Mark's Musings - December 9

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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A Tale of Two States regarding opioids (300 views)

WorkCompCentral this morning (Dec 2) tells the tale of two states and their experience with Work Comp and Rx opioids ...

• "Attorneys Say Workers Need Alternative Treatments as Opioids Continue to Decline" (subscription required) - California has dramatically reduced the use of Rx opioids ($6.5B in savings over 10 years, low per-capita death rates). For additional context read "Kudos to California!" (9/5/15) and "A CURES for the Disease" (7/11/16). However, there's concern about what happens next: "Hopefully, the savings will allow for an investment in successful return-to-work programs and not fighting alternative modalities of medical care for workers."
• "Reports on Drug Costs, Opioid Use Could Amplify Calls for Formulary" (subscription required) - Louisiana continues an opposite trajectory. "The number of opioid prescriptions per comp claim in Louisiana was 6.2, more than double the U.S. average ... The average morphine-equivalent dose also was second highest in the country, more than triple the median state's dosage." For additional context read "The Louisiana Trifecta" (5/10/17).

If you would like more info about Louisiana, read the summary and the details of a December 4 report from the Louisiana Legislative Auditor. While there appears to be another push for a drug formulary coming in 2020, the usual people are pushing back. I understand the opioid epidemic is now about illicit rather than prescription opioids, and some of the data used by NCCI and this audit are as much as two years old, and that Louisiana has several "hazardous occupations," and that claim severity is increasing while frequency is declining. But the numbers are the numbers and Louisiana continues to be an outlier compared to other states. The reasons for being an outlier are manifold - many of them political and judicial and unique to Louisiana. Drug formularies in Work Comp have been proven in other states to be part of the solution in conjunction with other tools and tactics (both in Work Comp and in general healthcare / society). Continuing to reject a drug formulary as one of the tools to help encourage clinically appropriate opioid prescribing (remember, "Appropriate, Not Zero, Opioids") puts the onus to fix it squarely on those who reject it.

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If ‘Pain Is an Opinion,’ There Are Ways to Change Your Mind (1,041 views)

The reason I'm posting this article (love the title) should be obvious because it says what I've been saying for awhile (#BioPsychoSocialSpiritual). Lots of interesting author anecdotes that help underscore the point of how important the brain is in the management of pain (especially #ChronicPain). Some important quotes:

• “All pain is real, no matter what is causing it. But also, all pain is made by the brain in response to the information available to it.”
• "If something in the mind — fear — can make pain worse, can some other thoughts or mood make it better? Yes, to an extent."
• "We can’t think away all pain. For one, we don’t fully control our thoughts ... For another, many people experiencing chronic pain are also experiencing other stressors."

"This points to the importance of addressing mental health alongside physical health." The good news is this concept is being talked about more often. The evolving news is that patients, physicians and payers need to do it, not talk about it, more. I've seen great progress since 2003 in the acceptance of modalities to treat psychosocial complications (even those not remotely related to the workplace injury) in Work Comp claims. However, we are still not (1) prescribing (2) paying for it enough.

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Patience (230 views)

Patience is a virtue. However, patience that leads to success is not passive. It waits (calmly) AND works (proactively). If you want to overcome a problem, waiting for something to happen usually won't make it happen. But lashing out because it's not happening probably won't make it happen either. Finding that delicate balance is the key to success.

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Our dangerous fear of pain (131 views)

Thanks for sharing, Kathy Hubble. I agree with you - this physician's article clearly outlines our problem with pain and the way forward. These excerpts provide a great outline for his story:

• Instead of learning from pain, we now regard it as an illness in and of itself
• Palliative care (using Rx #opioids) in those situations is almost always necessary and compassionate
• The fear of pain, and the belief that a pain-free existence is optimal or even possible, has been a catastrophe for patients
• Our present system overpromises and underdelivers on relief, fostering dependence in the process
• They teach patients how their nervous system can either calm their pain or amplify it, then give them the skills to direct that system

Ultimately, the successful treatment of #ChronicPain (or better said, a way of managing pain that yields higher quality of life and function) must take the whole-person into account thru a #BioPsychoSocialSpiritual approach. Every human being has encountered pain - physical and emotional - at some point in their life. Many times in their life. Nobody is immune. Not wanting to encounter pain makes sense until it leads to freeze or flee (instead of fight) when pain arrives and why "fear avoidance" is one of the primary psychosocial red flags that cause sub-optimal outcomes. Sometimes the only way to grow is through pain. You will probably recognize a famous phrase from this excerpt of Franklin Delano Roosevelt's 1932 presidential inauguration speech but what he says immediately after it is also highly pertinent:

"The only thing we have to fear is fear itself—nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance."

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Health Research and Development To Stem the Opioid Crisis: A National Roadmap (218 views)

A National Roadmap to Stem The Opioid Crisis is dense but important reading. This Oct 2019 publication by the smartest scientists in the US, with input from a wide range of stakeholders, is full of great observations and ideas. My summary follows:

1. Biology and Chemistry of Pain and Opioid Addiction: Scientific understanding is increasing but research needs to be more collaborative
2. Non-Biological Contributors to Opioid Addiction: ACE is an important predictor of use/misuse/abuse but not the only contributor to a predisposition
3. Pain Management: More education about and accessibility to non-pharma options is needed
4. Prevention of Opioid Addiction: Reducing supply and demand are equally important, but data is THE most important
5. Treatment of Opioid Addiction and Sustaining Recovery: "there is no 'one size fits all' approach"
6. Overdose Prevention and Reversal: Naloxone saves lives but comprehensive treatment after an overdose reversal keeps them alive
7. Community Consequences of Opioid Addiction: The impact on communities is broad and deep and expose structural flaws that further complicate a response

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What is Mentionable is Manageable (398 views)

I watched "A Beautiful Day in the Neighborhood" last week and this phrase stuck to me. A powerful statement, demonstrated throughout the movie (I recommend it). But even more powerful is the full quote from Mr. Rogers ...

“Anything that’s human is mentionable, and anything that is mentionable can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we are not alone.”

If you have something you think is unmentionable, change your opinion - and your life - to make it more manageable by mentioning it to someone. I ran across a subsequent article about how 2019 kids responded to 20th century Mr. Rogers and this observation is timeless - "Kind and calm. So that explained everything. In a world of so much chaos and noise, kids liked calm sincerity." I would argue it's not just kids that like that ...

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The weird power of the placebo effect, explained (769 views)

I posted something about the Placebo Effect a few days ago and this is a great follow-up. It includes an intriguing concept of "prescribing" placebo - actively encouraging it, overtly (no deception in clinical studies) - because it is essentially a "neurobiological phenomenon." So many examples are included, from fake surgery to acupuncture (with and without empathetic conversation) to Rx for Parkinson's disease to red/green light electric shock that show how it can be effective. It comes down to belief AND expectations by the patient, both built up in manifold ways. Invest five minutes to read the full article (including what conditions seem to respond better to placebo) and figure out how "tricking" your brain can actually be beneficial. Hat tip to Jason Parker for the article. "His own randomized controlled trials found that giving patients open-label placebos — sugar pills that the doctors admit are sugar pills — improved symptoms of certain chronic conditions that are among the hardest for doctors to treat, including irritable bowel syndrome and lower back pain. And he wonders if chronic fatigue — a hard-to-define, hard-to-treat, but still debilitating condition — will be a good future target for this research. 'Our patients tell us it’s nuts,' he says. 'The doctors think it’s nuts. And we just do it. And we’ve been getting good results.'” So maybe it's not "nuts" after all ...

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In addition, I published three blogposts:

• "Mark's Musings - December 2" on December 2
• "A Cannabis Tweet Storm" on December 4
• "The Brain is the Gateway to Relief" on December 6 by WorkCompWire

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

#PreventTheMess + #CleanUpTheMess = The Answer.