#PewPerspectives - Week of Apr 16

Following are the stories that I posted on LinkedIn during this week in case you missed them. View counts are as of 5:00pm ET on May 7.

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Relationship of Opioid Prescriptions to Physical Therapy Referral and Participation for Medicaid Patients with New-Onset Low Back Pain (1,309 views)

The use of physical therapy (consult or participation) early (within seven days) in the management of low back pain (LBP) "was associated with reduced opioid prescriptions during follow-up." And yet payers sometimes question whether PT should be used and for how long. The longer it takes to make the decision, the more the patient / injured worker becomes de-conditioned. Delivering the best evidence-based care for the condition as quickly as possible is the best journey to positive outcomes. We are learning that pills may be easy but may not be best. We are also learning that each individual needs to be treated individually. In order to #CleanUpTheMess we need to be open to #AllOfTheAbove. Hat tip to Brian Murphy for this study. If there isn't an issue that needs to be surgically repaired, staying active ("motion is lotion") is extremely important and needs to be done sooner than later. Since what doctors do is largely based on what they'll be paid for, the payer needs to be open to not slowing things down by focusing on (and paying for) function.

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Why doctors don’t use alternatives to opioids (1,622 views)

"The problem in American medicine is not a lack of alternatives to opioids, but the minimal utilization of the many non-opioid treatments for pain that already exist." #Amen. Providers need to be better educated on ALL of the options so they can make the best treatment choice for that individual. Payers need to be willing to pay for evidence-based treatment that might historically have been labeled "alternative" but works for that individual. Patients need to "own" their healthcare and if what's being done isn't working to research their options and demand something better. Finding the best treatment, whatever it may be, MUST be a trilateral conversation. Some of these alternatives have a reputation in Work Comp for over-utilization (e.g. chiropractic), or are historically uncommon (e.g. acupuncture), or are assumed to not be supported by science (e.g. mindfulness), or harbor concern about opening a psych claim (e.g. cognitive behavioral therapy), or broaches the lifestyle barrier (e.g. nutrition). Which means often payers deny their use. Short sighted. What we all need is more and fuller education on the options. We also need to remove the broad-stroke bias that "we've never prescribed/experienced/paid for that." In order to find the right treatment(s) that will help the patient, we all have to start with a broader suite of options because it's difficult to predict which combo will work.

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National Center for Complementary and Integrative Health (928 views)

Speaking of "alternatives" for pain management, did you know that the National Institutes of Health hosts a National Center for Complementary and Integrative Health? This is a great portal of information - providers, payers, but especially "consumers" (patients) - to understand natural products, mind and body practices, and other treatments that don't fit those two categories. They currently highlight an excellent article "Mindfulness-Based Stress Reduction, Cognitive-Behavioral Therapy Shown To Be Cost Effective for Chronic Low-Back Pain". If you're interested in options, go to their portal to learn more ("Research-based info from acupuncture to zinc").

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Change Your Mind-Set, Reduce Your Chronic Pain (783 views)

The title says it all ... "Change Your Mind-Set, Reduce Your Chronic Pain." This is their mic-drop moment - "Using low-risk CBT techniques over the course of several weeks, however, alters brain structure. It learns to ratchet down pain signals, which enhances the effectiveness of medical interventions and helps patients reduce their need for doctors and pills." Many highly respected clinicians (physicians & psychologists - medical directors, academic, active practice) have told me the same thing for several years which is why I've long been an advocate for CBT. For my #WorkComp friends, this does NOT introduce a psych diagnosis - it is behavioral treatment. #BioPsychoSocial is an integral part of #CleanUpTheMess. As Michael Coupland has long said ... "pain is in the brain." Not that it's made up. But that the brain has the ability to overcome or be stymied by pain by how it processes the pain. Changing our perspective from "what I can't do" (disabled) to "what I can do" (enabled) is a first step begun by changing the mindset.

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Despite OD Risk, Opioid-Benzo Rx Continues (604 views)

Thanks to Dr. Stephen Grinstead for sharing this article. The CDC and VA (and many scientific journals) are very clear - opioids & benzos (Xanax, Valium, etc.) should not be mixed. Beyond morphine & Percocet & Oxycontin & etc, be sure you add buprenorphine (Subxone, Subutex) to the list of "do not mix." With the focus by federal & state governments on the use of Medication Assisted Treatment (MAT) that often includes buprenorphine, if benzos are also being used we could be creating a new problem. Not that benzos are never appropriate (by themselves or with opioids), but ANYBODY who is taking a benzo needs to be EXTREMELY careful. If the doctors don't know this, it may be up to the patient and/or caregivers to know it. As one commenter pointed out, "never" is a strong word. Good point. There may be some instances where mixing an opioid with a benzo is clinically appropriate. There may be instances where using an opioid standalone, or using a benzo standalone, is clinically appropriate. But nobody will ever convince me their continued commonplace use together in healthcare , seemingly without contemplation of the dangers by either the prescriber or patient, is a good thing.

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Auburn’s pharmacy school looking to train community to combat opioid epidemic (636 views)

Great proactive leadership by Auburn University and their "Naloxone Rapid Response Program" with training and education not just on campus but in their community. Not only could this save lives, but it's also great real-life training for students in their Department of Pharmacy Health Services. If you know of other universities that have similar programs, let me know. If you're at a university and don't have something similar, this may be something to consider. Obviously, naloxone is not the solution to the opioid epidemic - it's use means someone has already overdosed. But you can't help somebody that is dead. And without naloxone, many more people would transition from the "non-fatal" to "fatal" statistics for overdoses.

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Why painkillers sometimes make the pain worse (920 views)

Great info on the concept of OIH. I've been confident that is real so was interested to read that opinions are mixed. This drew an interesting corollary to "chronic pain from nerve damage or fibromyalgia" and that it's difficult sometimes to distinguish between OIH and tolerance. But I found this to be of most interest - "Doctors who ignore hyperalgesia might bump up the dose when the right decision was to reduce it. And when a patient tried to taper off a drug, a temporarily lowered pain threshold might make it harder for them to manage without it." Thanks to Marcos Iglesias for originally sharing this article. This is the definition of iatrogenesis, where the "cure" (the Rx opioids) can be worse than the "disease" (pain) by actually increasing the pain. Does everyone that takes Rx opioids have OIH? Probably not. But how do you know - as a prescriber or patient - if you don't even know what OIH is?

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Surprisingly, opioids may increase risk of chronic pain (997 views)

"Surprisingly" surprised me. This was an interesting quote to me - "Compared with rats given saline, those that received morphine endured postoperative pain for over 3 additional weeks. Also, the longer the morphine was provided, the longer the rats' pain lasted." That's why there is a renewed interest in what had worked well for years prior to the normalization of opioids in the mid-1990's - alternating ibuprofen and acteminophen post surgery. I've had several people tell me that worked for them (and several doctors concur). Of course, not everything works for everybody, so we have to be careful in making broadbrush decisions. It will be interesting to see if these same results are shown in human trials. Thanks to Ryan Paul Liabenow for originally sharing this article. Caution is the word.

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How to make stress your friend (665 views)

Is stress the "enemy"? Or can it be your "friend"? When you change your mind about stress (helpful for performance), you can change your body's response to stress, prepared to meet the challenge! Learn about oxytocin (neuro hormone) starting at the 8 minute mark. Positive stress response = stress resilience = human connection. If a psychologist selected to do a TED Talk decided she had to change her mind about stress (to not fight it but to use it as fuel), who am I to argue?

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NAMSAP Says CMS’s MSA Policy Institutionalizes Opioid Abuse (287 views)

What they said. CMS - Are you listening? Hopefully they are.

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Americans are filling far fewer opioid prescriptions, new data shows (1,245 views)

Opioid use declined by an average of 8.9% across the U.S. from 2016 to 2017, with 18 states exceeding a 10% decline. This article doesn't state whether the decline is in the acute, sub-acute or chronic phase so I assume it's a mixture. There are obviously multiple reasons for the decline that I have documented over time. But overdoses & deaths continue to climb, largely because the #opioid epidemic transitioned a few years ago to more powerful illicit street drugs like heroin, fentanyl and carfentanil. Do less opioids mean they really weren't needed for that 8.9% of cases? As prescriptions for opioids have declined, what has replaced them? Is there increased use of NSAIDs or gabapentin? More exercise, better nutrition, deeper sleeping? More use of CBT, mindfulness, yoga, physical therapy, chiropractic, acupuncture? More resilience? #BioPsychoSocial is an integral part of #CleanUptheMess! And unless we add resilience where drugs used to be, we have the potential of careening from one "mess" to another.

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

#CleanUpTheMess