Mark's Musings - October 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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Toronto Man Leaves Heart-Wrenching Suicide Letter Naming Ativan as Murderer After Suffering Benzodiazepine Withdrawal Syndrome for 3 Years (408 views)

A sad excerpt from a suicide note that a Toronto man left behind in April 2015:

"I would like to report a murder ... The name of the murderer; I know the name ... His name is Ativan (also lorazepam) ... The important thing to remember is that this was a murder. I had zero choice in this decision. All I could do was delay it."

I have consistently - from the beginning - talked about the dangers of #benzodiazepines. The epidemic of their use. The complexity of their actions/interactions. The difficulty in their weaning. The fatality in their mixture with #opioids. There IS a place for them, from personal experience. When my Dad was in hospice, dying from the complications of Parkinsons in 2014, Ativan (along with Morphine) helped him die with dignity, reducing his anxiety and pain. I was VERY thankful for those Rx drugs while I sat in his room for almost two weeks. But that was because I did not care about the side effects, the potential of addiction, the possibility of euphoria. Obviously benzos help some people with anxiety or chronic pain. Not everyone has negative effects, although discontinuance should never happen without strategic weaning. But don't be naive to their danger. #BioPsychoSocialSpiritual #CleanUpTheMess There is a reason why the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends not mixing opioids and benzodiazepines (along with every other published treatment guideline). And yet I saw them consistently mixed together when I first started addressing the opioid issue in 2003 and even still now. While there is a role for them, it's definitely not at the scope at which they're prescribed. For patients - inventory everything you put into your mouth ... and why ... and identify potential alternatives (Rx and non-Rx) - in this case, google is your friend. For providers / prescribers - educate yourselves on the benefits and risks, appropriate and inappropriate uses, side effects and drug-to-drug interactions, and alternative treatment option(s) so together with the patient the absolute best choice can be made at this specific point in time.

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From 0 to 10 Million: Vaping Takes Off in the U.S. (321 views)

Of the following statistics -- "54.6 percent of e-cigarette users were also smoking cigarettes; 15 percent of vapers had never smoked cigarettes; 30.4 percent had quit smoking them" -- only the last one is good news. This statistic -- "use was highest among people ages 18 to 24, both occasional and daily users" -- indicates concerns for the next generation. And this -- "People with cardiovascular disease, cancer, asthma and depression were also more likely than others to be using e-cigarettes, and the rate was 10.2 percent among people with chronic obstructive pulmonary disease" -- doesn't make a lot of sense, especially asthma and COPD. Another marketing coup for purveyors of addictive substances. We know what happens when we (as a society, as a healthcare system, as Work Comp professionals) move from "trendy" to "trendier." Often times, the replacement is just as bad (or worse) as what's being replaced. Pay attention to what JUUL tells you (likely only because it was required) ... "WARNING: This product contains nicotine. Nicotine is an addictive chemical. JUUL was created to be a satisfying alternative to cigarettes." It's not benign. It's not meant for non-smokers (to start). It's not meant for developing adults under the age of 21. Remember what "addictive" means = "causing dependency." Is that something you really want to start?

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McKesson Announces Renowned Leadership for Opioid-Focused Foundation (333 views)

I had the great privilege of being on a panel at the ASAM conference in April 2017 with, among other esteemed clinicians, Dr. Andrea Barthwell. In fact, I got to sit next to her and so we had the opportunity to chat before/after. She's really (not just book) smart. She's really dedicated to helping people #recover from substance abuse. She's really experienced when it comes to public policy. Obviously, McKesson has been in the news about the #opioid epidemic (for the wrong reasons). However, their Foundation for Opioid Response Efforts sounds like a very helpful response focused on "education of patients, caregivers, and providers; opioid research; and increased access to life-saving and dependence treatments." And they're invested ... "McKesson has committed $100 million to the foundation as part of its ongoing mission of delivering better care for patients." And now with Dr. Barthwell as chairperson of their Board, they have instant credibility (at least with me). I will certainly be paying attention to not just their words but their actions. If they want to be part of the solution they can be of tremendous assistance.

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8 Things Doctors and Nurses Do to Stop a Cold in Its Tracks (838 views)

Helpful tips about combating a cold. However, four of the eight tips - give stress the boot, eat clean, stay hydrated, get some Vitamin D - are applicable to managing #ChronicPain as well. The first three I've talked about on multiple occasions, on social media and in-person. The last, Vitamin D, might not initially make sense. But I visited a functional restoration program several years ago and their medical director said Vitamin D deficiency was a common thread of people not managing their pain effectively (think about it - they often don't eat right, don't get outside much) and so they flooded their system on Day 1 with Vitamin D. That infusion was always a helpful kickstart to finding the most beneficial individualized coping skill(s). Whether a short-term cold or long-term #ChronicPain, these are skills and disciplines that can help manage the symptoms and increase function. Even if you're not sick or in pain, these are tools that can help you manage life's difficulties. Don't forget the simple stuff when developing / maintaining resilience.

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Sedentary (187 views)

Funny but true (and because of that ... sad) public service message from 2012.

"Ever notice how many things today kids can do without actually moving? ... Encourage your kids to get up, get out, and get moving."

That's not just an admonition for kids ... "Motion is lotion!"

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SAFE Opioid Prescribing: Strategies. Assessment. Fundamentals. Education. (297 views)

In case you didn't know, the American College of Physicians has a FREE (no cost, nada penny, $0) course of "Safe Opioid Prescribing." Not only does it offer CME credits (that all physicians need) but it provides very helpful information on how / when to use #opioids. There is likely more information packed into these six sessions than medical schools offer in their curriculum. They cover evaluation, counseling patients, starting/stopping/in-between best practices, screening tools, and the 411 on ER/LA opioids. All of this would be VERY useful information for clinicians that might not have had exposure to this education. And, did I mention, it's FREE? If you're a prescriber this would seem like a no-brainer (free, CME credits) to become more educated on the appropriate use of opioids. Knowledge is power and what we need (from all parties) to properly address the opioid epidemic.

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NIH research program to explore the transition from acute to chronic pain (264 views)

"The National Institutes of Health has launched the Acute to Chronic Pain Signatures (A2CPS) program to investigate the biological characteristics underlying the transition from acute to chronic pain. The effort will also seek to determine the mechanisms that make some people susceptible and others resilient to the development of chronic pain." Being able to (hopefully) identify "predictive “signatures” of transition or resilience to chronic pain" would be valuable. Obviously there's no mention of psychosocial considerations but they have their own screening tools (that aren't used as often as they should). If you want to participate in the study, the deadline for applications is October 24. One of the keys in addressing the opioid epidemic is doing a better job of reducing the number of times acute pain becomes chronic pain. I know that's not possible in all situations given the severity of the injury / condition, but I've observed many times that people can devolve into chronic pain (physical, emotional, psychological) when they didn't have to if the most appropriate treatment choices were made, early and quickly. Bad choices - or delayed good choices - often create long-term unintended consequences. Hopefully this research can help add to the toolset of proactively identifying problems before they occur.

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In addition, I published two blogposts:

• "Mark's Musings - September 24" on September 25
• "The Future is ... um ... Now" on September 27

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

#CleanUpTheMess