketing of new powerful Rx opioids, a corollary to (1)
3. Addition of Pain as fifth vital sign
4. The implementation of Press-Gainey patient satisfaction surveys

If you don't think that fourth item has anything to do with the over-prescribing of opioids, or doctors changing their treatment / prescribing patterns in order to secure higher patient satisfaction surveys, take five minutes and read "Impact of patient satisfaction ratings on physicians and clinical care." Here's the quote to remember: "Almost half believed that pressure to obtain better scores promoted inappropriate care, including unnecessary antibiotic and opioid prescriptions, tests, procedures, and hospital admissions."

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My Dad, My Hero (46 views)

If you deal daily with the loss of a loved one – two weeks or two decades ago – or are a current caregiver for someone whose end is near, I know how you feel. Today is the fourth anniversary of my Dad's death. For the support system, the pain is less physical and more psychological & emotional, especially for something so deteriorating and disillusioning as Parkinsons. If you need help, ask for it. If you've been there, be willing to help others going through it now. RIP Kenneth Duane Pew. You were - are - my hero. And I am trying to make you proud by making a difference. Just like you did.

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In addition, I published one blogpost:

• "Mark's Musings - November 5" on November 5

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

#CleanUpTheMess