#PewPerspectives - Week of Mar 19

Following are the stories that I posted on LinkedIn during this week in case you missed them, along with my additional editorial comments in bold. View counts are as of 4:00pm ET on March 29.

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Can This Judge Solve the Opioid Crisis? (235 views)

An update from the NY Times on the lawsuits against Big Opioid Pharma (for context, read my 11/7/17 blogpost "Making BOP Pay"). This personal profile of Judge Dan Aaron Polster, and a look at the evolution from skepticism & confusion to "cautious optimism" on the journey to settlement, is very interesting. He seems fully dedicated to "sooner than later" and ensuring the outcome involves real solutions and not just compromise. In fact, change has already come from it (Purdue Pharma's decision to no longer market OxyContin directly to prescribers - something I posted as it happened but didn't realize it's connection to the settlement process). As in all negotiations, most of what's happening will be private until an announcement is made. But after reading this article, I have a higher level of confidence that every point of view is being included and that (probably for the first time) these disparate stakeholders are truly talking. The early refrain of "This is not how we do things!" may be the best indicator that this process will be helpful. This isn't about being punitive (although if laws or ethics were breached then accountability is required) but about helping (1) those currently ensnared to escape and (2) not lose the next generation.

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Pot shops face bans in most of Massachusetts (667 views)

Massachusetts is rolling out legal recreational #marijuana as of July 1, 2018. However, NIMBY (not in my back yard) is on full display as evidenced by this map of restrictions. Although not to this extent, NIMBY is also at play in other states that have already legalized recreational use. Obviously, the motivation of medical use (to treat a medical condition) is a completely different issue than recreational use (to get high), as are the arguments and acceptance (and corresponding restrictions). But statewide votes are only one piece of the puzzle as individual localities make up their own minds. As if the subject weren't already complex enough for employers and workers' compensation ... Of the 351 total municipalities in Massachusetts, 189 of them have barred retail stores. However, it's important to note that only 59 have indefinite bans, which means the other 130 are apparently going to wait and see the regulations before making a final decision. However it turns out, recreational users will need to be cognizant of their GPS location.

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Mindfulness 101: Everything you need to know about mindfulness (475 views)

I talk about mindfulness a lot in regards to managing chronic pain. It can be defined as "paying attention, on purpose, in the present moment, without judgment." I know to some that sounds "squishy" feel-good stuff. But if your thoughts have ever gravitated towards negativity and you consciously redirected them to a more positive outlook, you have in essence practiced mindfulness. Most of the smart clinicians I've gotten to know that promote resilience to life's problems (including chronic pain) believe strongly in the practice of mindfulness (and the science that supports it's value). Is it a "one size fits all" modality? No. Is it right for everyone? Possibly not. Will it help some better manage their pain? Probably. Is it something that we should be more open to? Absolutely. This blogpost from "the blissful mind" (an appropriate title) provides an introduction. IMO, however you implement it, this is a tool that needs to be part of #CleanUpTheMess. Here are some of the benefits found by research: Decreased stress response; Increased immune system activity; Increased capacity for compassion; Improved ability to regulate emotions; Increased ability to relax; Improvements in chronic pain levels; Improvements in anxiety and depression symptoms; Improved ability to experience moments with greater clarity and objectivity.

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Florida Gov. Scott signs bill to combat opioids crisis (4,052 views)

BREAKING: It's now official - Prescribers can only prescribe a 3 day supply of opioids in Florida. The new law also provides more money for treatment and new PDMP requirements. Just to be clear, the 3-day supply cap is limited to acute pain and Schedule II opioids (a limited scope), with a potential extension to a 7-day supply where the onus is on the prescriber to validate the need in the medical records. In other words, this bill (now law) does not impact chronic pain patients (the doctor must notate "NONACUTE PAIN" on the prescription). There was a lot of (what turned out to be) unnecessary buzz of concern about the impact on chronic conditions because the limited scope was not well understood initially. This restriction, as well as the other items covered in the bill (mandated continuing education for prescribers, almost $1M to enhance the state PDMP, funding for a variety of support and recovery programs, and others), is effective on July 1, 2018. That means everyone in the healthcare system (including workers' compensation) has two months to get used to this new paradigm. This governing.com article ("Opioid Prescriptions Now Have 3-Day Limit in Florida") is the best explanation I found. If you want to read the details for yourself, you can find information on the chronology of the bill here and then the actual language that became law here. If you live in Florida, or know somebody that does, you need to know what's coming.

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The North Carolina Industrial Commission approves opioid restrictions (1,956 views)

BREAKING: North Carolina Work Comp has finalized their opioid restrictions, effective 11/1/18. Among the changes:

• Limit 1st prescriptions of opioids to a 5 day supply (7 days for post-surgical) with a max dosage of 50mg MED
• Subsequent dosages can go to 90mg MED if approved by pre-authorization
• For chronic pain, 90mg MED can be exceeded only if approved by pre-authorization
• Ban fentanyl
• Ban benzodiazepines or carisoprodol during the first 12 weeks (acute pain phase)
• Allow transcutaneous or transdermal opioids only if oral medications are proven to be contraindicated
• Consider co-prescribing naloxone

The rules can be found here. Hat tip to WorkCompCentral's March 21 article (subscription required). These are obviously only applicable to workers' compensation (not general healthcare), but their rules follow the generally accepted best practices when it comes to using opioids to treat pain. And everyone in the system has seven months to prepare (effective November 1, 2018). The intervening time should be used to identify claims that currently fit the criteria and develop a "transition" process for them while at the same time enacting business rules for any new claims. The year of 2018 will obviously be a year of adjustment in various jurisdictions.

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Rethinking Pain Management (4,801 views)

I'm in (no snow yet but the Nor'easter is coming) Boston for the Alliance of Women in Workers' Compensation "Rethinking Pain Management" event today. I'm honored to be the panel moderator on chronic pain with some really smart & experienced people - two that I know very well, Marcos Iglesias MD, MMM, FAAFP, FACOEM and Becky Curtis, and two that I'm getting to know, Alan Pierce and Dr. Patricia Cole. I don't believe in "monologues" so the pace will be quick and the dialogue will be concise, easy to understand and meaningful leading into the attendee collaboration session afterwards. We will be preceded by what should be a deep keynote and an excellent panel on pre- and acute pain. This will be a true 360 perspective on pain! Thanks to the Alliance and Kimberly George for the invitation. I'm definitely looking forward to it! I don't typically post my speaking events in #PewPerspectives (you can see them if you follow me on LinkedIn or Twitter @RxProfessor), but this one is even more important than usual as the full agenda was talking about how to better handle acute and chronic pain in work comp. That includes the concept of "pre-pain" where proper expectations & resilience are setup in advance (the pre-surgical consult, for example). The agenda was filled with really smart people in really influential positions that have and are "re-thinking pain." It's a discussion we all need to have - payers, providers, patients - because the way we've treated pain over the past twenty years in many cases didn't work. There will be a publication forthcoming of the collective thoughts from not just the panelists but also the attendees during their collaborative sessions. That document could very well be a seminal moment for our industry and roadmap for the future. You know I'll post it when it's ready!

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Stopping the scourge: An all-out effort to fight opioid addiction (1,255 views)

A comprehensive article of the "all hands on deck" approach to dealing with the #opioid epidemic. I was glad to see their point on "Education and awareness are key." But I was disappointed they did not address the elephant in the room - If opioids are to be used less, what will supplant them in dealing with pain? If you haven't noticed, my focus since 2017 has been on #CleanUpTheMess using a #BioPsychoSocial treatment model. While abuse of (and addiction to) illicit opioids like roxies and heroin and fentanyl is one aspect of the epidemic, there are a lot of people using opioids who are not abusing/misusing them and are not addicts. What's next for them? Lots of things - CBT and ACT and MI, yoga, acupuncture, mindfulness, NSAIDs, better nutrition, PT, chiropractic, biofeedback, smoking cessation, losing weight, diaphragmatic breathing, regular exercise, proper sleep hygiene, and (for some) even opioids. Engagement. Ownership. Every individual is just that - an individual - and requires a customized treatment plan. And since we don't know what works for that specific person, clinicians and patients need to have access to the entire set of potential tools. In other words ... #AllOfTheAbove.

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Heart failure risk could be reversed with exercise program (1,173 views)

"Heart failure is a serious condition in which the body's cells do not receive a sufficient amount of oxygen and nutrients because the heart muscle is too weak to pump enough blood." The researchers concluded that middle aged people do 4-5 days a week of exercise as part of their goals in preserving their health.

This includes:

1. At least one long session per week lasting around an hour of cycling, walking, tennis or aerobic dancing
2. One high-intensity aerobic session per week, such as four-by-four interval training (explained in the article)
3. One session of strength training per week
4. Two or three sessions or moderate-intensity exercise per week

With the long history of heart disease in my family, I have encouraged my dad (Mark 'RxProfessor' Pew) to increase his exercise frequency. Professor Benjamin D. Levine said, "The key to a healthier heart in middle age is the right dose of exercise, at the right time in life." Good advice from my daughter, Rachel Pew (and I'm a proud papa - get to know her). Including her admonition for me to step up my game on a more reliable schedule (guess she wants me to hang around). Although I've always been physically active, I strategically adopted an active lifestyle in 2013 as I lost 30 pounds. But a lifestyle is not enough - real exertion on a regular basis is. That's my next strategic step: to make the kind of exercise listed above as ubiquitous to my schedule as eating breakfast.

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

#CleanUpTheMess