Archive for the 'Progress Notes' Category

Suboxone for Pain? Not in Maine

Many patients who end up in Suboxone treatment have chronic pain. They were originally prescribed other opiates and ended up addicted to them.

Skeptics argue that his is just substituting one opiate for another. But that isn’t quite accurate. More on that in a bit.

In my seven years of prescribing Suboxone for opiate addiction, I have often observed how potent a pain reliever this medication is, even in fairly low doses. More on why in a bit, too.

Now and then I hear about patients who are prescribed Suboxone for pain and not for addiction. I’m not sure exactly how that is done, since Maine law requires prescribers not only to include our Suboxone license number, but also the ICD-10 diagnosis code (F11.20, opiate use disorder) on the electronic prescription.

We also, in the case of some national pharmacy chains (Walmart) who don’t understand the Maine law, have to add “Chronic”, which is only of relevance as opposed to “Acute” when it comes to pain. Medication Assisted Treatment is always chronic. Also, they require us to put “Code D”, which is indeed a Maine Exemption Code for Medication Assisted Treatment, but only relevant when the Suboxone (or methadone) treatment exceeds 100 Morphine Milligram Equivalents (MME).

Anyway, even though you have to indicate the diagnosis of addiction on scripts, I hear there are several Maine doctors who prescribe Suboxone for pain. The more I think about it, and the more I read up on it, the more sense it makes. But I’m not going to break any laws just because it makes sense.

This is what I know:

Buprenorphine, the opiate ingredient in Suboxone, is a partial (opiate) mu-agonist, which is the most obvious explanation why it has any analgesic properties at all. But it is also an ORL1 (nociceptin) agonist, which is another pain relieving mechanism. This one is among several proposed mechanisms for why buprenorphine has been shown to reduce Opioid Induced Hyperalgesia, a Fibromyalgia-like state of generalized increased pain perception that paradoxically can make patients with, say, opioid treated back pain start to hurt absolutely everywhere.

In fact, it has been observed that there is analgesic effect at lower doses than usually required for management of opiate cravings.

Buprenorphine is superior to traditional opioids for nerve pain and, because it also is a Kappa-opioid antagonist, it has antidepressant and anxiolytics properties.

Buprenorphine has fewer side effects than straightforward opiates, specifically less constipation, less sedation, less immunosuppressant effect, less induction of gallbladder spasm (morphine is a bad choice for gallbladder attacks), less or even no decrease in sex hormones, less risk for heart rhythm problems (QT abnormalities) and it is even safe to use in older patients with chronic kidney disease.

But the law is the law. Suboxone is for addiction only. How soon will that change?

Follow link (here) for in-depth background reading about buprenorphine.

Flirting With Functional Medicine

“I used to brag that I was taking all those medications so I could keep eating anything I wanted. I guess that isn’t working anymore”, said the rotund sixtysomething man in front of me.

I had never met him before, but I have seen plenty of people like him. His Hemoglobin A1c had been rising steadily over several years, and now his diabetes was way out of control and his copays for all the newfangled pills and shots he was taking were crippling his retirement lifestyle just as much as his obesity and neuropathy were.

I delivered my usual, miniature plain talk monologue, aided by my personal iPad. I have a table of what happened to another patient’s numbers in one year following such an intervention.

.

I call this person my “flex fuel man”, because, just like many cars, our bodies can run on different kinds of fuel, but most people are hesitant to switch fuel even though what they’re using now clearly isn’t working anymore.

I tell my diabetic patients that I agree with the notion that a balanced diet is generally best, but that their diet so far has probably been unbalanced enough to completely stress their carbohydrate burning system. It is as if they have already had their lifetime supply of carbohydrates and they now need to correct that imbalance.

The man in front of me became enthusiastic and said he would stop eating processed, carbohydrate rich foods and eat more like our ancestors, more similar to my own post-vegetarian diet (more on that here).

Thinking more deeply about these conversations that I am having more and more often, I guess I am steadily moving closer to what has had many names and permutations but has now become known as Functional Medicine.

Chronic disease is crippling our people and our healthcare system. Like the man said, many medications, blockbuster drugs, are developed and promoted so people can keep doing what is obviously hurting them. This is true for diabetes, hypertension and countless chronic disease processes we know to be linked to inflammation, gut bacterial imbalance and more or less subtle nutritional deficiencies and toxin buildups.

Functional Medicine is about addressing these root causes of disease.

I, for one, am starting to devote a few of my precious fifteen minutes with patients to the conversation starter “There is another way to handle this”.

Monday night, I registered for some free classes with the Institute of Functional Medicine and on my way up to Van Buren Tuesday night I finished Chris Kressler’s audiobook “Unconventional Medicine”.

My experiences with curing diabetes have nudged me toward a new journey.

How Often Should Doctors Check Labwork?

Back when cholesterol target numbers ruled unopposed (before 2013), we all checked fasting lipids every three months. Before 2012, we also checked liver function quarterly in hapless riders on the cholesterol pill merry-go-round. That year the FDA announced there had not been enough reports of statin induced liver problems to recommend routine monitoring.

I have many colleagues who still do this, and who also routinely monitor routine labs quarterly or even more often on patients on blood pressure pills and sometimes even in the absence of high risk medications, “just in case”.

For patients on the traditional blood thinner, warfarin, many colleagues monitor blood work on an almost weekly basis, and home-testing requires weekly testing in order to be reimbursed.

There is a problem with 1) doing blood tests often and 2) paying close attention to those numbers.

I liken this to driving your car in a snow storm with your high beams on. When you do this, you see way too many distracting snowflakes immediately ahead of you, and not enough of the road further ahead, to see where you are going.

This myopic arrangement tempts you to overcorrect your steering wheel angle; the road suddenly appears to curve in either direction and you assume you are entering a major curve, but it is just a slight wiggle in an essentially straight roadway. This could make you drive into the ditch.

The healthy way to drive in a snowstorm is to turn off the high beams and paradoxically see further ahead by not emphasizing all the snowflakes just ahead of the car hood. There is less detail in this view but a better sense of the general direction of the road.

Doctors overcorrect too often. Warfarin dosing is a common and frightening example. Over the years I have often seen the practice of ordering based on only the current dose and the current PT/INR value.

Say the INR is 1.5 (should be 2-3) on 5 mg of warfarin. The doctor orders 7.5 mg daily without seeing that two months ago when the patient was given that dose, the INR shot up to 3.9. Even electronic medical records sometimes display the current value (and/or the place to order and “sign off” on it) in a whole different area from where we see historical values and dosing (Any reference to Greenway or eClinicalWorks here is purely coincidental). This causes a risk for overcorrection very much like my winter driving example.

The same thing happens with all kinds of laboratory parameters. Recently I saw a man who periodically had to take a diarrhea inducing drug to treat high serum potassium. His kidney function is mildly reduced. After a lot of detective work, going back over bloodwork and medication orders two years back, I saw that a colleague had stopped the patient’s fluid/blood pressure medication, hydrochlorothiazide, one day when the kidney number jumped up a little. That medicine wastes potassium. Ever since, there had been incidents of high potassium, causing physician worry and subsequent emergency prescriptions for the diarrhea causing rescue medication.

Looking back and forth in time, I realized that the patient’s kidney numbers had fluctuated in the same range two years before and two years after the stopping of the fluid pill. I restarted it and don’t expect to have to fuss with high potassiums again. I believe this was another case of myopic laboratory analysis.

Some amount of testing is necessary, for example after starting a new medication like lisinopril, to make sure the kidneys tolerate it (people with poor blood flow to the kidneys don’t handle this medication well), but there has to be limits to how paranoid we continue to be about the medicines we prescribe for bread and butter medical problems; if ordinary drugs are that scary, should we even be using them?

What is a Dose of Psychotherapy?

I don’t know how many times a patient has told me “I was in therapy once, and it didn’t help”.

My response is always: “That’s like saying ’I saw a movie once and I didn’t like it’”.

That usually breaks the ice just a little.

In primary care we certainly run into a few patients with chronic mental health problems that could use some long term, in depth counseling. But usually patients in my practice have a specific problem they need help with.

So I went to my Director of Behavioral Health and asked: “Would you be able to offer a couple of sessions for people with insomnia, retirement quandaries, illness in he family…you know, typical life change stuff”.

He got inspired and came back to me a few weeks later with rough outlines for more than two dozen structured interventions for common psychological scenarios.

A month later, he mused about the concept of “a dose of behavioral health treatment”, like a treatment plan for any medical condition where cure or remission is anticipated: Ten days of penicillin, five weeks of radiation, several courses of chemotherapy or whatever.

Mental health agencies around me are struggling with how to adapt to the times we live in. Neither patients nor insurance companies want decades of psychoanalysis. Today, it’s all about solution focused therapy. My Behavioral Health guy is ahead of the curve by structuring interventions for common problems with a “curriculum” to show patients, insurers and referring clinicians.

We are doing that with chronic pain. Any patient who needs ongoing pain medication is required to attend four individual sessions to learn about what pain is, how the brain is the center of the pain experience, and how our pain experience can be altered by internal and external factors. We don’t use “pain scales” for the simple reason that pain is never objective.

We now have formalized treatment plans for a long list of common psychological symptoms, centered on one-on-one assessment and education with heavy doses of between session assignments.

Like the now so popular “coaching” modality, we explore drivers of thoughts and behaviors and challenge patients to get out of the ruts they feel so trapped inside.

The title of a 1996 book I bought around then at the Harvard COOP, skimmed through and put on a shelf, is frequently on my mind. I need to get back to it and see if it is really about what we are now doing. But even if it’s not, the title itself is beautifully inspiring:

“Doing What Works in Brief Therapy” by Ellen K Quick.

Update: The book is on Amazon and new ones are now fetching collector prices. I’m really enjoying it.

Helping Patients Accept Their “Imperfections”

Brian was in a lot of pain, I could see it. But his lumbar MRI showed only modest changes. Two back surgeons said they couldn’t help him. Physical therapy, chiropractic and osteopathy didn’t help or made him worse. Duloxetine helped only a little. After one day of a higher dose, he felt “loopy” and stopped it completely.

Then he found that marijuana helps a great deal. The only problem was that he started smoking a lot and began to act under the influence. His family didn’t support him becoming a “pothead”. His wife asked if there was anything other than duloxetine he could take.

A website that promised minimally invasive laser surgery several states away had caught Brian’s attention. He asked me what I thought.

The same day I saw a woman who cries a lot.

Holly carries a diagnosis of bipolar disease. She is on one of the newer “atypical” antipsychotics. She functions pretty well, but told me she cries very easily: Movies, songs and good news can affect her. She doesn’t feel sad, just the opposite, she cries more tears of happiness or empathy than of sadness or hopelessness.

She asked me if I knew of a medication for that.

In both cases I thought for a moment. Then I entered that mental space that gives me a sense of quiet authority and wisdom, as if I were speaking as a clergyman or a therapist.

“Brian”, I said, “I don’t think any medication will help you right now. You have your mind set on a surgical cure, and as long as you hold that vision, pills won’t work for you.”

He nodded in agreement.

“You gave up on the 60 mg dose after one single day of nonspecific side effects. You need to research the laser procedure.”

He nodded again.

“But let me point this out to you: you’ve told me that marijuana makes you less stiff and makes your legs move better. That means you’re not all rusted up. Marijuana does nothing to the bones, disks, muscles and ligaments in your body. The only thing it does is change how you experience things. If marijuana makes you limber, do you really need to have surgery, or can you change the pain experience through it and any other chemical or yoga, meditation, Reiki, prayer or whatever?”

His wife turned to him as if to ask him to answer me.

“The problem in your back can be overcome by changing how the nerves from your back and legs communicate with your brain. They are sending exaggerated signals that your back is completely broken when it really isn’t. It has some glitches, but even smoking weed makes you able to use it with less pain, and the duloxetine starting dose did the same thing.”

He looked straight at me and made a slight frown.

“But you’re not ready to work on it that way. You will only be able to do that if you know for sure surgery can’t make you “perfect”. Go see the laser folks and talk to me again afterward.”

I rose from my swivel stool and ended our visit. Brian and his wife seemed to exchange telepathic comments as they left the room.

“Holly”, I said, “I could give you some Paxil and make you cry less, but you would very likely then also feel less joy and empathy. Is it worth risking losing a really good quality that you have?”

“No. I think of myself as a very empathic person. I would give my sweater to a cold homeless person, I’m like that.”

“Right, you have bipolar disease, your mood may change quickly, but you are a very feeling person and maybe this world needs more people who can really feel things, be present in the moment.”

“I like to be called a feeling person. I wouldn’t want to not feel…I was just wondering if it is normal.”

I held my hands out, palms up.

“It is normal. It can be beautiful.”

She smiled and said “Thank you”. Her eyes moistened as she got up from her chair.

I didn’t offer any cures to these two, but I’m trying to help them see themselves as not some potentially flawless machines, but imperfect human beings, as we all are, who can still make the most of who they are and what they have.

Transdiagnostic Treatment Approaches in Primary Care

I learned a new word recently: Transdiagnostic, which refers to something that is applicable across a spectrum of conditions. It seems that this is becoming an increasingly popular concept in treating anxiety disorders.

No wonder. As I researched this word, I read this:

“As of 2013, there are twelve anxiety-disorder diagnoses and over twenty-five subtypes and categories of these disorders, with specific treatments for about half of them. Research has demonstrated that these treatments, particularly cognitive behavioral ones (Hofmann and Smits 2008; Norton and Price 2007), help most people recover from anxiety disorders. Over the last few years, however, researchers have studied the effectiveness of general, rather than specific ones for anxiety disorders. These new treatments target core factors thought to maintain anxiety disorders in general (Erickson 2003).”

It struck me how much this fits into my work as a primary care physician:

The three major diseases I deal with on a daily basis, Type 2 Diabetes, cardiovascular disease and obesity really respond to the same dietary and lifestyle interventions (low carb, high good fat, moderate exercise), and now we even have drugs with transdiagnostic benefits: Jardiance (empagliflocin), an SGLT2 inhibitor, makes you excrete more sugar in the urine (like one of my recent patients did on her own) and also happens to lower the risk of cardiovascular death by 38%.

Another example of transdiagnostic therapies in primary care is the fact that SSRI antidepressants are now first line treatment for anxiety, depression and irritable bowel syndrome. I am not smart enough to know where IBS ends and anxiety begins, but I do believe they are not one and the same.

Fibromyalgia and other neuropathic pain syndromes like postherpetic neuralgia and sciatica respond to SNRI antidepressants (duloxetine), which are also obviously useful tools in depression treatment.

Metformin is another example of a transdiagnostic medication treatment, used for diabetes and polycystic ovary syndrome, conditions that have similarities but also several differences.

This brings me back to the notion I was introduced to in medical school:

Be familiar with many medications, but develop expert, in-depth knowledge about the use of a few select ones with particular efficacy or breadth.

My new word reminded me of that.

And when it comes to the two dozen subtypes of anxiety, that just reminds me of the absurdity of ICD-10 codes, like “accidental drowning and submersion due to fall in (into) bathtub (W16.211)”

Drowning is pretty much drowning. And I refuse to believe that there is any practical need to have 25 different types of anxiety.

Transdiagnostic treatments eliminate the need for obsessive-compulsive diagnosticism.

When the Patient Can’t Tell You

Today I had a followup appointment with a young adult male with severe intellectual disabilities. He is barely verbal. Several weeks ago his caregiver told me that this young man often pointed to his chest and would say “hurt” or “heart”, they weren’t sure which. He also seemed to have gotten pickier about his food, and would literally pick at the food on his plate as if examining it. His appetite was definitely down, but he hadn’t lost any weight yet.

Jimmy is young and slender, not a smoker, and has no cardiovascular disease in his family, so I prescribed him omeprazole.

“So, how’s Jimmy doing”, I asked.

“He doesn’t bang his chest and say hurt anymore, and he finishes anything we put in front of him” was the answer. “And you know what, I didn’t say anything last time, but he’s been kind of grouchy lately, but that’s all gone, too. He’s like the kid I first met years ago, always in a good mood.”

“It’s humbling”, I reflected, “to care for someone who can’t tell you very much about how they feel. I’m glad you were so observant.”

(A brief aside about the Metamedicine aspects of this case: My first prescription for omeprazole was for thirty days and it had one refill. Jimmy’s caregiver said Mainecare wouldn’t honor the refill because chronic medications must be prescribed for 90 days, so he bought the omeprazole over the counter. I shrugged and told him that after sixty days a prior authorization is needed. So, even a “correct” 90 day refill would not have gone through. So we switched to famotidine and if that doesn’t work, we’ll apply for a Prior Authorization for the omeprazole.)

My visit with Jimmy made me think, again, about the importance of the medical history. Even an observer’s report is better than any number of tests.

Even people with normal intellectual functioning can be hard to diagnose because of ther inability to describe what they feel. I have written before about alexithymia, the inability to recognize and describe one’s feelings. These are the people who, when asked to describe their symptoms, start telling you what other people said about how they looked or how they acted. I had seen many people who were like that, but had never heard of the word that populated my Google search when I typed in my observations in the search window.

Primary Care, and perhaps even more Pediatrics can be like veterinary medicine: the patient doesn’t always TELL you his symptoms. Sometimes he shows you, and sometimes others report their observations to you, but it is your responsibility to make sense of it all and come up with a diagnosis.


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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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