#PewPerspectives - Week of July 24

Following are the stories that I posted on LinkedIn this past week, in case you missed them, along with my editorial comments. View counts are as of 11am ET on August 1.

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Ohio BWC Announces New Rule: Rest and Rehab Before Lumbar Surgery (563 views)

Ohio gets it right again with this "best practice" - focus on conservative care before opioids/surgery with lower back injuries. For injured workers or their advocates, it's important to note this is NOT about making it more difficult to get surgeries when needed. It's just that everyone needs to slow their roll before going down that path. Many options - PT, chiropractic, rest, NSAIDs, ice are mentioned - are much better starting points. Lower back pain caused by a strain or soft-tissue injury usually resolves on it's own within 3-6 weeks - if only discomfort within a week (https://bit.ly/2gPph1L). Managing anxiety and exercise will aid the healing process (https://bit.ly/2uFMclC). Unless there is structural damage, anything more than conservative care can create more harm than good. "We’re simply trying to educate patients and providers as much as possible about the risks involved and requiring other treatment options before choosing surgery." Excellent plan! Why isn't this universally considered THE standard of care? I have seen so often in medical records where a surgery was done that either was premature or clinically inappropriate, and the repercussions from that initial faulty decision created perpetual physical and financial pain. Just hitting the "pause" button is helpful to ensure the most appropriate treatment with the best possible outcomes is chosen. With how the Ohio BWC measures the results of their rule changes, I suspect we'll hear in a year or two how injured workers have actually received better care by making surgery and/or opioids a second-line therapy.

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Fear and Movement (415 views)

I saw this blogpost because it's author, Paul Rock, posted a comment on my blogpost "Fear and Pain". We obviously were thinking along the same lines without knowing it ... his is entitled "Fear and Movement". Whatever verb or adjective you add to "fear", the source is fear of something, and that fear has negative repercussions. This line from Paul's blogpost especially resonated with me - "Many people are bogged down with the right way to do things and forget that before they had issues they probably moved without prior analysis." Do what you can now and then get better at it. Fear is not your friend.

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California Division of Workers' Compensation Releases New MTUS Formulary Rules (210 views)

The CA drug formulary is making progress - new rules published on 7/18. Read PRIUM's recap and thoughts. Bottom line is the changes are helpful in providing more specificity but there's a LOT of work left to do by every stakeholder in the system -- including the DWC (e.g. filling out the new columns in the Drug List). Boy are the next 5+ months going to go quickly. FYI ... If you're interested in posting your own comments to be considered by the DWC, the deadline is Wed Oct 2 at 5pm PT. Per my quote in a July 20 WorkCompCentral article (subscription required), the stronger language around the transition process (9792.27.3) was worth the wait. And those plus other substantive changes proved that the DIR / DWC listened to the feedback provided by stakeholders and adjusted appropriately. Today is August 1 - tomorrow is August 2 - you have until 5pm PT to post comments.

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Overdosing Brooklyn man’s 7-year-old daughter takes the wheel after he falls unconscious (285 views)

Thanks to Bob Wilson for sharing this story of the child being the adult. My guess it's not the 1st time for them. From personally destructive behavior to child endangerment to highway safety, it shows how addiction creates a noxious environment for making bad choices. While addiction may be a disease, there are points along the way where conscious decisions are made to buy and ingest the product. At some point - maybe after he sees what happened in replay - he will make the choice to seek help and recovery. Fortunately, Eric Roman's 7-year old child had the presence of mind to literally take the wheel and ultimately to safety. How many more of these stories will be needed to #CleanUpTheMess? The unintended consequences from this epidemic are mind boggling and constantly bring up ethical dilemmas that we've rarely discussed as a society.

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One opioid begats another (1,327 views)

Here's the sequence ... 1st = Rx opioids in mid-90's. 2nd = Heroin. 3rd = Fentanyl. Anybody that argues the over-prescribing of clinically inappropriate Rx opioids (i.e. handing them out like candy) didn't start this mess hasn't been paying attention or is in denial. Anybody that argues the primary driver is still Rx opioids (while still a problem, the trend is downward) is likewise not paying attention. Unfortunately, over-prescribing created dependence and addiction, which has turned into demand for other products (heroin, fentanyl) as well as fed into the momentum in acceptance of medical cannabis. Imagine how our country would be different today if the "perfect storm" of (1) Launch of OxyContin and normalizing (thru marketing) opioids to doctors (2) Pain as 5th vital sign (3) Press-Gainey patient satisfaction surveys hadn't hit in the mid-90's. But it did. And now we have to #CleanUpTheMess. I had some interesting comments posted, including one from a doctor who said "The argument that prescription drugs have somehow lead to an "epidemic" of illicit drug usage by converting chronic pain patients into junkies is preposterous." And here's my response - "Respectfully, I don't think we're talking about the same thing. The epidemic isn't about chronic pain patients, although there is an argument that unintended consequences due to reducing opioid supply is making some of their lives even more miserable. The epidemic is about the overzealous introduction of opioids to people with new acute pain without proper due diligence by the prescriber and proper education for the patient that has initiated dependence and addiction in a subset of people (and created inappropriate polypharmacy while chasing cascading side effects for others). Whether via statistics or personal stories, it's my informed opinion that the resurgence in heroin use and the evolving disaster with illicit fentanyl is attributable to what happened in the mid 1990's to "normalize" opioids for ANY use by ANYbody."

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This App Tells You — and Maybe Someone Else — When You’re Depressed (518 views)

Can an app "predict depression, anxiety and schizophrenia" with "digital biomarkers" from "info on consumers’ phones"? Sound a little too much like Star Trek? Mindstrong "tracks users’ every tap, swipe and keystroke, then keeps an eye out for patterns such as reaction speeds. It looks at locations and frequency of texts and calls. It also tracks word use." The goal is to engage with the user (patient?) in advance of issues that might cause problems ... in other words, real-time predictive analytics based on cellphone behavior of mental health illnesses. It's very early in the process and not proven ... yet ... but this could be an important tool to help people get help. Would you take advice from a chatbot? If you order something online, you already are. But what about health advice - affirmation or concern? And how might the continued advancement of data acquisition of individuals affect our future choices in healthcare, employment, even relationships? At the rate that technology is evolving, I can't even imagine what being a human being will be like in 5-10 years. It will certainly be much different than today. The more you know how data is aggregated (for marketing purposes, and now for clinical purposes), the more you know there are no secrets. Which, for depression, could be a good thing.

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How eating a big breakfast helps you lose weight, according to science (409 views)

The saying "eat like a king @ breakfast, queen @ lunch, pauper @ dinner" has science to back it up. Big breakfast = Low BMI. This conclusion came from a seven-year study of more than 50,000 people over the age of 30 in the U.S. and Canada, not an insubstantial study. But it basically affirms common sense - Eating healthy and hearty early will allow you to consume the calories throughout the day (assuming you're combining healthy nutrition and an active lifestyle). Not sure if you noticed ... "break" the "fast" is a good way to think about it. Choose your foods wisely, but also choose their timing wisely. This is part of #CleanUpTheMess.

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Doctor urges weed-wary colleagues to prescribe pot, not opioids for pain relief (545 views)

Meanwhile, north of the border, movement from #opioids to medical #cannabis is underway, mostly driven by patients either scared of opioids or who can no longer get them (and likely a subset that dig weed). The next question: insurance coverage to help pay for it when a physician believes it's medically appropriate. The words I just typed were unfathomable when I first started studying the issue in 2013, which goes to show the impacts of the "perfect storm" of expanded state legalization + opioid epidemic. As patients are becoming more educated about the potential dangers of opioids, they are requiring doctors to become more creative with alternative methods for dealing with pain (acute, sub-acute, chronic). Is cannabis part of that alternative? Increasingly, the answer is yes in the clinical environment. But there needs to be at least as much due diligence with that choice as with any other. I agree with a statement attributed to the American Society of Addiction Medicine - “For every disease and disorder for which marijuana has been recommended, there is a better, FDA-approved medication.” In other words, cannabis should not be 1st line therapy, but only tried after treatment approved by the FDA and supported by evidence based medicine has not proven to be beneficial. Then, maybe.

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Maine Legislative Panel Mulls Raising 10 Percent Tax on Marijuana (284 views)

"finding 'that sweet spot so we’re not driving people to the black market'" certainly is a concern. I've read about that happening in other states, where the conditions and/or costs are too much. Choosing the taxes have more implications than just revenue. One of the legalization arguments has been that the "black market" will go away. It hasn't. And it likely won't. Creating a financial incentive by charging too much in taxes, thereby making "street" marijuana less expensive than "legal" marijuana, just exacerbates the situation.

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The physical benefits of yoga (964 views)

Beyond stress mgmt and emotional/spiritual centering, yoga can be helpful in managing pain itself. See the studies. Those quoted show the benefits for low-back and osteoarthritis (and maybe even rheumatoid arthritis) pain. Granted, some people with that kind of pain can't move very well. But it's obvious the less you move, the worse it gets. Yoga can increase flexibility, muscle strength and range of motion while also promoting relaxation, stress reduction, and better body awareness. Again, read the article, read the studies, read the benefits, and figure out how it might be able to help you or someone you know.

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Study suggests ending opioid epidemic will take years (767 views)

#CleanUpTheMess won't be easy, in large part because of the "intersection of legal & illegal markets." Every person who struggles with addiction or clinically inappropriate use or how to best manage their pain is an individual with unique challenges, which is complicated enough. But there are many stakeholders who hold different views (and motivations), and behaviors fostered by policies and habit that have to change. I've long said that we didn't get into this "mess" overnight and getting out of it will take even longer - this study agrees. Not that the lack of simplistic answers should slow the process down, but it should heighten awareness that only collaboration and compassion and change will help us overcome. This could be deflating news. But to quote Winston Churchill ...

Never, never, in nothing great or small, large or petty, never give in except to convictions of honour and good sense. Never yield to force; never yield to the apparently overwhelming might of the enemy.

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In addition, I published one blogpost:

• "Pew Perspectives - Week of July 17" on July 31

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

#CleanUpTheMess