Automatons…

Automotons 2The recent 350,000 subject study in the American Journal of Clinical Nutrition demonstrating consumption of saturated fats to be no more the cause of cardiovascular disease than consumption of polyunsaturated fats, is another blockbuster example of the rise and fall of yet another conventional wisdom.  For decades we have been fed garbage (pun intended) by media and by medical literature that the hydrogenation (saturation) of fatty acids (converts liquid fat to solid, as in margarine) is tantamount to chemical ‘perversion,’ and ingestion of such products is certain to result in premature death.  The recycling of age old ‘rock solid’ advice from physicians is in my opinion analogous to the frequent ‘turning’ of my backyard compost pile.  Depending on how deeply I drive my pitchfork, the more likely I am to find intact wine corks, jar labels, oak leaves and other paraphernalia from years ago.  Scientific literature, the term itself meant to be synonymous to ‘truth,’ is hardly that.  Facts are destroyed then reinvented in a truly bewildering and dangerous process.  When is the public going to raise its intelligence quotient to the level at which it realizes that scientific literature is often no better than my compost pile, occasionally far worse?

Now, this is not to criticize the mountains of ‘applied research’ that has led to astounding technological advances.  Information retrieval, data storage, communications, robotics…all have been made possible through science, and many if not most, make our lives much easier and productive.  However, when science is applied to the human body, not a machine, not a flask of chemicals in the lab, science does not exactly shine.  Medical science more often than not fails us.  It usually does not get it right the first time, or even the second, third or umpteenth time.  This does not reflect an evil underpinning to medical research, but rather the infinite complexity of humans, both the researcher and the researched.  The list of barely effective medications, medications that years later cause catastrophic health problems, or surgeries that do not cure but rather maim if not immediately after, but years down the road, is staggering.

Which brings me to my favorite subject, Obamacare.  One of the primary tap roots of ACA is EBM (evidence based medicine).  The presumption is that the medical literature will guide doctors and other worthy practitioners in their treatment of various human pathologies, for the noble purpose of applying the’ treatment at the right time’ (whatever that means).  This purpose has the effect of reducing providers of healthcare to automatons, who merely plug in patients’ complaints, physical findings and results of lab and radiological procedures and voila, up pops the right and timely treatment on the computer screen.

If only it all worked so smoothly.

Institutions…

American pain institute large sharpDr. Michael J. O’Connell, PainCare, New Hampshire, commented that the word “institute” is used quite a bit today in medicine.  There is the Institute of Pain, Institute of Internal Medicine, Institute of Headache, Institute of Addiction Treatment, and on and on.  In the New Hampshire Seacoast region alone, there are at least five “institutes” in the medical field.  What they all comprise is simply standard medical practices – a collection of physicians, nurse practitioners, and other providers.  They are hardly ‘institutes’ of anything.

According to Webster’s Dictionary, the word ‘institute’ means “an entity for advanced study, research and instruction.”  There is no research, no advanced study, no medical breakthroughs, no attempt at systematic instruction at any of these so called “institutes.”  In fact, with evidence based medicine, providers of all specialties will be reduced to little more than reciters of what Obama feels are the ‘real’ harbingers of knowledge.  Practitioners will no longer be encouraged, but in fact DIScouraged to learn from anecdotal experience, but rather relegated to blindly following and applying solely the knowledge gleaned from sterile peer reviewed double blinded scientific articles.

Clearly the word ‘institute’ is being misused, probably for purposes of marketing alone, as if by employing the word, prestige is bestowed.  But sadly, all of medicine, real medicine where there is a meaningful interaction between patient and practitioner, is changing forever.  The so called “science” of medicine has won out, practitioners reduced to automatons, and the patient has lost.

Recreational marijuana…

MarijuanaDr. Michael J. O’Connell, PainCare, New Hampshire, recently commented that the country seems abuzz (pun intended) with the grand debate about recreational marijuana.  One state after another has moved in progression from decriminalization, to legal ‘medical’ marijuana use, to allowance of small “personal use” quantities.  Big names such as Sanjay Gupta have come out in favor of medical use for certain otherwise untreatable disorders.  Development of vaporization techniques, analogous to vaporized nicotine, has virtually eliminated the detection of THC by the olfactory senses.  And of course, oral ingestion achieves the same, albeit with a less intense high.

What is sidelined in the debate is the problematic indisputable fact that marijuana by any method causes a sensorium change, thus placing pot in the same room with alcohol.  However, there is clear evidence that excessive alcohol (different amounts for different people) can cause substantial organic harm such as chronic liver disease, neuropathies, cognitive deterioration and cardiomyopathies.  Such long term injury related to pot is difficult to find well documented in scientific literature.  Statistics for motor vehicle and other accidents are not readily available due to the ease of detection being simple with alcohol, more complicated with pot.

Regardless, from afar, the reasonable observer would estimate that the safety record of pot is overall significantly better than that of alcohol, which has been legal since the repeal of Prohibition.  It is possible that over time,marijuana will be found to cause unexpected health issues, unveiled only with unfettered access to it.  But that is unlikely since pot has been around just as long as alcohol, and researchers have not found the smoking gun yet (again pun intended).

In this author’s humble opinion, marijuana will gradually be legalized for personal use, and eventually for regulated and taxable distribution, in all 50 states, and the debate will finally subside. Or will it?

Whether use of pot will go up or down, whether its legalization will somehow promote the use of more deadly chemicals such as opioids, benzodiazepines, and myriad designer drugs, will be answered in the next few decades.  Will there be consequences for releasing themarijuanagenie from the bottle?

Drug testing…

Drug testing 3Dr. Michael J. O’Connell, PainCare, New Hampshire, noted that the New Hampshire House of Representatives has so mutilated proposed legislation to mandate drug testing among healthcare workers that it appears to be DOA.  This is lunacy and can mean only one thing, legislators and the citizens they represent have little idea how much drug abuse there is among the population.  It is rampant.  It is epidemic.  There are many estimates that as many as 1 in every 5 of YOUR co-workers is under the influence of an illegally obtained, unprescribed drug.

What is equally nuts is not considering at all the prudence of drug testing for all recipients of disability, welfare, food stamps and other so called ‘safety net’ programs.  Such programs are used by a large sector of the population not as a ‘safety net,’ but as last ditch reliance on subsistence support.  These programs have become standard fare that is now firmly interwoven into the fabric, the social being of the underclass.  Do we REALLY want to be financially supporting drug addicts, or people who abuse drugs and drive on our roads?

The costs incurred in testing would easily be saved by eliminating those individuals who are scamming the system.  And there are many.

 

“Let’s Move” program…

Michelle Obama

Dr. Michael J. O’Connell, PainCare, New Hampshire, commented that when Michelle Obama turned 50 not long ago, she used the date to promote her “Let’s Move!” program, with the admirable goal of reducing the epidemic of childhood obesity.  Clearly she was excited about this, deeply dedicated to it, just as her husband is dedicated to his legacy…..oh well, we won’t go there.

Too bad Michelle does not lead by example.  Her efforts in weight control would be spectacularly vaulted if she were anywhere NEAR ideal body weight herself.  She is one BIG woman.  Did I just say that about the First Lady?  Yes. I will also say she is about the heftiest of all first ladies since before Eleanor Roosevelt.  Who is she kidding?  Perhaps this is part of the reason she has been so sensitive lately about her husband’s overt flirtations with some rather attractive heads of states.

Drop a fast thirty, and keep it off, and the First Lady would be eminently more credible.  Otherwise her ‘legacy’ will have a hard time getting off the ground.  No pun.

PainCare, hardly about pills…

Pill BottlesPain management is in many ways the oldest specialty of medicine with evidence of pain control through use of naturally occurring substances many thousands of years ago.  Serious pain usually accompanies (and sometimes continues after) healing of wounds and tissue injury including contusions, sprains, strains, bone fractures, lacerations, nerve compression, and the like.  In other ways pain management is one of the very newest of medical specialties, carving an important niche with advanced “modern” tools to combat pain.  The specialty has met with remarkable success in acute pain – to such an extent that there is virtually no reason why anyone with acute pain and access to a pain manager cannot expect good to excellent symptom control.  This expectation was even codified by the U.S. Congress in the form of a somewhat unfortunate patient “bill of rights.”

But for CHRONIC pain…ahhh if it were only that simple.  Attempts to use the same approaches as with acute pain conditions have often failed, and failed miserably in the long course. A prime example is the use of NSAIDs and opioids, two fantastically reliable drug classes for acute conditions, and in the early stages of more chronic conditions, but commence to spiral downward in efficacy as time drags on.  NSAID intolerance in the form of gastrointestinal bleeding and perforated ulcers and even coronary emboli (Celocoxib), severely limits usefulness when applied for more than a few months.  And once the need for opioid use has begun, NSAIDs fade into the background, and are usually and purposefully discontinued.

Opioids, the epitomy of a ‘double edged sword,’ are often prescribed for years for chronic pain patients with rather sparse evidentiary support for long term daily use from the medical literature.  Tolerance is the inevitable concomitant, and serves to erode the pain relieving qualities of the very drug that worked so well initially.  Dependence, meaning the development of withdrawal symptoms upon discontinuation, is also an expected concomitant even with very mild/low doses (but persistently consumed) opioids.  Withdrawal is perceived by the patient as evidence of the usefulness of the opioid, when in fact this withdrawal pain is only partly the patients underlying pain, but largely a “pain inflation” induced by the lack of the drug that suppresses the pain.

It is easy to understand how spiraling doses of opioids for chronic pain develop, and yet also to understand the false sense of analgesia opioids provide in the chronic setting.  This mechanism is hardly different from the use of beta blockers, diuretics, ACE inhibitors and other drugs for hypertension chrono/inotropic cardiac control.  When the patient suddenly discontinues such medication, hypertension can quickly become malignant to the extent of precipitation of a life threatening event such as a stroke or myocardial infarction.  This example serves to highlight one of the only positive features of opioid withdrawal….it is generally quite safe…supremely uncomfortable, but safe.

At PainCare, 70% of referrals are currently consuming daily opioids, the great majority on highly potent agonist opioids such as oxycodone, morphine and fentanyl.  Such patients are referred because the “easy” treatment of the pain (opioids) has worn out its welcome.  The primary care practitioner is no longer comfortable with the increasingly higher doses needed to defeat tolerance, and prescribing for ‘early outs’ (i.e. overuse).  The patient then becomes our problem.

The very laborious solution to this quagmire, is to first gain the trust of the patient by continuing the regimen, then to [only] suggest a gradual wean from the opioid, then finally institute said wean.  For a patient who firmly believes the opioid is “the only thing that works,” weaning is extremely difficult to institute and maintain and will often take months to years.  This patient resistance can only be broken down through herculean efforts at education, counseling, and reassurance by the pain practitioner.  At PainCare we find that at some point, a transition to buprenorphine is a most viable and valuable step.  Buprenorphine is a very weak opioid, but an avid binder to opioid receptors.  Due to the strong binding, the receptor remains occupied, thus alleviating the anxiety and physical (but largely emotional) stress of eliminating the beloved full agonist opioid (oxy, morphine, fentanyl) the patient has depended on for years.  Patients who successfully make this conversion routinely feel alert, engaged with life, and are now responsive to physical rehabilitation and conditioning, occasional steroid injections, medication previously eschewed such as gabapentin, tramadol, tapentadol, and anticonvulsants.  Again, the primary hurdle is establishing the degree of trust necessary to lead the patient toward this goal.

None of the above should imply that all patients will comply.  There will always be those who take a drug for unintended purposes (e.g., sedation for a sense of well being over analgesia).  If these patients have verifiable pathology that can generate the pain that is described, they can be extra difficult to identify and transition to more appropriate drugs to treat the underlying problem.  Also, the above should not imply that some chronic pain patients are simply addicts.  Many practitioners make the mistake of identifying all dependent opioid treated patients as addicts.  While all addicts are dependent (have withdrawal upon cessation of their drug), not all opioid dependent patients are addicts.  Most studies suggest that the small minority of patients with verifiable severe pain generators are addicted.  That minority grows when patients with less severe pain generators are considered.  It is therefore important that general practitioners of medicine not start full agonist opioids on patients with only modest evidence of pain generating pathology.

In conclusion, it is optimal for general practitioners of medicine to refer pain patients within a few weeks of continuous opioid use and allow the experienced pain practitioner to decide whether the patient requires subspecialist attention (ortho, neuro, etc.) or simple diagnostic injection with more specific definition of the pain generator, targeted physical rehabilitation with or without benefit of even temporary pain relieving blocks, viscosupplements for arthritic joints, radiofrequency lesioning of sensory nerves to pain generators, botulinum toxin for tight trigger points, spinal cord or peripheral nerve stimulation, etc. (i.e. the more advanced techniques).

Opioid addiction among young pregnant women…

 

Opioid Addiction among young pregnant womenAs addiction to various forms of opioids becomes even more prevalent, more young women than ever are presenting for delivery on methadone, heroin, oxy and other drugs.  This causes a considerable nightmare for those healthcare workers administering to the newborns.

Neonatal abstinence syndrome (NAS) is the withdrawal of the baby from the drugs mom abused before and during pregnancy.  The treatment for the newborn is continuation with gradual weaning from some form of opioid, often IV morphine.  The process can take weeks in the hospital and costs are staggering.  The treatment for the mom is less complicated and requires little additional hospital stay, but is just as unpalatable from a societal perspective.

There are few answers to this gestational addiction problem, but buprenorphine is a solid drug to address the issue while society figures out the underlying problem.  If the pregnant addict confesses to her addiction, and converts to buprenorphine (Subutex, Suboxone) early in pregnancy, the NAS is markedly reduced to just a few days.  The problem is how to convert the mother from the methadone, or oxy or whatever potent opioid she is taking to the buprenorphine?  Many studies are now emerging that support the safety of doing this in a gradual manner during the first trimester.  The process must be monitored by a provider experienced in such a transition, is very familiar with buprenorphine, and also has access to urine tox screening and quantitative LCMS.