Defiance

Ok, this is a beautiful and romantic song, and yeah, George Strait is pretty.

And then there’s the Offspring. Singing Self Esteem. Guess which I like better.

The Offspring: defiance and singing about all sorts of things that we don’t talk about: “The more we suffer the more we really care!” Some of my patients needed to listen to this song. Often the mom, with a spouse and three children, who was taking care of all of them but not herself. “Who takes care of YOU?” I would ask. “No one,” some moms would say. “Look. There are FIVE people in your family. You are one of them. You deserve the same level of care that the rest of them are getting. I want you to include yourself in the people you take care of.” “BUT” “NO BUTS. If you don’t, then you are setting expectations for your children: the boys that a wife will take care of them and the girls to be walked on. Is that what you want?” “NO.” “Change it.” They often would, slowly but surely.

And The Offspring are further my heroes because of this song: Opioid Diaries. Ok, a punk band telling opioid overuse people to get help. MY HEROES! Thank you Offspring!!! It’s not easy to watch but wait until the ending and what if offers. I treated opioid overuse for the last 12 years in my small family practice clinic along with everything else: diabetes, hypertension, whatever. I never felt threatened or frightened, but some of that is because I grew up in an alcohol family. I recognize addiction. Reminding my of my parents is not a good sign. And I had to learn boundaries at home first. This is an uncomfortable video to watch but to me it is beautiful, because it offers hope.

Update on Addiction 2022: Mouse Cocaine Addict Studies

Recent experiments on mice are giving us interesting information on addiction, and suggesting that l-dopa may be able to control/mitigate addiction. This lecture about how dopamine works in addiction using a mouse model (poor mice) blew me away. The mice fell into two categories: maintenance users and vulnerable addict rats. The study of the dopamine postulates a reason for the difference.

20th Annual Drug Conference Washington State from 2019

Notes from lecture 3: Paul Phillips PhD
Dopamine Neurotransmission in Substance Use Disorders: from Preclinical studies

For a long time there were no agreed upon animal models: rats don’t steal money from other rats to buy drugs. However, rats do get addicted and this can be studied.

There are features in rats, rat behavior and rat brains that might translate to humans.

1. Basic discoveries about dopamine neurotransmission in substance use disorders is discussed.
A neurotransmitter study checking every ten minutes in brain examines two areas: dorsal and ventral striatum. Dopamine is increased in the area between cells from the administration of substances “first time use” in animal models: cocaine, alcohol, methadone, cannabinoids, nicotine, amphetamine, morphine. This is the first clue re addictive drugs, whether there is an increase in dopamine intraneuronally. The endpoint is that direct effect on dopamine receptors, which has a different brain mechanism for each drug. Cocaine blocks the receptor that reuptakes the drug into the neuron. Methamphetamines and amphetamines reverse the reuptake pump, makes the receptor spit it out. Gaba neurons act to inhibit dopamine neurons, normally mu receptors on the gaba interneurons and the opioids block those. Ethanol has another mechanism of action. It changes inhibitory activity, lowering the inhibition of the gaba interneurons. Nicotine REALLY messes with multiple receptors and multiple cells, but main effect is increase of dopamine in the striatum.
Increased dopamine in human brain relates to the feeling of being high: brain PET scans show amphetamine and dopamine bound less, reduction in the binding. Subjects were substance abusers. Subjective questioning of how high they felt correlated with the amount of dopamine released on the PET scan. Methylphenidate was used in that study. Canada study: cocaine increases dopamine in human brain by PET scan.
Addiction does lead to changes in the brain, on both PET scans and functional MRIs.
PET scans measuring dopamine binding in the brain show that the baseline in brains of substance abusers differs from non-abusers. The levels of dopamine receptors is lower in the substance overuses and there is lower binding than controls: heroin, alcohol, meth, cocaine (and obesity and ADHD…..). (This has been known for opioid overuse and chronic use for a while: the brain cells withdraw receptors, so the same dose does not reduce pain because there are less receptors. The change in receptors appears to vary in different subjects. Recovery is very slow.)
The role of dopamine has been confusing. It is known that it is involved in the cue evoking cocaine “craving”, but is also involved with — satiety. This has been confusing and contradictory — what does dopamine do but also the dynamic structural signaling.

2. The animal studies demonstrate that the dopamine signals are phasic.
Rat studies measure changes in dopamine minute to minute electrochemistry for sub-second dopamine detection in vivo, which means we can measure changes in dopamine in real time. There is an identified output signature for dopamine levels, measure in 8.5 millisecond, ten measures per second.
The rats were voluntarily taking cocaine. The cocaine was available in a liquid with a light that would come on when it was available, for two hours daily. The animal presses a lever when the light cue is on and gets an infusion of drug. With the ten measures per second, the first and smaller dopamine response in the brain is before the lever is pressed. That is, there is a rise in dopamine BEFORE the rat presses the lever. If stimulated dopamine, the animal would go press the lever. Then there is a larger reward dopamine signal when the drug hits.
Dopamine is the chicken and the egg: signal to USE and signal that has ARRIVED.

3. Changes that take place with drug use
There is a signal change over time that correlation with features of addiction.
The mice had an implanted brain electrode, tinier than human hair, 7 microns, biocompatability — don’t make the brain attack it as a foreign object so rat brain keeps working. The study involves tyrosine hydroxylase, a precursor of dopamine. A food pellet response of the tyrosine remains the same at 1, 2, 6 months so can monitor substance abuse brain changes. These are cocaine addicted rats. They get cocaine via a nose poke of a button when it lights up. Pellets, not iv (they learn that faster). There are 2 ports to nose poke: active and inactive. The signal that cocaine is available and the pellet is active: a light comes on for 20s and then drug arrives. Can take again after 20sec. The rats titrate cocaine use: not continuous. They pace cocaine use, wait for it to wear off. Over time, drug use 1 hour access daily… slow increase, relatively stable.
When the access is bumped up to 6 hours access daily… rats do increase use — first of 6 hours, escalation of drug use faster — in humans development of tolerance.
With 1 hour cocaine availability, the dopamine response to the cocaine in the rat brain is lower by the 2nd and 3rd week, slowly decreases, then with 6 hours of access the loss of dopamine is very robust, happens faster, dopamine signal gets smaller every time.
Rats long access: were there individual differences? Yes, metric, nonescalated vs escalated groups so like humans. 60 escalated 40 didn’t and stayed stable. So essentially I named these “Vulnerable addict rats” and “Maintenance rats”.
Which group most motivated to take cocaine? The study ups the price of cocaine for rats, how many times are you willing to receive the drug? The escalating animals made more responses, “worked harder” for the drug. The escalator brains, Vulnerable Addict Rats, had just about a complete loss of dopamine signal by three weeks.
The nonescalators had more stable dopamine responses, retained some dopamine brain function.
The greater the loss of dopamine, the more the animal escalates the drug use.
The Vulnerable Addict rats would use cocaine to the exclusion of food, water, sex and sleep and died early.
This is a feedback loop. The rats get a success signal when the drug is taken — but over time don’t get the success signal because dopamine receptors are gone — so take more. In the Vulnerable Addict escalators, the dopamine signal of anticipation goes down in response to the cue, the drug effect takes a little longer but the pharmacological response to drug actually remains.
They tried giving l-dopa, a parkinson’s drug and if treat, the rats get a restoration of the dopamine cue — pharmacological response didn’t change — how does this affect behavior? A daily shot of l-dopa and the animals on the l-dopa have less escalation. (wow!) The l-dopa didn’t affect the nonescalators/maintenance rats. When they remove the l-dopa in the vulnerable addict rats, the animals jump to higher use and so the brain changes are happening even when it is masked by the l-dopa but does not stop the brain changes.
They ask the question: can you reverse escalation? With the the l-dopa, they use less.
Dopamine signaling to take drugs (the anticipation cue when the light goes on) decreases in animals that escalate drug taking, but does not change in animals with stable drug taking.
Restoring dopamine signaling with l-dopa can prevent or reverse escalated drug taking.
This dopamine signaling….

4. Mechanisms — drug cue elicits dopamine.
So this is about triggers. This is a paired drug cue: the light signals that the drug is available. If a non-contingent drug given to animal, the light still elicits drug seeking. Using a naive animal: pair reward with cue, over time the cue will increase dopamine.
(hmm. Facebook. blogging. Instagram. “You have mail”. )
The initial addiction has a short access time. One hour out of 24. When this is changed to long access, some animals escalate vs non escalation — as take more and more drug, the response to the drug taking cue gets larger in the escalators/Vulnerable Addicts. Presentation of cue — by investigator vs animal:
If elicits drug seeking than the dopamine response gets larger to the cue over time.
If the cue is given but other choices of liquid, then the dopamine response gets smaller in some rats — so terminating drug seeking. The Vulnerable Addict Rats had a larger and larger dopamine craving cue spike, the longer they were off the drug. The the increase in the cue drives craving and decrease drives seeking — so both bad.
The conclusion in the rats is that craving for drug, related to cues, is dependent to length of time off drug. The longer the rats were off the drug, the larger the dopamine spike when the cue light comes on. The measure of cue behavior gets worse …. 60 day study in rats, this is not physiological withdrawal, is prolonged way beyond the withdrawal.
1. noncontingent
wait a day or wait a month
work harder to get drug, harder a month out
reaction to drug cue presentation, enhanced over time
at start of drug small signal to drug cue
long access then cue gets bigger
same a day after stop drug
but huge in a month after no drug — huge dopamine response

(my thought was then swearing. how do we treat this?)
In chronic drug use the cue signal shrinks which reinforces drug use AND stopping increases the cue response which ALSO reinforces.

5. Implications for treatment
treating rats
They discuss a virus with promotor that affects dopamine cells, light activated ion channel, cells release dopamine when light stimulated
only activates release of dopamine, to understand mechanisms.
For the self administered nose cue …. In the nonescalator maintenence rats, dopamine cue response stays fairly robust, stimulate those cells and no change.
In the escalator/vulnerable addict rats… if do a virus stimulation of dopamine in the brain, more dopamine to cue boosted, so they use less cocaine and look like the non-escalators.
5th cue less dopamine than 1st cue: if put dopamine back then maintains the drug seeking.

What underlies the decrease in dopamine release?
When the animals use cocaine, dynorphin goes up (kappa antagonist).
They injected a kappa receptor blocker — animal no longer escalate (not in humans at this time, don’t understand well enough) treating animals that are escalating, so the bad addict/vulnerable rats.
Most animals don’t escalate — but pretty serious amounts of drug cocaine so not abstinent.

For future
Dopamine diametric changes: dopamine may reduce consumption but might increase craving, so it is difficult to treat.
l-dopa — treatment — some studies, looking for abstinence, does NOT produce abstinence. Does not make abstinence worse. Says that promise seen relates to the status of the subject — helps with people who are still using (some) but doesn’t help increase or prolong abstinence. So could reduce harm but not abstinent….politically unpopular. Happier with turning alcoholic into a social alcohol user, but that idea is less popular/politically ok with cocaine/opioids (and especially meth).

They are studying mouse nosepokes for alcohol — reduced intake when the rats are on l-dopa.

There is a functional agonist for kappa receptors == buprenorphine, might have effects on drug consumption, speculation across different drugs.

Dynorphin is a stress related peptide, so does that signaling produce escalation of drug taking? So other stress drugs — like corisol, CRF, plan for more studies.

Question: Stress related hormones– babies in stress in utero and in stressful childhood have less dopamine receptors and need more dopamine for pleasure, susceptibility to drug addiction (ACE scores) so is still really early studying neurotransmitters.

Dr. Question: why do people do better with agonist therapy than abstinence in opioids vs other drugs? Answer: we don’t know….. yet.

further information:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1920543/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC80880/
https://archives.drugabuse.gov/news-events/nida-notes/2017/03/impacts-drugs-neurotransmission
https://nida.nih.gov/

Vital signs II

For the Ragtag Daily Prompt: vital. For me, vital brings up vital signs. I wrote this poem in 2006. Pain was made the fifth vital sign in 1996. I have written about it here. In June of 2016, the American Medical Association recommended dropping pain as a vital sign. The idea that we should be “free” of pain has not died yet and the latest CDC report says that the overdose death rate for women has risen a horrifying 240% from 1999 to 2017. That report is here: Drug Overdose Deaths Among Women Aged 30–64 Years — United States, 1999–2017. My poem is still relevant and we still have to change our ideas about pain.

Vital signs II

Pain
Is now a vital sign
On a scale of 1:10
What is your pain?
The nurses document
Every shift

Why isn’t joy
a vital sign?

In the hospital
we do see joy

and pain

I want feeling cared for
to be a vital sign

My initial thought
is that it isn’t
because we can’t treat it

But that isn’t true

I have been brainwashed

We can’t treat it
with drugs

We measure pain
and are told to treat it
helpful pamphlets
sponsored by the pharmaceutical companies
have articles
from experts

Pain is under treated
by primary care
in the hospital
and there are all
these helpful medicines

I find
in my practice
that much of the pain
I see
cannot be treated
with narcotics
and responds better
to my ear

To have someone
really listen
and be curious
and be present
when the person
speaks

If feeling cared for
were a vital sign
imagine

Some people
I think
have almost never felt cared for
in their lives

They might say
I feel cared for 2 on a scale of 10

And what could the nurses do?

No pills to fix the problem

But perhaps
if that question
were followed by another

Is there anything we can do
to make you feel more cared for?

I wonder
if asking the question
is all we need

I took the photograph yesterday with my cell phone. It was so gloriously sunny that the water really was turquoise and I did no photoshop changes.

Herd

For the Ragtag Daily Prompt: herd.

I am reading Dopesick, newly out this year, by Beth Macy. I am wondering what make people try addictive substances. At what age and why? To be popular? Herd mentality?

I’ve interviewed my older smokers for years, asking what age they started. Most of them say they tried cigarettes at age 9. Nine, you say? Yes. Parents then look horrified when I say that they should start talking about drugs and alcohol and tobacco by the time their child is in third grade. Recently a woman told me that she tried cigarettes at age 7.

It’s not just talking to your kids, either. It’s modeling as well. What do you model for tobacco, for alcohol, for prescription medicines, supplements and over the counter medicines? Do you say one thing but do another?

I am 100 pages in to Dopesick. The most horrifying new information is that more people under age 50 have died from opioid overdose then died in the 1990s from HIV and AIDS. Also the failure of history: we have had morphine available over the counter until addiction swept the country. Then heroin. This round is oxycontin. And I checked the index: no mention of kratom, sold from southeast asia. It is related to the coffee plant but it works as an opioid. It has been illegal in Thailand since 1943. I think they figured out that it too is addictive a long time ago.

I was an introvert, a smart girl, a geek before there was a word. I did not party and was not invited. I went to Denmark as an exchange student. I tried a cigarette there and decided that I couldn’t afford it and it tasted awful. I drank beer there, but was careful. I did go to a party where I was offered a bowl of pills: no. I was cautious and became even more cautious when I returned to the US.

When and what did you try first? And WHY? What makes us try these addictive substances? The evidence is piling up that the younger we try them, the more chance of addiction. And certain substances addict very very quickly.

Who chooses not to be part of the herd and why?

Tobacco Use Disorder

With the DSM-V, there is no longer a separate diagnosis of Opioid Dependence and Opioid Addiction. The two are combined into Opioid Use Disorder. Opioid Use disorder can be mild, moderate or severe. And all of the addictive substances have the same list. So here is Tobacco Use Disorder.

According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:

A, Larger quantities of tobacco over a longer period then intended are consumed.

1. Unsuccessful efforts to quit or reduce intake of tobacco

2. Inordinate amount of time acquiring or using tobacco products

3. Cravings for tobacco

4. Failure to attend to responsibilities and obligations due to tobacco use

5. Continued use despite adverse social or interpersonal consequences

6, Forfeiture of social, occupational or recreational activities in favor of tobacco use

7. Tobacco use in hazardous situations

8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine in order to obtain the desired effect

A noticeably diminished effect from using the same amounts of nicotine

C. Withdrawal symptoms upon cessation of use as indicated by

10. The onset of typical nicotine associated withdrawal symptoms is present

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

Additional specifiers indicate the level of severity of Tobacco use disorder

1. 305.1 (Z72.0) Mild: two or three symptoms are present.

2. 305.1 (F17.200) Moderate: four or five symptoms are present.

3. 305.1 (F17.200) Severe: Six or more Symptoms are present

(American Psychiatric Association, 2013).

from: https://www.theravive.com/therapedia/tobacco-use-disorder-dsm–5-305.1-(z72.0)-(f17.200)

We have much more stigma attached to Opioid Use Disorder, but list for Tobacco Use Disorder is the same. Most chronic pain patients on long term opioids qualify for at least mild Opioid Use Disorder. UW Telepain says that if they only have withdrawal and tolerance, then it is questionable if they qualify. They also have said that “we don’t know what to do with patients with mild opioid use disorder”.

I find our culture peculiar. People get accolades for saying “I am quitting smoking.” or “I am a recovering alcoholic.” But it’s not ok to say “I am a recovering opioid addict.” People will shun you. Demonize. Gossip. It’s all addiction, so we should stop the demonization and stigmatization and help people and each other.

The photograph is not a brain. I took this about a month ago: it’s a brain size mushroom that was in the church lawn…

from the mist

For the Daily Prompt: forest.

My town is a forest at sunrise and sunset. The trees take over, dark against the sky. And look,  something is rising from the mist.

Medicine is like that too. Did the epidemic of unintentional overdose deaths catch you by surprise? People, including doctors, thought opioids were safe, if taken correctly. And that we should increase them if the person still had chronic pain. But the information is still changing and taking shape from the fog.

I have worked with the University of Washington Telepain service since 2011. I can’t attend every week, but many weeks I spend Wednesday lunch in front of the computer, logged on to hear a thirty minute lecture from UW and then to hear cases presented from all over the state.

I want to sing the praises of the doctors on Telepain and the Washington State Legislature for having this program. Here is a link to a five minute King5  news program about UW Telepain.

https://www.king5.com/video/news/local/fighting-opioid-epidemic-via-video/281-8115411

Forty two different sites were logged on. There are also UW Telemedicine programs for hepatitis C and for patients with addiction and psychiatric problems. The advantage is that all of we rural doctors learn from one doctor presenting a patient and the panel discussing it and making recommendations. We have Dr. Tauben, head of the pain clinic, a psychiatrist, a physiatrist, a family doctor who treats opioid addiction, a psychologist and a social worker. And often a guest speaker! We have a standard form to fill out, with no names: year of birth and male or female. It is a team that can help us to care for our patients.

New information in healthcare rises out of the mist….

 

Resources on opioid addiction

This is a list of resources on opioid addiction that I am putting together for a talk to a community advocate group this Thursday.

The big picture:

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic, January 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

CDC 2018 (It’s not getting better yet.) https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html


Snohomish County:

Snohomish County:

http://mynorthwest.com/878895/snohomish-co-opioid-crisis/

https://drkottaway.com/2018/03/03/reducing-recidivism-snohomish-county-sheriffs-office-and-human-services-program/

http://www.heraldnet.com/news/state-house-backs-snohomish-county-opioid-help-center/

http://knkx.org/post/snohomish-county-jail-now-offering-medically-assisted-detox-inmates

Washington State Pain Law

https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/OpioidPrescribing

https://www.doh.wa.gov/YouandYourFamily/PoisoningandDrugOverdose/OpioidMisuseandOverdosePrevention


Is it genes that make people addicts?
(The short answer is genes are a minimal contribution. It is society and patterns learned in childhood and adulthood.)

Adverse Childhood Experiences (put people at way higher risk for addiction):
https://www.cdc.gov/violenceprevention/acestudy/index.html


Books that helped me understand addiction
(in my teens):

It will never happen to me by Claudia Black (about the patterns children take in addiction households to survive and cope with childhood)

Manchild in the Promised Land by Claude Brown (a black male writes about his childhood in Harlem when heroin hit the community. He was in a gang at age 6.)

Causes of death: which does your doctor treat?

What is the number one cause of death in the United States? The heart. You know that.

You might know the number two: all the cancer deaths put together.

Number three is lower respiratory disease: mostly caused by tobacco.

Number four. Can you guess? Number four is accidents. Unintentional deaths. In 2012 number four was stroke, but unintentional deaths have moved up the list, here: https://www.cdc.gov/nchs/fastats/deaths.htm. The CDC tracks unintentional deaths, here: https://www.cdc.gov/nchs/fastats/accidental-injury.htm. And what is the number one cause of unintentional death right now? It is not gun accidents. It is not car wrecks. It is not falls. It is unintentional overdose: usually opioids, legal or illegal, often combined with other sedating medicines or alcohol. Alcohol, sleep medicines, benzodiazepines, some muscle relaxants. No suicide note. Not on purpose. Or we don’t know if it is on purpose….

And does your physician try to prevent accidental death? Do they talk to you about seatbelts, about wearing bicycle helmets, about smoke alarms, about falls in the elderly, about domestic violence, about locking up guns? About not driving when under the influence? Do they talk about addiction and do they treat addiction?I think that every primary care physician should treat the top ten causes of death. I am a family medicine physician and I try to work with any age, any person. I treat addiction as well as chronic pain. I have always tried to talk about the risk of opiates when I prescribe them. I treat addictions including alcoholism, methamphetamines, cocaine, tobacco and opioids. Legal, illegal and iv opioids, from oxcodone and hydrocodone to heroin. That doesn’t mean I can safely treat every patient outpatient. People with multi drug addiction, or complex mental health with addiction, or severe withdrawal must be treated inpatient. But I have taken the buprenorphine training to get my second DEA number to learn how to safely treat opiate overuse. I took the course in 2011. I was the only physician in my county of 27,000 people who was a prescriber for two years. Now we have more, but still the vast majority of physicians in the United States have not taken the training even when it is offered free.

I don’t understand why more physicians, primary care doctors, are NOT taking the buprenorphine and recognition and treatment of opiate overuse course. Most are not trained. Why not take the training? Even if they are not prescribers, they will be much better informed for the options for patients. People are dying from opioids daily. Physicians have a DEA number to prescribe controlled substances: I think that every physician who prescribes opioids also has a duty and obligation to train to recognized and intervene and be informed about treating opioid overuse.

A large clinic group in Portland, Oregon made the decision last year that every primary care provider was required to train in buprenorphine. One provider disagreed and chose to leave. However, everyone else is now trained.

We as a country and as physicians need to get past fear, past stigma, past discrimination and past our fixed ideas and step up to take care of patients. If a physician treats alcoholism as part of primary care, they should also be knowledgeable and trained in treatment of opiate overuse.

Ask YOUR physician and YOUR local clinics: Do the providers prescribe opiates? Are their providers trained in preventing, recognizing and treating opiate addiction? Do they treat opiate overuse? Do they understand how buprenorphine can save lives and return people to work and to their families? Are they part of the solution?

For the Daily Prompt: provoke.

Pain as a vital sign

A recent article in the Family Practice News says that a survey of 225 physicians reveals that 33% of them think that the opioid crisis in the US is caused by over prescribing opioids. 24% said aggressive patient drug seeking and 18% said it is due to drug dealers. How quickly things change.

In 1996 pain was declared the fifth vital sign, after temperature,  pulse (heart rate), respiration rate and blood pressure. I disagreed with it because it focused on pain, by telling the nurses in the hospital and the outpatient providers to always to ask about pain. I thought it would be better to focus on level of comfort than pain. I thought we were using opioids far too freely and I thought that patients were getting addicted. The pain specialists said that we had to treat pain, and we were given very few tools other than opioids. Primary care providers were told that they could be sued for too much or too little pain medicine.

I also disagreed with it because pain is NOT a vital sign. That is, the level of pain does not correlate with illness. If a person has a high fever of 104 I am sure they are sick, a fast or very slow heart rate, a blood pressure too high or two low, they are breathing too fast: these are vital signs. They often correlate to illness and help us decide if this is outpatient, urgent or emergent. But pain does not. A chronic pain patient may have a pain level of 8/10 and yet not be an emergency or in a life-threatening state at all. That does not mean that they are lying or that we don’t wish to help with pain.

In June, 2016, the American Medical Association recommended dropping pain as a vital sign. https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign. The Joint Commission for Hospital Accreditation dropped pain as a vital sign in August, 2016. https://www.jointcommission.org/joint_commission_statement_on_pain_management/

Why? Not only were people getting addicted to opiates, but they were and are dying of unintentional overdoses: sedation from opiates with alcohol, with anxiety medicines such as benzodiazepines, with soma, with sleep medicines such as ambien and zolpidem. If the person is sedated enough, they stop breathing and die. The CDC declared an epidemic of unintentional overdoses in 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm and said that more US citizens were dying of prescription medicines taken as instructed then from motor vehicle accidents and guns and illegal drugs.

So the poem below and a second poem I will post tomorrow reflect how I thought about pain as a vital sign. It is not a vital sign, because a high pain level does not tell me if the person is critically ill and may die. It does not correlate. Pain matters and we want to treat it, but the first responsibility is “do not harm”. Letting people get addicted and killing some is harm.

Also, opioids have limited effectiveness and high risk for chronic pain. I have worked with  The University of Washington Pain and Addiction Clinic since 2010 via telemedicine. They say that average improvement of chronic pain with opioids is about 30%. Higher and higher doses do not help and increase the risk of overdose and death. And the risk of addiction.

I think of pain as information. Studies of fibromyalgia patients with functional MRI of the brain show that they are not lying about their pain. In a study normal and fibromyalgia patients were given the same pain stimulus on the hand. The normal patients said that they felt 3-4/10 pain. The fibromyalgia patients felt 7-8/10 pain with the same stimulus and the pain centers lit up correspondingly more in their brains. So they are not lying.

Why would opioids only lower chronic pain about 30% even with higher doses? The brain considers pain important information. We need to snatch our finger away from a flame, stop if we smash our toe, deal with a broken bone. I think of opioids like noise cancelling headphones. Say you are listening to music. You put on headphones/take round the clock opioids. Your brain automatically turns up the gain: the music volume or the pain sensors. Now it hurts again. You take more. The brain turns up the gain. Now: take the noise cancelling headphones off. The music/pain is too loud and it hurts! With music we can turn it down, but the brain cannot adjust the gain for pain quickly.

We do not understand the shift from acute pain to chronic pain, yet. The shift is in the brain. I think that we are too quick to mask and block pain rather than use the information. Now the recommendations for opioids are to only use them for 3-5 days for acute pain and injury. For years I have said with any opioid prescription: try not to take them around the clock and try to decrease the use as soon as possible. Some people get addicted. Be careful.

If we don’t hand people a pill for pain, what can we do? There are more and more therapies. Jon Kabot Zinn’s 30 years of studying mindfulness meditation is very important. His chronic pain classes reduce pain by an average of 50%: better than opiates. Pain and stress hormones drop by 50% in a study of a one hour massage. Massage, physical therapy, chiropracty and acupuncture: different people respond to different modalities. Above all, reassuring people that the level of pain in chronic pain does not correlate to the level of illness or ongoing damage. And pain is composed of at least three parts: the sharp nocioceptive pain, nerve pain (neuropathic) and emotional pain. We must address the emotional part too. We have no tool at this time to sort the pain into the three categories. My rule is that I always address all three. That does not mean every person needs a counselor or psychiatrist. It means that we must have time to discuss stress and discuss life events and check in about coping.

In the survey of 225 providers, 50% estimated that they prescribe opioids to fewer than 10% of their patients. 38% said less than half. 12% estimated that they prescribe opioids to more than half their patients. The survey included US primary care, emergency department and pain management physicians.

Handing people a pill is quicker. But we can do better and primary care must have the time to really help people with pain.

Vital Signs I

In the hospital now
I am told we have a new
Vital sign
Like blood pressure and pulse
We are to measure
Pain
And always treat it

Sometimes I wonder

Mr. X is in the ICU
I tell his family
He may die

On a scale of one to ten
What is his wife’s pain?
His daughter’s
We are not treating them
Only Mr. X

We try to suppress pain
Signals from our nerves
Physical pain is easier

I think of our great forests
We suppressed fire

And that was wrong
If fire is suppressed
Undergrowth builds up
Fuel levels rise
Fire comes
Rages out of control
All is destroyed

If fires burn
More naturally
More regularly
What is left?

At first it looks desolate
The tall trees are burnt
Around their bases
But they live
Adapted to the fire
Majestic pines
Revealed
Would our values were as clear

Some pines
Seeds
Pinecones
Will only germinate
In fire
When the undergrowth
Is cleared
Conditions are right
For new growth

Perhaps pain is our fire
Grief is our fire

If we block pain
Where does it go?
Does the fuel build?

I wonder if the tall pines
Fear fire
Would they avoid it
If they could

Perhaps suppression
Is not the answer

Perhaps we can change
Remain present
Acknowledge pain
As normal
As joy

Perhaps if I
Step into the fire
I can remain
Present
For you

And you will be
Less alone
Less afraid

I open my doors

Let the fire burn

poem written before 2009

CDC guidelines for treating chronic pain: https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf