Kudos to Papplebon!

PapplebonDr. Michael J. O’Connell, Healthcare Consultant, Barrington, New Hampshire commented that last October we witnessed on the professional baseball field something that doesn’t happen but once in a blood moon.  A ballplayer (Jonathon Papplebon) called out a teammate (Harper) for not hustling his run to first base on a routine fly ball.  The two argued briefly in the dugout, then scuffled with a few punches flying briefly, all caught on televised broadcast.

Such laziness and lack of hustle is commonplace in baseball in particular (showing late for practice is commonplace in football).  In decades past this behavior was met with fairly severe measures including counseling by the manager (on and off the field), fines imposed by the team, possible suspension.  This discipline never happens nowadays, partly due to the union influence, partly due to our politically correct society.

The real travesty though is not Harper’s lack of hustle, that’s expected, but the fact that Papplebon was suspended.  Not Harper… Papplebon.  Jonathon should be rewarded for having the balls to do what today’s coaches/managers/owners are scared to death of doing. For what the players are paid, for such incredibly narrow talents/skills, they should run out all fly balls – run like they mean it.

Open letter to the Republican Party….

Republican Party TwoDr. Michael J. O’Connell, Healthcare Consultant from Barrington, New Hampshire commented:

  1. I understand the need to pander to the religious right, especially during the primary season, but let’s make sure we have a solidly right/centrist candidate for the general election – Mitt Romney where are you? Let’s not embarrass ourselves with a cretin like Trump or Cruz.
  1. Can you please forget Obamacare? It’s here to stay and it makes all Republicans look petty and desperate with these efforts to repeal.  There is no way legislation would successfully override a presidential veto, so it’s all window dressing.
  1. Likewise window dressing is the stance on debt with this menace, the monthly debt crisis – get things squared away after a Republican is in the White House.
  1. Gun Control – Let’s pull away from the NRA finally and ensure that assault weapons are banned. Sure they are plenty fun to shoot, but remember the Ford Pinto was pulled off the market?  It was fun to drive but turned into an inferno when rear ended.
  1. Abortion – I’ts here to stay. It’s a protection afforded by the Supreme Court.  Let it go—see #2
  1. Fiscal Responsibility – Definitely, Liberal spending must stop.
  1. Defense – Absolutely necessary to have a strong mobile force.
  1. The country, nah the world, needs measures to control population growth – the poor in this country are often ill-prepared to have more babies – Planned parenthood is the best tool to assist them in more thoughtful family development. Stop efforts to defund Planned Parenthood – again makes the party look stupid and totally alienates the left.
  1. Climate Change – WAKE UP REPUBLICANS – it’s occurring – only a few loony bin pseudo scientists reject – let’s admit to global warming, regardless of the cause. To deny is to look like a Monkey’s Ass

 

Is it addiction or dependency?

Addiction vs dependency6Dr. Michael J. O’Connell, New Hampshire commented that the distinction between addiction and dependency is constantly mangled by the press, lay people and even many professionals.  The difference between dependency and addiction is not withdrawal.  Withdrawal is a phenomenon common to both.

Addiction marks a transition into pathology; the chemical, activity or behavior to which one is dependent (oxycodone, heroin, alcohol, THC, sex, eating, extrovertism/introvertism) becomes harmful…physically, psychologically and/or functionally, to the individual.  Withdrawal or craving is not necessarily a pathology and therefore not necessarily an indication of addiction.

One would be hard pressed to declare a weekly snorter of heroin or cocaine an addict.  If a person dreams much about food, craves certain tastes or dishes, but lives a functional work and social life and is not obese, this can hardly be defined as an addict.  If another has elevated liver enzymes, presence of abdominal fat in an otherwise slender body, is thinking about drinking alcohol much of the day, has a couple DUIs, occasional blood in theAddiction vs dependency3 stools, and yet persists in drinking alcohol, this is most likely an addict.

If a chronic back pain patient that had a laminectomy and then fusion, still requires pain meds but goes into intense withdrawal with sweating, shakes, diarrhea, and piloerection, when away on a trip forgetting meds at home, this is dependency, but unlikely addiction.

Pain management and opioids…

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Dr. Michael J. O’Connell, PainCare, New Hampshire wanted to give a clear explanation as to what pain management is al about because there are many misconceptions about it.  Pain management is in many ways the oldest specialty of medicine with evidence of pain control through use of naturally occurring substances many thousands of years ago.  Serious pain usually accompanies (and sometimes continues after) healing of wounds and tissue injury including contusions, sprains, strains, bone fractures, lacerations, nerve compression, and the like.

In other ways pain management is one of the very newest of medical specialties, carving an important niche with advanced “modern” tools to combat pain.  The specialty has met with remarkable success in acute pain – to such an extent that there is virtually no reason why anyone with acute pain and access to a pain manager cannot expect good to excellent symptom control.  This expectation was even codified by the US Congress in the form of a somewhat unfortunate patient “bill of rights.”

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

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

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

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

The very laborious solution to this quagmire, is to first gain the trust of the patient by continuing the regimen, then to [only] suggest a gradual wean from the opioid, then finally institute said wean.  For a patient who firmly believes the opioid is “the only thing that works,” a wean is extremely difficult to institute and maintain and will often take months to years.  This patient resistance can only be broken down through herculean efforts at education, counseling and reassurance by the pain practitioner.

At Paincare we find that at some point, a transition to buprenorphine is a most viable and valuable step.  Buprenorphine is a very weak opioid, but an avid binder to opioid receptors.  Due to the strong binding, the receptor remains occupied, thus alleviating the anxiety and physical (but largely emotional) stress of eliminating the beloved full agonist opioid (oxycodone, morphine, fentanyl) the patient has depended on for years.  Patients who successfully make this conversion routinely feel alert, engaged with life, and are now responsive to physical rehabilitation and conditioning, occasional steroid injections, medication previously eschewed such as gabapentin, tramadol, tapentadol, and anticonvulsants.  Again, the primary hurdle is establishing the degree of trust necessary to lead the patient toward this goal.

None of the above should imply that all patients will comply. There will always be those who take a drug for unintended purposes (e.i. sedation or a sense of well being over analgesia).  If these patients have verifiable pathology that can generate the pain that is described, they can be extra difficult to identify and transition to more appropriate drugs to treat the underlying problem.

Also, the above should not imply that some chronic pain patients are simply addicts.  Many practitioners make the mistake of identifying all dependent opioid treated patients as addicts. While all addicts are dependent (have withdrawal for example upon cessation of their drug), not all opioid dependent patients are addicts.  Most studies suggest that the small minority of patients with verifiable severe pain generators are addicted.  That minority grows when patients with less severe pain generators are considered. It is therefore important that general practitioners of medicine not start full agonist opioids on patients with only modest evidence of pain generating pathology.

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

Nelson Mandela…

ImageDr. Michael J. O’Connell noted, Nelson Mandela was an effective revolutionary, perhaps even great.  He spent nearly a third of his life in prison for the cause of destroying apartheid.  This has the face of a noble cause versus an entirely ignoble system of racial inequality.

Political leaders from the past two decades were tripping over themselves to attend his funeral.  Why taint our remembrance of the man with the puny and tainted minds such as Obama, Clinton and Carter?  On that note, why should we remember Mandela only for his courage in the face of African violence, when the total view should include his disloyalty to Winnie, his wife, during his quarter century of incarceration, and his loyalty to such infamous thugs as Libya’s Khadaffi and Cuba’s Fidel Castro.

Something smelled bad about the celebration of Mandela’s life (the stadium in Soweta was apparently half full – not full as it is during World Cup Soccer), without a remembrance of his innumerable warts.  The moral to this story is that all men and women have weaknesses and skeletons.  Let’s once and for all realize that and stop the nonsense of idolizing fallible humans.

Mindfulness and chronic pain…

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Our scientific understanding of acute pain vastly overwhelms our knowledge about chronic pain.  While there are many isolated pieces of information, there is no cohesive explanatory theory of chronic pain.  While acute pain is dependent upon the degree of tissue injury and inflammation, the progress of uninterrupted healing, our psychological response to and prior experience with chronic pain is often reported in the absence of continuing or increasing tissue damage or overt inflammation, and in the midst of apparent healing (as adequately as our bodies are capable), tens of millions of Americans suffer from chronic pain.

Perhaps it is the “suffering” that is the more important aspect of chronic pain.  Here science gives us a wild assortment of explanations, which conveys to me only one thing; no one knows why pain sufferers suffer.  So, if suffering is the central feature of chronic pain, yet we cannot explain it in a meaningful or useful way, treatment should arguably focus on lessening suffering, and for now, ignore the fact that suffering cannot be adequately explained or understood.

A very interesting phenomenon has been noted by many of our patients.  They tolerate their pain and reduce their overt suffering, if they embrace their pain, as though it were a natural part of their bodies’ experience, which of course it is.  Patients who suffer the most are divided into two categories:  those who cannot accept the fact that they were initially injured, angry at the causal event or the circumstances in which they find themselves, and those who are hyperaware of the presence of pain, to the extent that they cannot lead even close to a premorbid existence, furthering the extent of pain through deconditioning and weight gain.  Therapy should be directed toward achieving a balance between these two quite different responses to chronic pain.

Those patients who seem to suffer less or not at all with reported severe pain are those who accept the pain as part of their being, yet are determined to achieve the highest level of function.  This balance is a thesis of the “mindfulness” philosophy in which meditation is the tool to accept and achieve without anger and stress that typically accompanies chronic pain.  Mindfulness may well become a very important tool for pain practitioners and their patients.

Journal Club…

ImageDr. Michael J. O’Connell, PainCare Centers’ CEO/Owner announced that the monthly Journal Club meeting had two presenters, Megan Taylor, RNA, APRN and Charles Deibelbis, MD, at the meeting on Wednesday, June 25, 2013.  Daniel Grauber, MD, moderated both sessions.  The presenters are providers at PainCare’s ‘family’ of practices.

Megan Taylor presented a case recorded by Andrew J. Engel, MD, from Medicos Pain and Surgical Specialists, Chicago, Illinois concerning the “Utility of Intercostal Nerve Conventional Thermal Radiofrequency Ablations in the Injured Worker after Blunt Trauma.”  Intercostal nerve blocks have shown to offer short-term relief and when utilized for long-term pain, relief of intercostal neuralgia.  There had been no historical evidence as to the efficacy of the procedure until Dr. Engel performed a case study with six patients participating.  Ultimately, four of the six patients were pain free by their final visit.

Charles Dreibelbis, MD, gave a presentation, “Buprenorphine and Buprenorpine/Naloxone Diversion, Misuse, and Illicit Use,” and noted that opioid abuse and dependence are major medical concerns throughout the world.  The dire consequences of misuse are written about in the newspapers, seen on television, heard about on the radio, but it is a more widespread problem than in Hometown, America.  Dr. Dreibelbis went on and spoke about the extent of dependence, safe use and clinical efficacy, as well as abuse, and illicit use of Buprenorphine just one of the drugs in the opioid family.  The medical benefits and non-medical use were discussed along with the negatives that accompany it and behaviors that cause overdosing with it.  Dr. Dreibelbis addressed the novel delivery systems for Buprenorphine that could represent innovative ways to prevent diversion of the drug.

Oromandibular Dystonia (OMD)…

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Dr. Michael J. O’Connell, Barrington, New Hampshire, has suffered with his own variety of OMD for the past 4 1/2 years, following a snowboard jumping accident.  This unusual neurologic disorder can have several causes, but more often has no obvious cause at all.  It can be severe or mild, generalized or focal, or in between.

Dr. O’Connell had just mastered the skillset of doing vertical flips and during a final practice run had made sure to wait a full minute for the landing zone below the jump area to clear.  His account of the incident follows:  “No skiers or boarders were even present on the terrain park, given that it was a mid-week afternoon.  I hit the ramp with my knees gently flexed and accelerated high into the rotation of the jump, during which I briefly saw what appeared to be a skier doing a snowplow far below me in the landing zone.  I recall contacting him (or her) with a glancing blow of my board on his shoulder, but then recall nothing more until waking up with a ski patrol staff member standing over me.  The skier was gone and fine according to the patrol and I was soon on my feet, and rode off ten minutes later, slightly dizzy but OK.  As I boarded from the slope into my vacation home, I noted a slight pulling sensation over my entire lower lip.  Glancing in a mirror I saw no asymmetry of my mouth as with a stroke.  There was no numbness, but the pulling sensation remained.  I decided to leave then for my permanent home and during the two-hour trip noted some relief of the pulling by chewing food, and gum.  The following day at work, my speech was ever so slightly impaired; I found it tiring to speak at length to patients, and my speech toward the end of day was distinctly slurred.  Again there was no asymmetry or motion about my mouth or face, but the struggle to speak, which was mild but persistent, was resulting in a dyscoordination of my entire lower lip.

I self diagnosed this as oromandibular dystonia, in this case a result of a head injury with concussion.  Seeing no progression of the symptoms I verified the likely diagnosis over the phone with some neurology and physiatry friends.  Eventually, I visited a motion disorder neurology specialist in Boston, and an MRI confirmed a small scarred lesion in the putamen, an area of the brain that assists in coordination of muscle function, explaining the symptoms and lack of sensory loss.  I had been very lucky, in that the scarring likely represented a hemorrhagic infarct, and obviously could have been much more extensive.  I have tried numerous treatments including Botox injections and physical therapy, stretching and strengthening exercises, topical oils, acupuncture, chiropractic manipulation, but nothing provided relief except chewing gum or sucking on hard candy.  So I do a lot of the latter and have just learned to live with the inconvenience.”

This experience of Dr. O’Connell’s provides several lessons:

1.   Although Dr. O’Connell obviously monitored himself carefully, and survived, doctors should not risk self treatment.

2.   While the OMD has caused Dr. O’Connell to gravitate away from and eventually cease his work as a physician, he has elected to continue as administrator, and with snowboarding (albeit without major jumps), and has taken up rock climbing to maintain endurance, concentration, and upper and lower body strength.

3.   Despite wearing a helmet, Dr. O’Connell sustained a significant head injury and concussion.  What would have been the consequences had he not worn the helmet?

Dr. O’Connell noted that he was a very lucky guy on the day of that accident.  “While a definite inconvenience and career affecting problem, there surprisingly were benefits.  For one, I take nothing for granted.  I try to enjoy and be enriched by each day, and my former sense of invincibility has certainly been tempered a bit.  I am doing OK for a sixty year old.”

The journey to nationalization and socialized medicine…

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Dr. Michael J. O’Connell, Barrington, New Hampshire noted that there are many healthcare professionals, as well as lay people, who believe strongly that the federal government is the answer to this country’s healthcare problems.  This should not be surprising since when we confront catastrophies, such as invading forces in World War II and cataclysmic natural disasters, it is the organization already in place in the form of big government which seems most capable of mobilizing defense and relief.  So it is predictable that many should feel the same about healthcare.

If we assume the premise, that there is indeed a problem with healthcare…is there a flaw in this thinking?  Dr Michael J. O’Connell feels that we might learn something from Ayn Rand’s Atlas Shrugged.  “We all read this powerful novel of the stifling effects of nationalization of industry and socialization of society – the book was very entertaining, but when I read it as a freshman in high school, it seemed only a remote possibility, if even that.  Well, we are poised in this country and have already begun to take the plunge, into the nationalization of healthcare.  In my opinion, while government regulation of healthcare has proven to have salient effects in a number of areas (vaccination programs, investigations of epidemics or lethal infectious outbreaks, care of the permanently infirm, the hopelessly demented) the general trend toward more restrictions and government control over healthcare will likely have an overall suffocating effect on the system.  Even though Obamacare has not even reached its pinnacle effects, the healthcare industry is heavily impacted now, by fear of the future.  Hospitals are girding for turf battles by inefficiently gobbling up ASCs and office space, physicians are saddled with debt due to reduced reimbursements (in real dollars) and staring at the EHR requirements by Obamacare and selling their practices to various institutions or simply going out of practice (see Atlas Shrugged), pharma is retracting from research and development and have laid off half their representative workforce (ibid).  All of this for fear of the increased and impending government controls, with its multitude of intended and unintended effects.”

There are three examples I would like to describe of the effect of nationalization, of government imposing its will on a populace.

#1        In 1986, I visited East Germany by rail from Stuttgart West Germany into Berlin, and then crossed to the East through the infamous “checkpoint Charlie.”  West Berlin was a thriving historical, clean, and vibrant city.  Upon passing through the gate in the Berlin Wall, East Berlin loomed before us, gray, homogenous, police infested, with stores that sold little or nothing, all cars were same small cheap Russian vehicles that were notorious for poor quality, massive pollution and frequent breakdowns and they littered the streets.

#2        Social security disability – This program is highly abused by any measure.  We see it everyday in our practice.  Folks who have been declared by their physician to be ‘disabled,’ and yet are able to drive, to celebrate, to walk, to obtain nourishment, to talk.  Why are they on permanent disability?  How can they possibly qualify?  Are there conflicts of interest among the professionals involved?

#3        Food stamps – It is not heart warming to see our tax money at work at the grocery store check-out line.  The unhealthy foods that are purchased with these stamps is mind boggling, but not more so than the fact that most of these food stamp recipients are vastly overweight, unmarried and often several filthy children in tow.  I am usually assailed at this point by liberal defenders who point out that poverty necessitates the purchase of cheap high fat, high sugar, high caloric foods that are naturally unhealthy.  The facts are that fresh vegetables are less expensive than equal quantities of highly processed foods; albeit less tasty, they are low calorie, high in nutrients and fiber – all the necessities to grow healthy lean bodies.  How many cans of V-8 juice vs. Coke are purchased using food stamps?

Consistent with the theme of Atlas Shrugged… “each according to his ability, to each according to his need,” this country is slowly sliding toward socialism, and Obamacare is yet another nudge in that journey.”

A Brief Overview of Suboxone

By Michael O’Connell, MD, MHA

Suboxone, the trade name for sublingual buprenorphine, is used for the treatment of opioid addiction and also off label for chronic pain. Unlike methadone, a commonly used treatment for opioid addiction, Suboxone generally provides no noticeable high or state of sedation. As such, Suboxone treatment may prove to be more appropriate than methadone, as it provides far less potential for misuse. Health care professionals in many countries have noted a lower rate of relapses in patients treated with Suboxone. Some have even gone so far as to dub it a “miracle pill.” While not exactly miraculous, it is extremely useful in combination with group counseling.

Derived from the opium poppy plant, Suboxone reacts with the k-opioid receptors within that portion of the brain that is directly involved with pain, consciousness, and addiction potential. Suboxone was initially used in 1980 as an injectable analgesic, but was later discovered to possess properties that aided in withdrawal of patients from potent opioids.

In addition to its use in treating opioid addiction, Suboxone can also be prescribed “off label” for moderate to severe chronic pain. Cancer patients as well as individuals who suffer from neuropathic or musculoskeletal pain, especially those who are highly tolerant and dependent on potent opioids, may benefit greatly from this drug. Many physicians choose this medication over others due to its high safety profile, long shelf life, and often surprisingly good analgesic qualities.

About the Author:

Dr. Michael J. O’Connell of Barrington, New Hampshire, has forged a distinguished career spanning over three decades, as entrepreneur, physician, businessman, philanthropist and healthcare consultant. As former owner, administrator and CEO of a 225+ employee multi-specialty medical practice, Dr. O’Connell has dedicated his entire professional life to helping patients with family medicine and especially those experiencing chronic pain and all aspects of addiction.