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Pain Management

Joe Kim



1. Curbing the opioid epidemic: indications for therapy, initiating/terminating therapy, complying to state and federal regulations.

2. 5-minute low back pain consult: identifying red  flags, indications for conservative management, indications for costly assessment tools.

3. Review of modalities of care: Comparison of treatment modalities when conservative management fails: assessment of efficacy of physical therapy, injections, psychotherapy, and surgery. 


Joe Kim

Physician, Yakima, Washington


  • October 28, 2016
    2:00 PM
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Good afternoon. First talk after lunch to see how this goes I see hook a as I would a prayer. Our Father in heaven. We are just so compelled to look deeper into what you've given us as scientific research just confirms continuously over and over again what you've told us we're grateful for all that we have a perspective that's heavenly and we do do not want to become complacent but we want to use your blessing as we search out how we ought to serve you in this world we ask your blessing and for attention for the gift of communication that. I know the Lord your Holy Spirit the best communicator we do ask for your presence here as we discuss this topic we ask him a Jesus a man. A magical Oh you know you got the both spectrums you hear the pill mills before you know him just stacks of prescriptions one one for one claim just close down locally in Seattle area of our guest a couple hours away where he the TELL ME HAVE LIKE button eight clinics and I forgot how many deaths twenty thirty deaths in the clinic and. Multiple prescribers and never seen a patient repeat notes and whatever else. He got the pill mills on the other side you have this reputation of dismissal jockeys that needle jockeys you know the ones that one doesn't act everyone in sight. You know teacher down with and they don't you know this is going to fix you. I want to admit I am a international pain specialist and I will tell you right off the bat. I have never once cured someone with a needle. I just wanted it as humbly admit it and it's up challenging topic to the ten challenging. Field but I love it. First Very says the reasons. I got the problem is the one exception how I feel somewhat the needle and that epidural blood Pat. After I punctured a hole in their spine. Then you touch it with blood that things work pretty well but everything else I'll tell patients. I can't heal you. I need. Your help I can give some relief for the duration of time but it's almost meaningless unless you're motivated to make some changes in your life and it's absolutely true. The research is continued support that just a clarification sake. If you had looked at the objectives of darkness. Number three I kind of dropped from my objectives. Because I am not going to be able to cover in any meaningful. Expansive way and so forgive me I will show some slides talking about different modellers he's in their role in pain management specifically we're going to have a back pain of not covering enough where I feel that it's a covered objective and so the first object about curbing the opioid epidemic and then the five minute back pain console is what we're going to cover today and I again with time permitting will cover some up I'm sure all of you have either participated in or told your patients about or your uncle tried this and it worked and invariably when I finish these talks and I do a lot of these talks invariably someone will approach me and you guys are health professionals are related to some degree health professional fields. Aha someone asked me I have to have you tried this and have you read this on and have you put this on your face before and I probably haven't and I I don't know much about it. Whatever you're talking. I just haven't tried it. There are a few I mentioned today. I have the same goal access that you do for some one piece therapies. And I try to cover in some in the glancing way how I approached those therapy sort of speak but as as a rule when you look at for instance everyone. You're prime at somebody who got back pain and looked up online natural pain remedy. And I just want to give a little bit of advice though. After you read about thirty forty fifty sixty of those sites. They actually copy each other. And they copy each other resources too and you got understand that it is all let's try this cloud that clar this you know. Herb or that or I basically have a you might judge. Before this pipe is like we have a Tylenol rule. You know if it's safer than time I works as good or better if I have some reasonable use to it if it doesn't. Use it. Your own restore to speak but will cover some of those in a minute but again I want to honestly tell it out there. I don't mind questions about them. I just have as much information as you do a lot of these things. There are some exceptions though. So I love this passage from the health reform are July first eight hundred sixty eight all references you can email me about him. Joe five four at yahoo dot com I didn't put it up to not to clutter the slides though. I love this passage and I took excerpts so much was actually talking to invalid women who were having pain. And that should have outdoor exercise a part of the prescription for every such patient should be light physical labor pleasant employment out of doors. Let this class of suffer as I know is very small that we clearly let this class of sufferers have pleasant employment out of doors suited to their several conditions. Both the nature work and the time they should be engaged in it in the words patient specific and studies showing that individualized care obviously getting more advanced results. Many of that are very feeble can walk if they only think so. I love that passes because we're learning today that just physical modalities are working as well as mental model it is combined We're learning all that even in primary care fields you know that you've heard a lot of this and we're going to talk about some of them today. So you hadn't said it over a hundred years ago many of that are feeble can walk if they only think so. So soon. If get a suitable exercise program and we need to change the way people think is what she's basically trying to say I love this passage. They have not the disposition and you will hear them plea. Oh I cannot walk at this. I cannot walk it put me out of breath I have pain in my side pain in my back. Try to exercise moderately I first have rules that govern you. This is what I mean quotations. Walk. Yes walk if you possibly can walk. Try to shore. Does that first you think what would that walking isn't possible you will no doubt. Become weary your side may take your back. If you go back may give you pain but this should not frighten you. I think Ellen would have been an excellent pain manager for the obvious that the doctors walk you can think of and do it you know less that you get them a pass the and most people. I'll be honest with you. Nothing works as well as something in studies show us you know get to some more detail later to get past that acute episode but they keep coming back and study the same way whether you inject them fuse them manipulate them pinch them bruise them whatever else rub up something on them. That physical modalities are changing their behaviors as part of the equation and more and more we have to change the way they think in other to overcome chronic issues the acute pain the people that are motivated they're going to get better or most do. The beginning my talk is on opioids. And you know I spent so much time in the office there were thirty minute busy tell to spend twenty minutes of the time talking about opioids pain killers. And I end it with a patient listen we spent so much time on this you going to think that this is the only thing we have to offer and we spend so much time on it because it's such a complicated issue. How much when to start when to stop you know and I always tell the people listen if we're going to start this. And we get into more detail how we start you understand this is not the most important thing we're talking about today we just spend a lot of time talking about it because so complicated and challenging in regards achievement. So new thoughts new behaviors. I do recognize the prime most here probably statistically don't have conic opioid patients or if they do. That's not the major part of their practice. But please keep in mind this is what the epidemic that we have in this country. If you have any kind of clinic at all that these patients. You have patients that are chronicled your therapy you do. And if you do. Then even if you don't write them. If you're out responses I can write to opioids I guarantee you a chronic pain patients will find a solution. They'll go somewhere to find someone to get the pain or to control and some you cannot save I do recognize that but we're missing a vast part of the population. Just saying I don't opioids go to the doctor danced down the street. I think he does. And so your patient may be on opioids and you don't write them your guilt free aren't you. But keep it keep in mind there. If they drink alcohol smoke tobacco. If they are obese. If with the rest of the problems using it. They're on benzodiazepines TCAS you've got out of their elderly their renal and have had a conscious distinction. You've got to recognise they're still your patient we don't pick partial patients and have them quarter's you know go to that doctor he has lots of meds that you'll be real happy with him you know at least a working knowledge is going to be helpful in curbing this issue though opiate up and down that President Obama made a statement about this in the last summer in the spring and the C.D.C. made a statement which I have some strong reservations about but it's a it's a step in the trying to stop us. If you don't I. Up next couple slides on talk about how many of your friends with back and how many of you know someone who has started yoga or mindfulness for their back pain. Maybe if you start talking to friends. I suppose ninety percent of hands of go of you to all you do you do yoga hot yoga so I thought. I wanted to get the details about yoga or mindfulness. I fist found out of pay for health care provider we work very closely in our clinic. She's teaching our patients mindfulness and I've been talking about clinicians like Hey let's talk about this. What are we using and what indication we're using this for but real quickly yoga hint the Hindu Buddhism Jainism background maybe five hundred B.C. ultimate goal is freedom about having self realization of self-knowledge. There's actually strong evidence about short term and moderate evidence about long term back control pay control back pain with yoga. This is from the British journal journal of medicine British generals by Sports Medicine excuse me. Mindfulness. Is the meditative quality where you're sort of how do you put it come to a self realisation of where you were at in this. And your feelings and thoughts and then a non judgment to wait. Be aware of them you know and to control pain and study the show in the meditation involved in Dodge's opioid pathways the introducer to the more modern mindfulness is John Zen in the seventies and even though most practitioners say well mindfulness has been has been the deal religion eyes we don't really teach the eastern medicine part of it. How do you really do that when you have all the forms of what you know that eastern religion if you think about it. How do you just assume it's like I haven't to go to church. Let's pray to give off an assassin music is there a sermon but that's the religion eyes that Adventism you know is just do all the forms F. I have a hard time differentiating and I'll be honest with you. People will seek after treatment if you don't provide treatment. I'm not saying we can save all because chronic pain is that it's a Pandora's Box and you open that you've had that one patient right. That took up your whole afternoon but it's still trying the other patients that they keep giving poem calls and messages and nurses. So I'm so sorry Dr can I just have one more question the back in the front desk and screaming and yelling you know it had that patient and this is the challenge on the field and I can see why it be so easy. I can't write this stuff you know it's too complicated. It's too much of a burden and risk and I hear a lot of patients come in my office say my primary care plan my opioids get the so they can be arrested or lose their license that what I can't blame them. I'll be honest if you for them. Hearing that because it's so much scrutiny. So looking at all why it's statements about morphine in general majority of statements will say and this is not all the drugs they miss the morphine and again it's all references just you can email me how to do with you know we don't want to do these habit forming things that create appetite for more does basement falling further and further and further. She also tends to mention several times that drug use in general. It'll cause us to avoid to the game to the root of the problem that's what I want to talk about today actually get into the whole thing. Some of the problems we have a chance of a talk today is that opioid manager her concerns one of the concerns she had was to avoid getting to the root of what's causing the patient's pain. And digging deeper. I do use alternative therapies a person I've never recommended mindfulness to a patient my do use I for what I feel are all alternative methods of therapy. But in the end I want you as a clinician what I'm really trying to think what's getting to the bottom of this in terms of what the causes patients pain it is sometimes it can be challenging and sometimes nearly impossible case this is simply speaking. So twenty percent of visits of non-cancer pain. Receive opioids another was one of five patients come in the office they don't have cancer. I have pain. Hopefully not your office are getting pains corruption's partitions as they walk out. That's two hundred fifty nine million scripts written in two thousand and twelve. I think that number is still going up. That's enough for one prescription for every American adult a year. And National Health interviews society. Eleven point two percent of adults have daily pain. So we're losing the battle to them or more people being disabled having pain and all the same talking all this who is saying stop using opioids and what the primary care providers has to do is get yelled at you know or fear losing their license. So the data we have so far less than twelve weeks of pain the data is actually pretty good then. If you've I never gave birth to my baby to babysit for but my wife's in there. I told the doctor give the epidural you know just give it you know I mean that. I didn't. It's a personal choice of yours and not people go to. Natural birth or whatever but there are situations in which probably opiate out is superior than just biting a stick or whatever else you know and you have to choose for yourself on the occasions occur but good data proof action in the short term chronic therapy. We really don't have very good data we know that we don't have good data three to four percent of the American population is on conical pure therapy or have been recently on Chronicle there. Nothing about this or three to four percent of the American population American adult population. So from up roughly ten million people right. Let's say nine out of ten people of those are just seekers of abusers or so. There is a whatever Also the saying if you're really odd how does my psych you know these guys just get drugs off of me. You know ten million. That's a nine out of ten are in your office along purposes. I still got a million patients that should have genuine pain concerns and if they found a better off. I'm talking one out of ten here that found better options. They're willing to buy. What entity what church has better resource the cheap people to think differently and act differently than our seventy seven a stretch. We have that let's say is a million. That's about as many people that have been diagnosed with rheumatoid arthritis in the United States one point three million I think it's losses that I saw and so that's a large population level that you can jump on they're open they're ready for change. They're ready to have decisions that are going to be life changing what appeal me. And again most of it is going to put your hands in the air and the I can't believe I just had the second afternoon is going to be frustrating and almost pounded to the ground in terms of discouraging but there's a large population that are ready to change. That's what kind of got me into the field sort of speak is a little bit of. Thirty seconds if you allow me. I was doing my rotations as a training and there was attending a look at Columbia University and he was one of the world renowned and a concert surgeon he invented you know minimal basic direct to me he got melanoma and he was going to die and he happen to be on my rotation that I was taking care of him. And you know this rolled around surgeon brash and we're talking medical students or what not. When he's facing life and death and chronic pain. They talk to you as a person. Just the comedy nominator they know that their lives are ending. They talk as a person ahead of the cancer patient could wreck accounts of cannot roll onto his backside to the pain I said we let me do something on a burn something you're not going to walk afterwards or walk right in his I don't care I'm not going to have more a few months so I took an alcoholic and local anesthetic to measure how much alcohol I do use and put them up local anesthetic in there. I mean as a test and then I put up all of them. This is pretty aggressive stuff you know but. No burn them as they say could say Curly and rolled up his backside like. The relief. Then I said Well at this point. I come in the room with. Whose quality he's going to give me your next section of your study. I mean that's actually a treatment he's our Bible worker locally. Oh sure. Granted I've nothing else to do right now anyway. You know he took on his Bible studies on to his death and those. You know those for those in middle are few and far between the not every single patient I want to make changes in our lives. But these are patients that need to do desperate things and the bad things ADESA things in the right things. OK so a leading cause of accidental death in the US two thousand and fourteen one hundred thousand. For prescriptions ten thousand heroin. Get this rest of slide just for sake of time. So what we know there are no studies that prove benefit greater than a year to the functional pain scores in regards to conical purity management you want to know that you can actually say this with confidence that look in a patient in the eye say listen there's no studies the on a year about this improving your quality of life. Risk do increase with those that's obvious. It seems like twenty milligrams morphine equivalent dish fifty milligrams is seems like when the risks are to take on that heavy focus that what I'm looking for that. Exponential rate you know twenty fifty one hundred you know when you get to the threshold and I get to fifty I caught a column my personal time I'll say what are we doing here. You know. I'm sure take it that this off screening tools are difficult to use we have a go. R T So our brief brief risk him a toy. We still know how to use and that is a very weak in regards to here's a soap test let me see it in all your high risk or low risk they just haven't shown great correlation with treatment. There have been good. Actually there have been good studies and I get it just not to clutter up the screen and are successful therapy. To different degrees exercise their Peacocke to behavioral therapy. Now as opposed to mindfulness What is the difference being content conative behavior therapy and mindfulness does anyone know. Yes. It doesn't. It's very good summary I summarize a condo behavioral is a change of thoughts to create change in your activities you know its truth based sort of speak. Oh this lady didn't meet me for lunch. You must hate me. You know change your thoughts about what you think about that change or add to it into the how you respond to it. Con to its truth base with the truth about this instead of imagining everything. Mindfulness is again that self meditation what's in your heart what you feel. Nano be thought pharmacology. Will get into some studies about that should be effective intervention therapy that's my field. So we do have actually high quality evidence about Pip in the office our thought is that exercise therapy actually helps. I'm going to may not have time to illustrate a study later so I'll just talked about it now since I started three minutes late. I'm going to skip it later. They have the study in the medicine and science in sports and exercise never heard a journal. If I saw this article. So basically had a very small study twenty four patients and they've had a lot of studies about people who exercise for acute pain and get better relief but they didn't really have any goods and they had studies about chronic pain for athletes but didn't really have exercise for non-athletes and that's what they got non-athletes twenty five individual twenty four individuals a very small study. Or basically for six weeks they would. Exercise a seventy percent of the max which is a mop maximum exercise ability and three times a week and they brought them back with a basically how they did the study was in two ways One is they did the pressure monitors whether they felt the pain as they were pressurizing their arm another way they were holding onto a some kind of. Pressure caliper or some kind of pressure monitor as well and they had a sling monitor on their arm and they kind of inflated up to two hundred. And the person would hold as long as they could the had to release. And this is for chronic pain people exercise and it's a kind of unique study came out two thousand fourteen. Then you do more research. But what if I'm missing was this. They didn't find any difference in terms the exercise. I mean the pain threshold. In other words both groups are feeling the pain at the same times but they found a higher level of pain tolerance with those exercised and so basically they put up with the pain better if they were getting the body more fit sort of speak and these are people who didn't exercise. So what I tell patients you see this man pushing a rock up and down the hill. If they have acute pain I basically am going to say I'm going to inject you. Is not going to cure it. And I'll be honest with you if you're walking and doing everything else your par get better. Anyway look most likely looking at M.R.I. or looking at a physical exam was I say that for acute pain for the chronic pain patients I do actually tell them as I said listen. I'm going to do an injection. I may need to do one two three. There's no magic number three by the way of epidurals before and since I might end up doing one two or three injections. You'll be the same exact person that it three six months so that if we are lucky and fortunate you've had pain for ten years. If I give you a three to six month window where you having a little bit more pain relief. You have to get to work you need to do some late years or exercising or else you be in the same exact boat that you had more steroids in your body. Do you agree to this you know and I actually put in those terms of the under no notion of that becoming a thing as neurosurgeon came me sent me here to get some epidural to fix this back pain. I always tell them. Sam thinks that this won't fix you. You have a lot of work to do I. We had to get to work now of course we have the palliative care patients that are another group now into the opioids we have no information about. I mean no good studies about low back pain headaches and fibromyalgia and they would have a patient in the clinic. Bless your heart you know we it's a tough challenge to disease treat and manage always hung colleagues and talking discussing care anyway that's about the Iraq question the rocket. I'll get you gone but you have to kind of get it on the way on the other side they're OK this is my own pneumonic so to speak. So they come and ask for medications. It doesn't always have the medications in western medicine that are basically five methods. There's much more options obviously but major methods that are covered by insurance is it reasonable accessible. You know that's what I mean by five methods of pain management psychotherapy rehab injection surgery medications. When they come in. Ask your medications always go through a list. Have they gone through assessment is a psychological assessment of the kind of C P T PA feed or whatever else have they gone to rehab and injections would be possible other surgical candidates and of course have a discussion of medications and so mentally always always always at the they go straight to the end but you have several right car to the asshole meds OK The patient is medications. Please keep in mind of again there's many many many more medications but which are easily accessible covered by insurance is and whatever else anti-inflammatories antidepressants membrane stabilize muscle relaxers opiates. Now it's true as I found towards muscle relaxer I can say for short term treatments they'd long term treatment are very good studies or are very good for long term usage to depress memory stabilize the other end of the spectrum the people need to recognize the need to be in this for the long term and explain that to them. I want to spend plenty of time for the back pain cons I find I know some of you are here for just of that and hope yours might put you to sleep but this is what we're met with in regards to your what's expected of us and so I try reversing hit the highlights. So you need to be able to tell them to like it more likely harm you. If you're on higher doses if you're currently on Baen's that has a pain sleep disorders Paddick renal failure if you're elderly if you're pregnant. Obviously mental health issues a history of substance abuse most recommendation by state boards they have to have a history of substance abuse they need to be screened prior to initiating Chronicle pure therapy or if they already are on it. The recommendation is that should get assessment as soon as possible mental health provider if locally available in other words it is OK An illegitimate say listen I have history suicide is five years ago but it was on opioids. I need to do the screen part to use done every good ground I'll be. You might get a really upset patient but you do stand on good ground. So this is the key. That a goal review it frequently if you're on opioids don't just say it was a pain six. OK here's your Majesty an X. next month. You know set X. this size school. How much are you walking. Are you keeping your job. Are you losing weight. You know and he starts to set a goal about their lives and they achieve it always tell him this is always on a child trial basis never let this the thought come in the mind this is permanent and tell them this is the way we're going to just continue when we accomplish that goal or if we fail that goal set a goal accomplish or fail but one of the other mothers with a time period on this almost like it's a race and not just a journey for the rest of our lives discussed or is this obvious if anyone wants us to send our own wrist discussion up be happy to email of a form that you can use that we use that our clinic. OK So just to skip time that you can you know what the risks of opioid therapy. OK so what I'm discussing when they come in you put them on your opiates whatever else. What that does a tough there's a come in and they're asking. I'm in terrible pain still or whatever else. Or maybe they have a five out of ten what that means is that kind of moderate pain I get more and I'm like good base you're all your discussions whether it's injections with a name or for P.T. with a new medication change whatever outcome function sassed them how you sleep and I exercise the same thing base your decision making. I always base my decision making might not always but for the most part base my decision making about my injections based on the level of functionality that is that couple to use that normal life for use Yeah it's OK even if they point at the top ten pain to keep at it. Keep up the good work. You know eight out ten pain but that they're dealing with that they're functional I asked a question you're walking where you're already a bookkeeper job taking care of kids or you wash your dishes. As I have piles of laundry pile up in the house you know. OK so the only state this is the purpose of monitoring program we have in Washington. Here is called secure access Washington and have. Passed their own secured petition monitor program. Who here is has applied or has purchased a monitoring program privileges anyone in this room here. It's kind of standard of care. Now it's not illegal not to write it's kind of standard care more so because past decade only Missouri is the only state that doesn't have prescription monitoring program. And they were just shot down recently ironically by a by a physician who was a politician as well. Drug screens. OK By the way every month is kind of every bit as difficult times we do it ever is because we have ancillary stuff that doesn't force while staff to handle this. But people say every three months is no contract exact consensus at least every year is what the recommendations are from experts. Check multiple prescriber So basically have the sheets as where they fill the prescription who wrote it. How much insulin a day. It's really handy. It's been a it's been a game changer for sure with opioid this drug screens and so at least yearly two to three times a moderate risk in three to four times a severe risk per year. I think is a reasonable and when I read that in the C.D.C. report I would agree. Now with the modern of severe there's a lot of ways to kind of sort them out. You know that's the kind of the gray area. Think of the keys to your car. OK. And think of low risk as someone you would you know here in Palm Springs know how to go out to Safeway to go buy some groceries as the lower station here Mikey's you know go get the milk and they go run off get some milk you know they have a driver's license of the pie result person you are your kids and you get the milk at Safeway and buy the not to stress out about it right. That's my low risk. Think about moderate risk as your teenager. Who doesn't have a driver's license yet you see in the drive around the neighborhood a couple times a pretty responsible they you know they haven't gotten any real big trouble yet. That's why moderates like it. Teenager walk to see you there pretty good driver. Purrs possible for somebody like what you asked your mom if you will and go with you to do this you know this moderate risk of severe. Asking an elementary school or toddler putting the keys in their hands they go get the milk you know you know your gut tells you sort of thing that's actually pretty accurate as opioid there's a lot of tests and screening actually to specify this and again I mentioned some tests but they are hard to use but in regards to your gut that look at Personally I would you lend them your car. And you know what how they look like to use or see how many drug screens that they filled out kind of give you just the where you want to be sort of speak roughly. I'm going to kind of skip this you. Sixty milligrams is your morphine is when they want to put your people recommend putting on the time release medications or thirty milligrams of oxy code roughly speaking as when they talk to me on the patches or. Oxycontin whatever else. If you're an internist are hospitalised post-operative I would encourage you probably if the most struggling in pain you want to start a long acting medication that is pumping away at their breakthrough pain medications and you can refer to pain soon which I would advise probably against chance and all because as you put it on. You bought that for a week some nurses are good at valuing assessing retarded titrate I guess you know so that's part and part my last I suspend all is that inpatient it's a hard quick titration whereas your Oxycontin more things a little more brisk sort of speak good might abuse deterrent does not mean up use prevention. They had what city was that they had just a quick image Tory of addicts come into the suboxone clinic and they asked if I saw a are still abusing up Oxycontin and a third them said they were is after from two thousand ten to twelve it lowered the use ox converts kind of stable off in other words they're finding ways to cook the awkward Cotton still use it. They have the bees to turn to make it like a call. The way you know or jelly in the Matrix and they still have ways in that they always a step ahead. If you really need it. You're get it. And so there's a team of there's no say if those sort of speak and discover that someone's going to skip some to the back pain. I recommend not changing after four five half lives. Because the next dose and what not. Most are two to four hours is sort of speak Keep in mind that now has a half life of sixteen twenty four hours. Of people north and that's half life of the that part of writer Brian group an orphan. Thirty six seventy two hours sometimes methadone for eight to fifty nine hours so these are hard medicines the type to quickly. I tried not to morphine on the there is alas they work for me I try not to change methadone but on the Thursday by the way I want to see them closely be aware and available. Keep in mind heroin is a few minutes have any of you ever seen heroin in the urine screen before Prime not because ten minute Half-Life if you see heroin in the urine clinic. They might have taken it in the waiting room. You know you might not use the six man monosyllabic morphine in the clinic it has a fast half light. If you see more feen in here and screen not being written. I want to see a terrier on but it's terrible and you know if you see the spot. You're unscreened more for your good morphine I look at pain pills no morphine. It's heroin just you know it's not heroin but keep that in back your mind you know it's. I never see her in the urine hardly ever maybe once in my career as in heroin. OK So there's a. So this is what these two centers are important. I can isolate them. You can look a patient in the eye and says with confidence overall in confidence. Now there is now an established body of scientific evidence that this won't help you. It's overwhelming evidence actually to. This is touchy because people get fired. You know and patients get fired C.D.C. state boards no one ever says Fire patients you hardly ever see any state recommendation a fire patient. They always say offer a tapering plan you're kind of liable. Now I do understand the situations in which used they pop to your door they have medication that may not be case but if you have a relationship with them sort of speaking as care because I see a P. and P.. Multiple doctors you see someone else you're Khana liable you have to at least offer or there's addiction training or are tapering plans. Or not quite off topic anymore as they would see later they can have some legal around for cases one when I review charts I'd I've done a lot of expert assessment charts and whatever else the worst charts I've seen are the ones that are just fifteen pages for every clinic visit but they just copy and paste copy paste obvious on the heavier singles charts and the review charts apart every single page of the same and to get a chart like two hundred picket pages and it's the same no every single one. You look at there is one in the world is the pain I filled me with no after reading all this you know copied everything every seen that chart that let the tech and you'll get nailed for those contracts. You have to have a chart that actually says he had discussion with them that mean so much. One couple she's like that more than one hundred cheat sheet in other words even if you continue saying stuff like oh this person walking their dog. Now you know and by the way he he got a job at Safeway is that he's that or he's a clerk there stuff like that means so much more to an expert than if you just say patient had no complains of pain no sedation Pride's constipation. You feel medication those look terrible and expert witnesses in terms accidental death overdose and what not. Adding things like you just got a puppy and you grooming him now is that I mean so much an expert witness in the reading your notes. Keep in mind that majority of initial kit episodes resolve but two three percent will go on to conduct pain I'm going to skip the rest of slide there. A Keep pain. We're going to talk about the back pain here in just a minute. Again I add a slide I know wasn't talked about for those at one of the whole presentation. I am going to really try my best to stick within the restrictions of the time restrictions today. So returned as I am going to skip It's kind of self-explanatory for a look at the chart itself. Most They don't say. Don't go more than three months without seeing them that's really on the edge if you have conical period there. And skip that one as well. Our hospital house of a in agreement with our clinic where they will formulate Mela Markand are no locks on and so they can pick it up and we don't. Some people who recommend everyone should be on our policy in our clinic is that people over one hundred milligrams of morphine daily should have that available in the house to use and when I remind patients that the half life is like an hour or so you know and so your opioids are going to last longer than that. So family if you don't call nine one one you may have to read those into the three minutes sprayed each nose one time. Every two or three minutes at a patient had a pump replaced by a provider in our office and they missed the pump those pain pumps you know they put all the morphine inside that doll and so she went to the hospital and and then she went to the store just pick up her medications you know and start passing out or for the my what my doc my wife's passing out you know if they get her to the E.R. And sure enough you know entered into pickle medication while placing the dollar Paddy and sewed Pushkarna in our can drip tapering. Getting ten percent ish is probably the most you will do if there are really huge doses you can go faster if it's not in a year and you don't have to taper them. OK they're not taking it just why if I keep that in mind and they may need psychosocial support these are great links. Interagency guidelines prescribe opioids and I got to read a fast. If you want the actual presentation I email it to you have Kindle Fire for at yahoo dot com By the way C.D.C. guidelines for prescribe opioid two thousand and sixteen and the model policy. Now the bottom of the model policy used to opioids most states will copy that and use it as their model policy so that's part of most common one is up to two thousand and thirteen. They're long but you don't read the whole thing but you can use them as guidelines for your practice. So I'm going to back pain consol OK so. I do want to chance cover this. I tell you if we can plan as a systemic I've been scratching my head about this too. How do we get this remember the bills million patients I'll tell you about you know those two to three percent of the adult population that. Be a therapy which is eight ten million people even one out of ten were sincere true pain chronic pain people how do we get them how do we as I have this message change and change in thought process change in activity people who are searching for something better. How do I bring them in. And so I think all this should be so when I'm going to save everyone regardless fixing the back pain. But there are people that just want something better and our message is so appealing to what they're needing actually. So restructures or back pain age of course mail. Family history lack of exercise obesity psychological history. Menopause osteoporosis. Now caffeine there's a there's a hoppin study. The service where I trained at and. I still touchy and I tell patients that stop your caffeine for your back pain it's primal caffeine withdrawal that are caught in their back pain. I don't know of any great studies about direct link of back pain and caffeine there's some poor evidence but I just tell me anyway just start by the add that into the patient I talk to. Now this is a study that says that people who have severe back pain people who are tobacco users now there is good evidence about tobacco use heavy lifting machine tools now moderate back pain. Specifically the activity is people that are jogger specific across country skiers they found in the study of. You know I journal bone and joint surgery higher risk of moderate levels of back pain that's your friend and my friend. What can go wrong. Now some attorneys you know sponsor low list these not spondylosis generically if you really have EVER them are spondylosis generically means spine degeneration those specifically some people were for to us as officer in the spine both are probably correct of spondylosis spondylitis they have the fractures in your pars and into articular. And spawn a lot of this piece this is when you have the sliding is actually one of the last few real indications or Medicare will pay for spinal fusion these day and ages so everyone gets flexion extension films from the surgeon before they. Because they need that. Confirmation for most. Fusion surgery unless of some Katic going on or whatever when mom. Or some medical merge to say OK so don't sit on these cancer unexplained weight loss in a minute suppression other words we'll see in a month see how it goes the can't. Immunosuppression steroids I.V. drug use U.T.I. as this year increase with rest. Pain fevers trauma bowel battering Konitz I don't think you would. Anyway or urinary retention physical red flag saddle and a C. just think you're tone loss major motor weakness fevers and for table tennis that is actually good studies but it has to be done right you know no one can hurt the back to push hard enough in the virtual But I mean this one is processes so assassin when the patient comes in office. I have back pain usually labs are not indicate unless you're concerned about tumor and infection. You do not need it for acute pain though. Radiology actually is not recommended unless they're above fifty. I would like to add probably a lesser younger to eighteen or younger as well which radiology might have a role concern of compression fracture the elderly with a fall and off and that two months they're still not sure evidence is makes it unless they have a ridiculous with involving a pain whether or not X. rays will change or outcome but after two months i Pod would at the interventions i Pod would get extra screening. Advanced imaging by all means right in the beginning if there are signs of infection caught it canna cancer with core compression or potential candidates for surgery or injections. Now I put really small on purpose. These screeners. This is the PH to nine Has anyone ever heard of the PH to dying a Ph. Do you foresee for getting a charge if you have any patients on pain medicine just so I know it's extra work and we're adding a lot of things I have to tell every patient at B.M.I. Now my office I have no idea why they have no idea why sometimes I have to for meaningful use you know have you had B.M.I. to your chart no student not. And so but we have we had the PH Q. screener and that's a G.. That there are two reason why I kind of blurted out is this you may not know how to score it over reporter or use it all I can say is that you get to have a disk looking real quickly and they have a bunch of those then send him somewhere. We're talking about you know I'm saying over to the rights they pump a lot of the lower half of those look at a little careful it's a quick bang you know many of the ad just look at it will quickly. It's actually a good way to lead into competition about depression and anxiety. That's a piece by the way. OK studies show that opioids over the first few days of acute pain do not return to full activity any faster than people that are at combination and said and Tylenol this is a twenty milligram dose I profile in five milligram the Tylenol no studies show keep pain return to full activity. So used to show that muscle X. the probably better placebo early on. That's why I told you and said muscle relaxers early on Condit muscle asons I know many people are on them. I just can't justify very much. Probably equal to and said and anyone ever given those packs of pain back pain fast. You don't have to admit it. Yeah I have but I would have figured those tackle back pain will. If you practice long enough you have to probably will eventually but there's no evidence and they'd actually discourage against it. That one does one of those things like how do you know the packs are cold dry air. You just kind of don't say it but people do it you know I don't like the fact that a primary care provider binder saying. OK so how do you treat it. Nothing we were told earlier to keep back pain sixty seventy percent probably get better over next six to nine months with doing absolutely nothing. These are evidence based studies showing good can P.T. posture car parking must stop massage acupuncture and Jackson's terms of treatment. But again I tell the patients you prying it better on your own. You know I want to have to function over the next few months we're going to do to do that all telepaths will quickly I do spend a lot of time with posture with my patients. So you know. Feet shoulder with the part you know and chin about. Level two like a window eye level you look out the window look at Sun or something. Shoulders back and down and I tell him to Dr Matic breathing where your breathing with the diaphragm going to come up out and breathing in person. This Out. You see that right. Right. I told a couple minutes a day times a day is that a time. Don't do so fast that you're passing out. I told you for about a month or two and reason being is yes. It reduces things I didn't stress I tell them you can't breathe right. Unless you're in the crockpot you can't be like. You know it's Or it's at least a lot harder just so you know they're going to straighten themselves out and after a while I tell patients if you get used to breathing correctly you can do most your activity hopefully in life in the correct posture and it's about doing activities whether shoveling walking sitting or taking notes here. People have the posture because I want to breathe right and I tell patients. You can be sitting slumped over and almost and realize you're not breathing and like. And instead do that when you're lifting when you're walking you want to posture. To improve your back pain. OK We have good evidence for modern efficacy about C.B.C. exercise spine manipulation into display we had them use rehab with conative. Focus too and firm is less effective as a medium for and I was hoping to get a nice For mattress and a low pillow top on top. What position do I sleep in people will ask me honestly what are feels best but typically pull if they heard pillows The beneath your knees or if you're side sleep or between your knees and having the top any kind of crossed over like that. Cold interesting. Thirds are very good about cold therapy the one incident of my do tell patients they use cold as initially right when they have that trauma you know you look at sprained ankle it's at least bring your bag back. But there is a pretty poor. Actually the only real mode that the put on your back modality that's pretty good evidence is heat. And so if there's no evidence of trauma on the put on the heat first. It's not sleep over at night obviously but if there is evidence of the first day I do at Aston to apply the cold after the first day or two. You should just tell the patient whatever feels better fifteen minutes at a time every hour. If you need to but this. Don't bear it on regards the cold showing any better improvement long term. OK so. Challenge study about modalities of care especially those that you plug in and apply. And this is actually surprising his results are basically ultrasound or a lot of the other things that are used to apply to us or to speak evidence is lacking of any benefit and this is the surprise of studies that tends in actually there was good evidence of lack of benefit. You know surprising actually collide. I put on a ten zero myself and I back and it feels great. Actually I'll be honest with you. You know but there's actually good evidence of lack of benefits and no minute. Now listen. I've let's be realistic here. I just epic I do. Epidurals very unjust I've done thousands in my career and I know the statistics about epidurals their index or spinal stenosis I even go in and tell the patients. Listen spies are terrible. That this is going to help me at a hall you realize that right. So what we're going to do is this because you've tried everything I really really don't want to start on painkillers and you don't want to either are they've expressed that to me said this. We're just going to open up hopefully a six month window. Hopefully at best but for the cold months but you better really work your tail off in that time period because you're going to the same person with tears in your body not you know that the first one doesn't work out. Tell him I really don't think the second is going to be much different. Second it doesn't work to say eighty nine percent with zero relief from the second will get there only from the third and so I tell patients that I say listen I'm going to contract with you. We do this what our goals are about this because I know in the back of my spinal stenosis a terrible indication for epidurals there for most cases for us and gnosis. Anyway studies show that moderate evidence of heat wraps short term reduction of a Q. and A subacute back pain is better with exercise and there's insufficient evidence about Cole. This is a study about the exercise and tolerance with non-athletes. Exorcised Now the study says they had to reverse up early on you. Any one of her if as I just heard of Mackenzie exercises and what not. Previously thought is that borne out that for acute pain Mackenzie exercise may be helpful. At this point we don't know of any specific exercise for acute back pain other than just walking and getting back to normal function I mean there's actually a really good studies about getting back to normal function. Terms of getting over that acute phase that Mackenzie Williams of that flexion type exercise that people do stretching know better than just getting back to normal function I don't talk a lot about exercise with the patient is up in the sheets on you more than. My Tom do at the physiatrist and master it but not just getting a sheen going on then you know the some that could be beneficial. I talk about are you doing your dishes what posture to hire dishes up in your cabinets at home you know are you doing your laundry or walking your dog in taking out your garbage and whatever else and that helps to get a good sense of where reacting to the treatment. This poor evidence of an exercise which one is better. I think this there is a low bar out there par are we just kind of that this one is it's a infancy about which are best. So why tell the patient this is actually mine also important line that I have for you today. X. and it has no words. I tell patients I say listen I need to get you walking rigorously believe the heartbeat twenty thirty minutes a day three to five times a week we've all heard a number similar to that and I said listen if you can't walk you need to get on at the core by twenty there Mr if I was away because something's been that that you can get a look at on a bike. You need to get into a pool. You know just like oh my that passes I'd mentioned earlier in again till pull against gravity to start doing this deal if you can you know with up without gravity not against gravity. You can do that just on the ball try to balance you know do you know sit up straight erect and try to keep a good positive breathing exercises but I'm trying to say is get them at the level of their out and get them up to a point which hopefully can start and relating. Find their functional level and get them moving fine. Everyone has something so gross. I have no legs Dr can't get actually size table I just are doing your arms and you know I'm saying Find them up functional level and move move forward from there. Now this next lie is somewhat important to. If I had to rank the slide importance of the fact passable is one this want to be number two what I usually do is honestly you hear people doing strength exercise and flexibility or whatever else do yoga Dokic introduce stretching I saw these instructions on the. I basically will tell them if you can walk twenty therapists down flat surfaces and you've got enough on your plate in regards to strengthening and flexibility if they can do that easily easily without discomfort and severe pain in doing or at recovery pain taking more than a day afterwards. Then do your steps for strengthening or resistance or incline or some like that but you can do on a flat surface with good shoes on grass. Then your strength thing may not do as well and you're going to be more inclined to use the wrong posture to deal with things that compensate you now and then you can acquire yourself. And so if you can move up strengthening incline steps resistance by that if you can do strength thing well then you can move and or even mild weights on your hands and receiving to strength thing well then you can try move over to flexibility I always tell people do flexibility exercises with the profession or someone who's trained. I never given handouts the start of the steel in that deal unless they're virtually just in reasonable good shape. What not but that there can be some bad things to hand over flexibility by the way. It should probably most cases to supervise and to the flexibility training even though there are some exceptions. I have met someone certainly leave enough time for the next lecture and skip that. I skip this about there's mixed reports about manipulation. Shifted completely last decade in regards Carr practica decade ago I don't recommend it to anyone and still some high velocity cervical manipulation I'm still kind of the initial Bob but evidence does bear out that some side bears Journal medicine. That is a bit better physical to me if I'm in physical therapy for chronic pain though this is a Swedish study that conflict with and so at this point at least enough evidence to tell people this is my Patterson's OFF A Well as far as good as a pill. You know. So if it's better than taking a pill than and you feel better not to harm painful afterwards by all means. And that's kind of my stance now is not a large stance but I mean a strong stance but is what I did for the patients of advice. Let's get this for the time in this is a talking about. Mr met on Alice's Now this is the last couple of lines here and apart and here I told him beginning that invariably after every talk someone walks up to me and and if you do. Bless your heart. I'll be happy to talk with you. I always get to talk like this on the body. Have you solve this or have you can find this black stuff you know. And I just told you the beginning. No I don't I have the same Google search engines as you do and so I just keep them on a couple things. They have them study compares to is the Vioxx which is now off the market. Willow bark and similar responses. Keep in mind the Devils claw I think is pretty close to solicit acid to space that they asked for in regards to chemical structure. The walls barred actually all those bark actually lost in a head to head with that cliff a knack to Merrick that's the one or the has got a lot of attention recently and a really good study is. Superman is kind of like a byproduct of America you know one of the so they're still trying to figure out what's best for the most if you've been an innocent enough of the patients going to ask you if you should take the stuff on the biggest issue about circumvent America is pretty safe in fact studies show that if I said better to see a bow and some patients taking eight thousand milligrams a day which is about you know how thirty two times the amount that the other studies showed no toxicity is bioavailability lot of people are interesting enough in their system because people are recommending that making gels in the most of the. Nations for the temerity to be able to absorb into your body they recommend black pepper to take which America for to retard the the metabolism of the to American the system you know a piper in which is again another constituent of black pepper and so keep that in mind we're not sure how to put in the system where he stays in the available absorb but there's some promising information out to America. I have some conversations about this with colleagues and I haven't started prescribe and I don't exactly know that those are what kind of Calo oid or most of the patients are right and quite honestly. But there's an interesting things and promising things about America but I'm not looking for the quick rub on even though those are nice lifestyle changes thought changes all these things along the way are great but if I can get two things are going to be in long term benefit that's a great my last thought thirty seconds I don't want to any more time for the next lecture. Haven't anyone ever use capsaicin. If they use it once and don't use it use it once don't use it all the doing rubbing on her in the south rubbing on hurting themselves you know you have to keep on using it to get any relief three to four times a day to the affected area you're trying to desensitize is not the right word because that the T.V. channels are still working but they're not taught as they kind of exhaust their pain modulators and so it basically just keep rubbing it on you can hurt yourself. Every time and neuropathic pain as well as think hard for the half a percent. Perhaps now that you can take every three months. You can use for Method time. Mechanical stop the pain not as great. Again that Kindle Fire for at yahoo dot com If you have any questions or from other presentation itself so much to say but I want to get focus I will not take more time than for the because it has a great doctors following. Thank you very much for your time intention bless you. 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