Opinionated on Opiates and the Treatment of Pain -- Independent and Strong Sports Medicine Physicians and Our No Opiate Rule

President Obama just allocated $460 million to states to bolster resources to treat opiate-abuse disorders.  The goal apparently is to reduce opiate-related deaths, which are on the rise, especially amongst middle class whites.

I disagree with President Obama and his advisors when it comes to managing opiate-related concerns.  This is throwing money at the back end of the problem, tantamount to pouring extra water on an already extinguished house fire while an arsonist is next door dousing surrounding homes with gasoline and carrying a lit match.  Soon you're gonna have a bigger problem with which to deal.

The problem is opiates are catastrophically overprescribed.  This practice stems from the pharmaceutical industry led movement that began in the 1990's. I recall enjoying what seemed to be weekly free lunch provided for by a pharmaceutical company peddling their opium-derived drug.  A well-paid physician stood in front of me lecturing on the drug while my free boxed lunch set off 'triple point' endorphins as I ate my delicious sandwich, chips and chocolate chip cookie, pocketed between 1 and 10 shiny new drug-logo pens, and naively sat marveling at my having 30 additional minutes of free education as a school-loan supported medical student in New Jersey  that bolstered the idea that "pain is a "vital sign" to be measured routinely and monitored over time by your doctor at every visit like your temperature, heart rate (pulse), respiratory (breathing) rate, and blood pressure.  Pain is not a vital sign.  It cannot ever truly be a vital sign.  A vital sign must be objectively measured, by a reliable and trained health care provider or medical device.  Pain is subjective, and only measured by patient report. 

Opiates are reportedly prescribed to treat pain by physicians or other licensed non-physicians. 

Sadly, I report that I also fell victim to the influence of Big Pharma.  My 'retrospectoscope' now clearly places my naive self in the very center of the problem.  I am fortunate to be a reformed opiate prescriber.  Our office does not prescribe opiates.  I am often asked by colleagues how we can 'manage' to not prescribe opiates as they admit to wishing to stop prescribing them as well.  I would bet that a clear majority of physicians would choose to stop prescribing opiates entirely if they felt it was moral and ethical to do so...the problem is we were taught otherwise to more aggressively treat pain and prescribe opiates even if unsupported by evidence.  Taking opiates carries the risk of addiction, pseudoaddiction, tolerance, gastrointestinal side effects, impaired brain function, and as we know from well publicized media reports, death from opiate overdose.  Great financial windfalls are enjoyed by Big Pharma, and a growing illegal black market triggering many patients treated for seemingly legitimate concerns to divert some or all of their medication for cash.

In an era proscribing to adhere to 'Evidence-Based Medicine' I should point out that the pain research supports a clear absence of functional restoration for opiate users.  This means that persons taking opiates for pain do not demonstrate improved function in their daily life -- perhaps most importantly and objectively measurable, they do not return to work at higher rates than non-opiate users with pain.  As would be expected, opiate users do report higher quality of life scores.  Opiate drugs contain the same active ingredient as opium (same as heroin) and when they bind to our cell opiate-receptors provide one with a sense of euphoria.  We can probably agree that we're likely to rate our quality of life fairly high at a moment of euphoria?!!!

Opiates treat suffering moreso than pain.  Suffering ensues when pain is associated with a decline in function (e.g. inability to work or play), loss of control, and/or a decreased quality of life perception.  Opiate triggered euphoria transiently solves suffering.   What a wonderful concept for the cancer patient on her deathbed, or the battlefield wounded who may not survive his injury -- we can alleviate suffering at such a critical time.  However, pain is not suffering.  Pain is our bodily response to physical or psychological distress.  We need to experience pain to inform how we manage and hopefully cure such physical or psychological distress.

Nowhere is the distinction between pain and suffering more evident than in sports medicine.  Athletes overall are very high functioning individuals motivated to get better to return to their sport.  When they present to me relatively early on following injury, they typically have pain that resolves in a predictable manner with activity modification and therapeutic exercise.  They then return to play and their pre-injury high level of function.   Suffering may develop in the athlete unable to cope with their functional decline and/or if the athlete perceives a loss of control or decrement in life satisfaction.  Fortunately, most athletes have a wonderful capacity to heal and often have strong coping skills and positive life outlook.  This helps most athletes avoid pain-related suffering.

I have learned quite a bit about pain and suffering through my own personal experience.  I had spinal surgery for a disc herniation and nerve damage in 2007.  I dealt with high levels of pain before surgery and more mild-moderate levels of pain following surgery.  However, I escaped the realm of suffering.  I did not once use opiate medications before or after surgery.  How (or why) one might ask?  My pain did not transition to suffering due to my deep understanding about what my body was going through.  I did not feel worried or anxious as most people do because I knew why my body hurt and why my leg was weak and numb.  I understood my surgical and non-surgical choices. 

I can understand why physicians and other health care providers might wish to prescribe opiates to patients who present with suffering.  I think we are easily drawn to be overly empathic in the face of suffering, wanting to use our anti-suffering killer miracle drugs, readily losing objectivity and forgetting that opiates are not indicated for non-malignant pain (i.e. terminal cancer).  But unfortunately on some level we ignore our oath to 'first do no harm.'  We often treat our own anxiety, because it is easier to sign an opiate prescription than to recognize, diagnose, and treat suffering.  I don't know how to treat suffering in a brief office visit...but I'm very adept at recognizing it.

I agree we need resources directed towards treating these needy and suffering individuals who now are most often treated with opiates.  Funding should be directed to the training of additional mental health providers who are expert in recognizing, diagnosing and treating suffering, and appropriate public health messaging.  Teach people the difference between pain and suffering. 

While I entertain a discussion on the topic of opiates and the confounding health messaging by the pharmaceutical industry, our government, and the media, I am reminded of what I believe to be the true definition of health care:  health care is what happens in a closed room between a physician (which, by the way, comes from the Greek word for 'teacher') and a patient.  Health care does not happen in the local, state or federal legislature, in the boardrooms of pharmaceutical or medical device manufacturers, or in the offices of media executives -- that is where power is heralded.  Let us be transparent and clear.  In an age where more doctors are employees of hospitals or large health-care systems than self-employed, and more often considered merely interchangeable and 'evidence-based guidelines' technicians or line-workers, health care consumers are at risk of losing the opportunity to have individualized medical care provided by unconstrained independent thinkers.  As my fabulous partner and famously independent thinker, Gary Chimes, often chirps, "people who want great medical care deserve doctors too."

Meet the Team: Natalie Hoyte!

Welcome to the team! Can you tell our readers a little bit about your role at Lake Washington Sports & Spine (LWSS)?
Thank you! My role as a medical assistant is to help make each visit with Dr. Hyman go as smoothly as possible, from gathering information at the start of each visit, making sure appointments stay on schedule, helping to draft referrals, setting up equipment for procedures, drawing blood for PRP injections, and serving as a liaison between Dr. Hyman and patients by helping to answer any questions or concerns patients may have related to their care.

So far, what is your favorite part of working at LWSS?
There are so many things to love, it is hard to say! First, I enjoy the culture of this office and the sense of community I already feel with the entire team- this is a small office and we are all driven to learn and become 2% better, every day. For example, it is a part of our office culture to never be afraid to ask questions, and to encourage providing feedback so that others can learn and improve their role in the practice. I also like that I can always count on doing a post-work workout in the office lobby with Laura and Elianna, or swap stories about the many hobbies and activities that we all pursue outside of work. Most of all, I love how much new information I am learning each day. I plan to continue my education and further my healthcare career by attending a graduate program to become a physician assistant, and the doctors undoubtedly take special care to teach me things that will help me when I become a medical provider, whether it be teaching me what they are looking at in an ultrasound, explaining the reasoning behind their medical approach, or encouraging me to study my anatomy and keep asking questions.

The LWSS mission is to KPA- Keep People Active. Can you explain how that mission guides the day-to-day care that the doctors provide?
Both Dr. Hyman and Dr. Chimes are very active in their own lives, and it is clear that they care deeply about helping their patients lead active lives as well. In my short time working at LWSS, I notice that the doctors take the time to address all factors that may be influencing a patient’s condition, including the patient’s lifestyle and activity goals. The doctors spend significant time educating patients about their given condition and treatment options, and they take the time to explain their thought processes throughout the diagnostic process, so that patients can have an active role in their own recovery. Dr. Hyman and Dr. Chimes offer treatments that can help patients get back to activity, rather than just masking the source of pain. Both doctors have faced their own fair share of injuries, and it is clear that they strive to be the kind of providers that they would have liked to see when going through their own recovery processes.

How do you personally align with the KPA mission?
One of my favorite ways to stay active is to get outdoors and take a hike! I love exploring nature and reaching new vantage points. I am always rejuvenated after getting to spend time outdoors, and this past summer I hiked the John Muir Trail, which is a 210 mile hike that goes from Yosemite to Mount Whitney, the tallest mountain in the contiguous states. I took 20 days in total, and completed the journey just one step at a time! In the short days of winter, I like to stay active by rock climbing at the gym or strength training so I can improve my climbing abilities. Most importantly, I want to take advantage of the capabilities of my body, which is an incredible system that allows me to experience the world in amazing ways.

What are the advantages of being treated by an LWSS physician vs. a physician in a large organization?
The advantage of being treated by an LWSS physician is that, unlike physicians working in a large system, Dr. Chimes and Dr. Hyman have significantly more control over what kind of care they can provide. They have the autonomy to offer PRP and prolotherapy injections, for example, which many larger organizations would not be able to offer due to insurance restrictions. The doctors can choose to have longer patient visits, which would otherwise be impossible in a larger organization where ‘productivity goals’ stipulate how many appointments the physician must have each day. Since it is a smaller office, it is also much easier to get a short-notice or same-day appointment, which could otherwise take months at larger practices. Also, it is pretty special that you may get to visit with Bucky, Nala, or Winnie, the lovable dogs that frequently keep company at the office.

Ok, now a little more about you! What are 5 fun Natalie H. facts?
Few people in my adult life know this, but growing up I was known as the “llama girl.” At one point I had four llamas and twenty-two sheep!

In college I discovered that one of my passions is helping others get outdoors to experience the wonders and rejuvenating power of nature, so for three years I led backpacking and kayaking trips through my university’s outdoor center.

My goal for 2016 is to ride my bike more, and this summer I would love to go on a multi-day cycling trip; there are so many beautiful places in the northwest, and traveling by bike would be challenging, but more efficient than hiking!

If I had to only cook with one spice for the rest of my life, it would without a doubt be garlic. I love it so much that once, in an attempt to convince others of its ultimate plant superiority, I made a roasted garlic apple spice cake. Suffice it to say that by the end of the evening, the cake had been devoured and I was left with only crumbs.

I love to cook, and if I could have one super power, it would be the ability to conjure up any plant food at the snap of a finger- I could cook the freshest of meals and I would never have to grocery shop again.

Viscosupplementation

What is Viscosupplementation?

Viscosupplementation is a procedure that is often utilized by the doctors at Lake Washington Sports & Spine, mainly for patients who suffer from osteoarthritis of the knee.  Osteoarthritis (also called degenerative joint disease) is mechanical wear of cartilage and bone within a joint and often limits patients’ abilities to remain active.  Since our goal at Lake Washington Sports & Spine is to Keep People Active, any procedure that helps our patients maintain their level of physical function is a great tool in our belt. 

Viscosupplementation (also known as hyaluronic acid injections or hyaluronan injections) involves injecting a lubricating fluid into a joint (most commonly in the knee, which is the only joint that has historically been covered by insurance, but it can be helpful in other joints as well).  Hyaluronic acid is an important component of the joint fluid in healthy joints and is found in lower concentrations in osteoarthritic joints.

What is it like to receive a viscosupplement injection at Lake Washington Sports & Spine?

Both Drs. Hyman and Chimes typically recommend that their patients receive a series of three injections over the course of three weeks (one injection per week).  The patient will come in at their regular check-in time and fill out a follow-up form.  As always, we recommend patients wear athletic clothing to the appointment (shorts are particularly ideal).  The doctor will perform the injection under ultrasound guidance to make sure that the hyaluronan is accurately placed into the joint space.  There is a chance that patients will start feeling benefit after the first injection, but typically, maximum benefit is gained after all three injections have been completed. 

Doctors’ recommendations post-injection:

1.       Ice the injection site if patient is feeling any local tenderness

2.       Continue any mild to moderate cardiovascular exercise routine

3.       Avoid any High Intensity Interval Training (HIIT), weight training or resistance training for the first 48 hours after the injection

4.       Call the office with any other questions/concerns that may arise

The benefits of viscosupplement injections can be felt for between several months and a year, but of course, these numbers vary greatly between patients.  It is possible for the series of injections to be repeated; usually our doctors and insurance companies require at least 3-6 months between the first series and the second.   Additionally, it is important to understand that viscosupplement injections are not substitute for total joint replacement surgery if a patient’s osteoarthritis is severe. 

What if I have osteoarthritis in areas OTHER than the knee?

Currently, the use of viscosupplementation is FDA approved to treat knee arthritis only but it has been shown to be beneficial when used in other arthritic joints such as hips and ankles.  As a practice that focuses on delivering “pure medicine”, our doctors do not want patient care to be restricted by insurance companies, and therefore we offer competitive direct-pay pricing for viscosupplement injections not covered by insurance. The doctors at Lake Washington Sports & Spine will make it clear if they feel viscosupplementation is the best method of treatment, whether or not it is covered by insurance. 

If you are suffering from osteoarthritis that is keeping you from participating in the activities you love, we recommend you call our office and set up a consultation to see if viscosupplementation is the right choice for you!

Graduation Ceremony

Graduation: high school, college, completion of treatment?

The Graduation Wall

Have you ever been to a clinic where they have a ceremony to commemorate your success? Better yet, a clinic that celebrates when you don't have to schedule another appointment?  

Here at Lake Washington Sports and Spine, we believe it’s crucial to recognize our patients' dedication and determination to get back to being active. Our graduation wall represents the collective achievements of every patient who has completed treatment and returned to the activities they love.

The Sights & Sounds of an LWSS Graduation

Our whole office pauses for a moment to recognize your success! At graduation, you write your name on a sticky note, then slap the note on our graduation board while performing an exercise that utilizes your rehabbed body part.  As you post to the board, the LWSS team cheers and shakes maracas in celebration. But wait, it doesn't end there!  Once you walk to the end of our hallway, you press the "Emergency Affirmation" button and are congratulated with a “swag bag”.  Celebration, gifts and a body back-in-motion, who doesn't love that!? 

Why We Believe Graduation Is So Important

LWSS is built on the foundation of "Happiness Based Musculoskeletal Medicine", so we always focus on life's positives!  What could be more positive and happy than returning patients to doing the physical activities they enjoy? We recognize that you put the work in and think you deserve the credit!

For patients who are just beginning their journey with us, we hope the Graduation Wall serves as an inspiration and we look forward to celebrating you and your future success!

5 tips to prevent holiday weight gain & stay active

1) Hydrate
H2Oooooohhh yeah! Drink a large (16 oz.) glass of water 15-30 minutes before every meal, especially before hitting a holiday buffet. Water will help you feel fuller, eat less and aid in the digestion process.

2) Indulge in moderation
Deprivation is a recipe for disaster, but so is unlimited indulgence. Find a happy balance and allow yourself 2 or 3 small portions of your favorite holiday treats. For the rest of the meal, stick to healthier options like veggies, lean meats, low fat cheese and fruit.


3) Weigh in
While it’s tempting to reach for elastic waist pants and hide your bathroom scale for the month of December, neither will help keep you accountable. If you see the number on the scale creeping up or feel your favorite pants getting tighter, you’ll likely pass on that slice of pie.

Think you can take an accountability hiatus and start again in the New Year? Neglecting healthy eating habits and exercise during the holidays will only make your resolutions more difficult.

4) Make exercise appointments
Consistent exercise and protected time to de-stress are more important than holiday shopping and gatherings. To avoid making excuses or falling into the trap of being “too busy”, schedule exercise on your calendar just like you would any other meeting. Bonus, you can even set an event reminder alarm to alert you it’s time to get moving!

5) Share fitness with loved ones
The best part of the holiday season is spending time with friends and family, so connect while staying active! Take an after dinner walk with your kids, go hiking with your cousins, attend a fitness class with your best friend, or register for a fun 5K. Make fitness a new part of of your holiday tradition!

ven

Healthier Options: Thanksgiving Edition!

I LOVE the fall and winter holidays!  The sights, the sounds and especially the holiday FOOD.  I remember as a kid, the scent of my Mom’s turkey and gravy wafting through the house on Thanksgiving Day.  My family and I would indulge ourselves on the bountiful feast spread before us and celebrate the holiday giving thanks to family, friends and health.

Fast-forward 20 years and I am going to be preparing a Thanksgiving meal for my OWN family now.  I will definitely have Mom’s recipes in mind and will be trying my hand at lightening some Thanksgiving side dishes so I can stay on a healthy path and not fall into the Thanksgiving “coma” from over-eating heavy foods. 

This year I plan to be a more mindful eater. I will prepare some recipes in advance to test out new, healthier side dishes so I know which ones my hubby will enjoy (and which ones he will attempt to feed the dog on the sly).  I have included some lighter side dish recipes below and encourage you to also experiment on your own!  Have fun this Thanksgiving and remember: It’s a holi-DAY not a holi-MONTH so instead of embarking on a month long food fest, take control of the day and kick-start your motivation for a healthy holiday season!

RECIPES

1.   Healthy Potato Gratin with Herbs: Skip the mashed potatoes this year and try a lighter potato dish that loses the heavy cream but keeps the flavor with fresh herbs.

http://www.foodandwine.com/recipes/healthy-potato-gratin-with-herbs 

(recipe courtesy of Food and Wine)

2.   Cider-Glazed Roasted Root Vegetables: Instead of a basic sweet potato/yam dish, try this delicious recipe that brings an added sweetness with apple cider.

http://thescrumptiouspumpkin.com/2014/11/25/cider-glazed-roasted-root-vegetables/ 

(recipe courtesy of the Scrumptious Pumpkin blog)

3.  Cranberry-Pear Wild Rice Stuffing: Take unhealthy “stuff” out of your Stuffing this year with wild rice, whole grain bread and dried cranberries.

    http://www.vegkitchen.com/recipes/cranberry-pear-wild-rice-stuffing/ 

(recipe courtesy of the VegKitchen with Nava Atlas blog)

How to Prepare for Your PRP Visit and What to Do After

Platelet-Rich Plasma (PRP) is an example of proliferative therapy that we’ve discussed on this blog before. The treatment is useful for many musculoskeletal disorders, ranging from lingering tendon, ligament, and muscle injuries (e.g. hamstring and rotator cuff tears) to joint pain (e.g. knees and hips). We at Lake Washington Sports and Spine tend to recommend PRP after other conservative measures, particularly physical therapy or chiropractic care, have not produced meaningful results.

PRP is one of many treatments that we perform in the office, but it is one of the more time-intensive ones. This is due to the nature of the therapy itself. When we perform other injections in our office, medications are drawn from vials then injected into a patient. However, with PRP, the medication comes from the patient! Our blood is not just a homogenous red substance that courses through our veins. There are many types of cells in our blood – which include, but are not limited to – cells that carry oxygen, others that fight off infection, and the ones we are most concerned about: the healing factors.

These healing-inducing cells include platelets, as you probably guessed by the name of the therapy. The portion of plasma containing platelets - as well as other healing factors - is obtained by spinning blood in a centrifuge for 15 minutes, which separates the different aspects of the blood into distinct layers. The platelet-rich concentration is extracted from the resulting vial of separated blood, and injected under ultrasound guidance into the site of injury. This not only concentrates healing factors near the injured area (exactly where it needs to be), but also causes an inflammatory cascade which brings its own set of healing responses.

What can you do to prepare for the procedure itself?

1.     Come early.  Coming in 30 minutes prior to your appointment start time allows us to perform all the steps (draw, centrifuge, and platelet extraction) before the actual injection without making your appointment run late. It also gives us a time buffer in case we run into any issues during the blood collection. Additionally, this time is beneficial to patients as it gives them a time to relax between the blood draw and the injection. If you do not arrive 30 minutes early, there is a chance your procedure will need to be rescheduled. 

2.     Hydrate! Water is an important component of blood, and makes it much easier for any healthcare professional to draw blood from your arm. Your veins are fuller (making it easier to perform the actual blood draw) and your blood moves quicker (less time with a needle in your arm!).

What do you need to do after the procedure?

1.     Rest and get more sleep. Sleep is a wonderful thing, so I feel strange having to recommend it. But many patients do not get enough sleep, and lack of sleep can have a very detrimental effect on your healing rate. Use this procedure as an excuse to get more restful sleep. I recommend using your recovery phase from this procedure as a jumping off point to establish a good sleep routine you can use when you’re back to your fully functional self.

2.     Limit forceful weight bearing and movements with excessive range-of-motion.  Imagine a glob of peanut butter sandwiched between two saltine crackers. Now imagine squeezing the crackers together and spilling the peanut butter onto the floor. You don’t want peanut butter on the floor, just like how you don’t want the Platelet-Rich Plasma anywhere other than where your injury is located. The general idea behind PRP therapy is to concentrate healing factors into a specific, targeted area. An excessive contraction of a muscle, or movement of a joint past normal range-of-motion, can “squeeze” the platelets away from the targeted area. For some cases when the PRP is meant for a lower body part, we may recommend being on crutches for two weeks to really ensure the PRP stays where it should.

3.     NO NSAIDs.

4.     I repeat, NO NSAIDs. Your body’s natural response to injury is to cause inflammation. We typically only associate inflammation with pain, which is why people often take an NSAID (non-steroidal anti-inflammatory drug) like ibuprofen or naproxen (e.g. Advil, Aleve). However, inflammation also triggers a healing response by the body. PRP therapy will cause some inflammation and therefore may increase a patient’s pain level for the first two weeks. This is a completely normal part of the healing cascade, and is temporary. Taking NSAIDs to alleviate the temporary pain will reduce the likelihood of having a more permanent recovery. Do not sabotage your ultimate goal of getting back to fully functional activity for some temporary relief. Keep your end goal in mind!

5.     Ice if necessary, Tylenol if necessary. If you’ve been to our office, you know that we extol the benefits of ice like we’re the ice farmers of Frozen. We recommend ice as our first-line pain reliever, as ice has been shown to reduce pain and inflammation without having to take medication. However, PRP might be the only instance we recommend discretion when icing. As I’ve said previously, forms of proliferative therapy cause inflammation, so icing is counter to what the therapy is trying to accomplish. Therefore, we recommend icing only when completely necessary and the pain in unbearable. You can also try acetaminophen (e.g. Tylenol), as that is a non-NSAID pain reliever.

And that’s it! This is only a general overview, and I’m sure you might have more questions. The doctors here at Lake Washington Sports and Spine always have a consultation with a patient to review the appropriateness of PRP for a given patient, the risks involved, and potential outcomes. They are more than happy to answer any and all questions you may have regarding this procedure at that time.

Stay active!