AMA Advocates 7 Principles for Health System Reform (HSR)

Following the news regarding legislative proposals for Health System Reform (HSR) can be stressful for all of us, with all of its complexities, and our concerns about the future availability of quality, affordable care.

In my search for sources of information that look at the facts of current legislative proposals, I believe that the American Medical Association (AMA) offers a perspective that is truly concerned about patients having access to quality, affordable care.

The AMA has studied health system issues and advocated for constructive reforms for over 20 years. As an organization that is driven by the time, energy, and experience offered by volunteer physicians, the AMA advocates for 7 guiding principles to achieve meaningful health system reform.

As we follow the debate and proposed legislation, the AMA continues to monitor proposed legislation as measured against these 7 guiding principles, commenting on how well legislative proposals live up to these principles.
-Provide health insurance coverage for all Americans.
-Enact insurance market reforms that expand the choice of affordable coverage and eliminate denials for pre-existing conditions or due to arbitrary caps.
-Assure that health care decisions are made by patients and their physicians, not by insurance companies or government bureaucrats. This sacred bond should include the right of patients to privately contract with physicians, so that their health care choices are respected.
-Provide investments and incentives for initiatives that improve quality and enhance prevention and wellness.

-Repeal the Medicare physician payment formula … a formula that will trigger steep cuts and threaten access to care for senior citizens.

-Implement medical liability reforms to reduce the cost of defensive medicine.

-Streamline and standardize insurance claims processing requirements to eliminate unnecessary costs and administrative burdens.

The AMA web site has lots of useful information for patients and their families, in addition to their perspective on the latest legislative proposals, and how they “measure up” to each of the 7 principles. You can find more information at http://www.ama-assn.org/ama/pub/patients/patients.shtml

H1N1 Vaccine: What to do?

H1N1 Vaccine: What to do?


“THE MEDICAL LETTER” is a publication that has provided credible information to healthcare providers about medications for over 20 years. It is funded by subscriptions and does NOT accept no funding from any other source, including pharmaceutical companies.
The October, 2009 issue reviews the H1N1 vaccine for prevention of flu. The article concludes that the H1N1 vaccine “is prepared in the same way by the same manufacturers as the usual seasonal vaccine. Those who are at increased risk of flu complications should receive the vaccine first…[they include] pregnant women, people who live with and provide care for infants <6 months old, all persons 6 months – 24 years old, persons 25-64 years old with illnesses that increase their risk of flu complications, and healthcare workers.”



I believe that credible sources such as the “THE MEDICAL LETTER” provide reliable information to healthcare providers and consumers, helping us to make the best possible decisions about risks vs. benefits of medical treatments. For further detail, consult your healthcare provider.

Is it OK to take medication for a long time for anxiety or mood disorders?

In my experience and according to scientific research, chronic anxiety and mood symptoms are extremely common. I think that, for many people, these symptoms can be due to being overloaded with all of the things that we expect ourselves to do (parent, spouse/relationship, work, friends, other family, etc, etc). When stressful life events happen, these are often “the straw that breaks the camel’s back.”


From my point of view, the important thing is for each individual to find out what works to feel better and function better, by that person’s own idea of "better." This means that the individual is better able to accomplish more of what they want & need to do, and to get more pleasure & fulfillment from those people & activities that are important to them.

It's always best to emphasize non-medication techniques as much as you can actually do, in the real world. These include exercise, spending time in green spaces, prayer/meditation, relaxation techniques, massage, stress management, and counseling/therapy.

No one that I ever known has been able actually do all of the non-medication techniques that they could/should do due limitations of time, energy, & money.

Even if you could, clinical research and our experience indicate that non-medication techniques are only of limited benefit for pain, anxiety, mood and/or sleep disorder symptoms that have been present for a long time, or are beyond a mild level of severity.

If medication works to do the good things (reduce suffering and improve ability to do things you want and need to do), and is not causing significant side effects, then I believe that it is actually having a positive healthy impact on the central nervous system and overall health, with benefits that often include reducing the impact of stress on things like chronic pain, IBS, PMS, headaches, asthma, blood pressure, as well as risk for heart disease and immune system disorders.

As a rule, I think it's good to learn about possible side effects that can occur from any medication that you're taking on a regular basis and for more than a few months, and to always call your prescribing physician if you feel worse in any way, especially after a dosage change.

If you've been taking a particular medication on a regular basis and for a long time, I think that it's always good to speak with your prescribing physician about trying a step down in the dose for a short period of time. If you feel worse and nothing gets better, then you can go back to the original dose. If your symptoms are not in complete remission, then speak to your prescribing physician about a trial of a step higher in the dose, with careful continued monitoring for benefits vs. side effects.

If you feel better on a lower dose, then you can talk to your prescribing physician about taking another step down in the dosage.

"The Body Toxic: How the Hazardous Chemistry of Everyday Things Threatens Our Health and Well-being" by Nena Baker

(I watched this program and felt this was worth sharing. There are some very credible scientific sources that are used. The following are excerpts from her presentation about the material contained in her book & on her web site. Although I am not necessarily advocating this, I felt it was worth posting).


Nena Baker contends that the chemical make-up of several of the products that make contemporary life easier and more convenient may be responsible for serious health problems. Ms. Baker argues that the Toxic Substances and Control Act of 1976 was ineffectual in regulating potential industrial contaminants and presents her research on products that she deems of possible danger, which range from the non-stick coating on cookware to several different types of plastics. This event was hosted by Google at their headquarters in Mountain View, California.


About the Author: Nena Baker has been a reporter for United Press International, The Arizona Republic, and The Oregonian.


From End Of The Program:

“I’m often asked what changes I’ve made in my life based on what I’ve learned, and why I’ve made them. I don’t obsess about chemical pollutants. I make informed decisions based on my understanding of the hazards of pesticides, plasticizers, flame retardants, and stain protectors.
When I know something contains suspect substances, I ask myself ‘can I find an alternative?’. The answer is usually ‘yes’ but sometimes I decide that the benefit of using a certain product outweighs the risk.


I would be more careful if I were at a younger age & considering having children, or if I had children in my home.


Regarding individual choices, & what each of us can do to make a difference in our own lives, she states: “It would be easy to [just resign yourself to the fact that there’s nothing you can really do to make a difference] & continue to buy & use the same things. But small adjustments in your own life can lessen your exposures and risks.”

“I’m frequently asked what I do to reduce my exposure to the types of chemicals that I write about, so I wanted to share my own list. Here, in no particular order, is what I’ve done to lighten my chemical load:”

“I buy organic foods whenever possible because they’re pesticide free;

I gave up microwave popcorn because of chemicals (fluorotelemers) contained in the packaging [that shield the paper from the grease but also get into the popcorn];
I got rid of my plastic food containers because they leech hazardous substances into the food when heated in the microwave; better to use glass or ceramic containers instead;


I canceled my monthly pesticide service for both inside & outside of the home. I use non-toxic ways to control pests, rather than potentially hazardous chemicals used by pest control services [see her book for detail];

I decline all optional stain resistant coatings for furniture upholstery or floor coverings;
I use no or low DFC paint for home improvement projects;
I don’t use [hard plastic bottles] for water or other beverages; I use an (aluminum bottle);
I vacuum home & office at least once/week because dust contains many hazardous chemical pollutants (PVDE’s) that are of concern;

I’ve replaced my old Teflon cookware with hard anodized aluminum cookware;

I ask retailers questions about things I buy, and if they don’t know the answers, I call manufacturers;

I read labels about products I’m considering purchasing;

I share the changes I’m making and why I’m making them with friends & family.”

“You can find information about non-toxic products in online resources such as “The Green Guide” http://www.thegreenguide.com & “the environmental working group” http://www.ewg.org ;”

For more information: www.thebodytoxic.com

My Thoughts On Ted Kennedy, Jr.'s Speech At His Father's, Edward Kennedy, Funeral

Though I did not always agree with Senator Edward Kennedy on political and legislative issues, I was struck by the reaction of so many people, often holding opposing political points of view, to countless stories of his often inspiring statements and actions from his life outside politics.

I was particularly struck by a story told by his son, Ted Kennedy, Jr. at his funeral, about a father helping his 12 year old son as he struggled to deal with the consequences of severe medical illness and resulting physical impairment:

Ted Kennedy, Jr (son) speaking at Ted Kennedy Memorial (7-29-09)

When I was 12 years I was diagnosed with bone cancer and I remember a few months after I lost my leg, there was a heavy snowfall…my father went to the garage to get the old flexible flyer sled and asked me if I wanted to go sledding down the steep driveway. I was trying to get used to my new artificial leg, and the hill was covered with ice and snow and it wasn’t easy for me to walk, and the hill was very slick, and I struggled to walk. I slipped and started to cry, and I said: ‘I can’t do this. I’ll never be able to climb up that hill.’
And [my father] lifted me up in his strong, gentle arms and said, ‘I know you can do it. There is nothing that you can’t do. We’re gonna climb that hill together, even if it takes all day.’

Sure enough, he held me around my waist, and we slowly made it to the top.
You know, at age 12, losing your leg pretty much seems like the end of the world. But as I climbed onto his back and we flew down the hill that day, I knew he was right. I knew I was going to be OK.

You see, my father taught me that even our most profound losses are survivable. And it’s what we do with that loss, our ability to transform it into a positive event, that is one of my father’s greatest lessons. He taught me that nothing is impossible.

BASICS: Brain Is a Co-Conspirator in a Vicious Stress Loop

An interesting article from The New York Times entitled, "BASICS: Brain Is a Co-Conspirator in a Vicious Stress Loop"
By NATALIE ANGIER

Chronic stress changes the brain, but relaxation can change it

http://www.nytimes.com/2009/08/18/science/18angier.html

Look forward to your feedback.

Have a great weekend!

Dr. Blotner

Help with Losing Weight & Improving Health

This past weekend on Book TV on C-Span-2, I watched David Kessler, MD speak for 1 hour to an audience at a bookstore about his new book, “The End of Overeating: Taking Control of the Insatiable American Appetite.”

http://bit.ly/1aMHez

Dr. Kessler served as Commissioner of the U.S. Food and Drug Administration from 1990 to 1997 & is a former Dean of Yale University Medical School.

For this book, he spoke with several scientists, physicians, and food industry insiders, and reviewed scientific evidence that suggests that American bodies and minds have been “reprogrammed” by too much sugar, salt and junk.

He also revealed his own seemingly endless struggle with losing and gaining weight over many years.

In his book, Dr. Kessler suggests that our bodies and minds are changed when we consume foods that contain high content of sugar, fat, and salt, resulting in profound biological impact on brain’s pleasure centers, and contributing to serious long-term health problems.

He suggests that the high levels of these ingredients, certain food industry practices, advertising, and lifestyle changes combine to impact core brain self-regulating biological mechanisms of a large percentage of Americans of all ages.

He suggests that food manufacturers manipulate sugar, fat, and salt content to stimulate the brain mechanisms that control craving and consumption of food, resulting in patterns of uncontrolled irrational eating, and (ultimately) obesity and other serious health problems.

When these unhealthy foods are associated with advertising, some individuals develop a “conditioned” behavioral response. This means that the brain’s biological craving for these foods is triggered by reminders contained in advertising, leading to “conditioned hyper-eating,” which Kessler believes is a disease rather than a failure of willpower.

This also provides an explanation as to why it is so difficult for so many to resist these unhealthy foods, despite knowing that these foods contribute to their health problems.

Dr. Kessler then suggests ways individuals regain control over their eating habits, supported by his review of scientific research.

He presents a simple food rehab program that help us identify cues that trigger overeating, changing the way we perceive these foods, and reducing the impact that advertising has on craving and consumption. For example, one person in one of the studies stated, "I think of the French fries as my friend. I know if I'm feeling bad, [fast food restaurant] French fries make me feel better."Dr. Kessler suggests that we begin to think about the French fries differently. He suggests that we think of French fries as a combination of sugar, fat, and salt designed to turn on pleasure centers in the brain and to cause craving, not unlike addictive substances such as alcohol, habit-forming medications, and illegal drugs. By thinking of unhealthy foods as we would think of addictive substances, we become more aware of the potential for harm, reducing our craving, making it easier to reduce the consumption of these unhealthy foods. For example, most people know that small amounts of alcohol on a few days per week does not seem to cause significant harm, but large amounts of alcohol on a frequent basis can quite harmful. So, most people are wary of the potentially addictive nature of alcohol. Regarding public policy, he suggests that the public’s health would be best served by adopting some of the same changes that have occurred with tobacco over the past 15 years.

He states that tobacco has been marginalized in the culture due to public policy changes and educational campaigns, and that similar tactics would have a positive impact on reduction of craving & consumption of foods that contain high content of sugar, fat, and salt, with resulting benefits to the health of individuals and the public at large.

How God Changes Your Brain: Breakthrough Findings from a Leading Neurocientist

I found this article and video quite interesting. Look forward to your feedback:

"How God Changes Your Brain: Breakthrough Findings from a Leading Neurocientist by Andrew Newberg."
Click Here: http://bit.ly/d4Av2

From Tennessee Medical Association (TMA): Health System Reform (HSR) Breaking News

Last night (7/29/09), the Tennessee Medical Association (TMA) received breaking news from the American Medical Association (AMA) concerning the agreement between Energy and Commerce Committee Chairman Henry Waxman and the leader of the Blue Dog Democrats on HR 3200. Payments in the proposed public option reportedly would be negotiated rather than based on the Medicare fee schedule. States would have the ability to establish health insurance co-ops as well as their own state-based health insurance exchanges. AMA had recommended and supported each of these proposed revisions. Please note that Congressman Bart Gordon (D-Murfreesboro), who has been a long-time advocate for organized medicine, will be offering a series of AMA-supported amendments to address the medical malpractice crisis. TMA has worked closely with the Congressman over the years on these and other options on med mal reform. The announcement also includes the latest on Senate Finance Committee negotiations.

Adrian Blotner, MD to host Seminar Series: “Rx for Burnout: Caring for Yourself & Those You Love”

“This seminar series is about helping individuals achieve healthy balance in maintaining physical & emotional health, while accomplishing those things that they want & need to do while also caring for loved ones," according to Dr. Blotner.


Memphis, TN, July 26, 2009: Achieving healthy balance is the challenge that we all face, as each of us strives accomplish our goals as parent, spouse, friend, adult son or daughter to aging parents, & work, as well as participating in community & church activities.

It is no wonder that burnout effects so many of us, with so many things that we expect ourselves to do. With the recent increase in financial challenges that so many of us are facing, it is more difficult than ever to find the time & energy to do all of the things that we want to do for those we care about most, as well as the challenge of maintaining our own health at the same time.

According to Dr. Blotner, "It's like the fable of The Goose & the Golden Eggs: If you want the golden eggs (your ability to do for others), then you've got to take care of the goose (yourself)."

Dr. Blotner has over 20 years experience in the comprehensive management of chronic pain, mood, anxiety, & sleep disorders. He has always been interested in the physical as well as emotional impact of stress, and how individuals can learn to reduce the impact of stressful situations on mind & body.

"The purpose of these seminars is to share stress reducing methods & techniques that can be done right away, to enhance each person’s ability to accomplish what is really important to them, and to enhance their ability to enjoy your healthy sources of pleasure & fulfillment," says Dr. Blotner.

These will be ample time for seminar attendees to have their own questions & concerns addressed during "Q&A" as part of each seminar.

Seminars begin at 7:30am on one Friday per month, at a cost of $30 each. A light breakfast will be served. The first seminar is September 9, 2009:

“Rx for Burnout: Caring for Yourself & Those You Love”

SEMINAR DATES & TOPICS

9/11/09 Home, School, Work: Achieving Healthy Balance

10/9/09 Managing Holiday Finances

11/6/09 Managing Holiday Stress

12/11/09 Enjoying YOUR Holidays

1/15/10 Healthy Beginnings for Your New Year

2/6/10 Enhance Your Romance: Valentine’s Day & more

3/12/10 Reducing Stress at Tax Time

4/9/10 Spring Break-Give ME a Break!

5/14/10 School’s Out: Oh, No, Now What?

6/11/10 Beating the Heat: Enjoying YOUR Summer

7/16/10 How to NOT need a Vacation After Your Vacation

8/13/10 Family and Friends: Achieving Healthy Balance


About Dr. Blotner

Dr. Blotner specializes in the comprehensive management of chronic pain, mood, anxiety, and sleep disorders since 1988, emphasizing healthy physical activity, non-addictive medications, stress management and lifestyle adjustment as the foundation of health and healing.

For reservations & information contact Joanna
Phone: 901-761-3255 x302,
Email: jwhitney@lshmedicalbill.com

WHAT ABOUT SLEEP MEDICATIONS? ARE THEY SAFE?

Over-the-counter medications promoted as sleep aids are primarily anti-histamines & work well for many with mild sleep disorders (especially if you have a chronic sinus allergies). Some people experience side effects of daytime drowsiness, disorientation, blurred vision or dry mouth, which makes this otherwise safe medication too difficult to tolerate. They do not provide effective and sustained relief for more severe sleep disorders.

The "benzodiazepines" are the most widely used prescription medications indicated for short-term treatment of anxiety and/or insomnia. These prescription medications bind to the GABA receptor complex reducing anxiety, inducing muscle relaxation and inhibiting convulsions as well as promoting sleep.

They are generally safe and effective for short-term use. They include Temazepam (Restoril), Triazolamm (Halcion), & Lorazepam (Ativan). Their possible side effects include decreased daytime alertness, energy, concentration, and/or memory functioning, and possibly even depressed mood. With regular use for more than several weeks at a time, these medications may significantly reduce time spent in REM sleep, resulting in these and other side effects including mood swings, irritability, temper outbursts, anxiety, and (ironically) insomnia.

Because they are potentially habit-forming or addictive, regular use of benzodiazepines for more than several weeks at a time should be avoided, except in rare cases. In addition to the side effects noted above, the negative consequences long-term daily use include the need for increased dose to achieve the desired effects (becoming "immune" to the medication or "tolerance"); the urge to take more medication than is prescribed ("abuse"); and the uncomfortable and potentially dangerous withdrawal symptoms on attempts to discontinue the medication (due to "physiologic dependence").

Care should be taken when by anyone with liver and kidney disease to those who are heavy snorers, and to the elderly. These medications have been associated with birth defects when taken by pregnant women. It is extremely important for women of childbearing age to use the most reliable methods of contraception possible when taking these medications.

Zaleplon (Sonata) & Zolpidem (Ambien) are non-benzodiazepine prescription medications for insomnia. They have minimal adverse effects on sleep architecture, and no evidence of rebound insomnia at recommended doses. Side effects can include memory impairment, sleepwalking, and morning drowsiness.

For chronic insomnia associated with other symptoms of Clinical Depression, I have had excellent results with the so-called "anti-depressant" medications. They are not habit-forming, restore sleep architecture to normal, have minimal to no side-effects when properly selected and dosed. They tend to improve all symptoms of the syndrome of Clinical Depression, as well as reducing a wide variety of aches & pains. Examples include Trazodone (Desyrel), Amitriptyilne (Elavil), and Remeron (Mirtazapine).

Regarding “anti-depressant” medications, talk to your healthcare provider about trying the lowest dose possible and about gradual increase of the dose until your symptoms are resolved. These agents can potentially have a wide variety of side effects, including daytime drowsiness & decreased impaired daytime energy, which are usually minor and temporary. In some individuals, these medications can actually worsen sleep disturbance & mood.

Remember: what counts is how you feel, not how many hours of sleep you've had. If you are alert, feel rested, and function well during the day, chances are you're getting enough sleep.

Sweet Dreams!

For more information: National Sleep Foundation http://www.sleepfoundation.org

Solutions For A Better Sleep

Sleep is a basic physiological need-as vital as the need for food & water. Although much about the nature of sleep still remains elusive, great progress has been made over the last three decades in understanding how and why we sleep, as well as health consequences of lost or disturbed sleep.

FIRST THINGS FIRST: SETTING THE STAGE FOR A GOOD NIGHT’S SLEEP

Mild or moderate insomnia may be cured with improved non-medication interventions, known as "sleep hygiene." Before considering these, it is important to recognize that there are individual differences in what works best to help people improve their sleep. For example, some need absolute quiet to fall asleep, others fall asleep best when listening to music or watching TV.

Top Ten Tips for Better Sleep Hygiene:

1) Sleep as much as needed to feel refreshed and healthy during the following day, but not more.
2) Limit your time in bed to the time you intend to sleep.
3) A regular arousal time in the morning strengthens circadian cycling and, finally leads to regular times of sleep onset.
4) Go for timely exercise in the late afternoon, 5-6 hours before bedtime.
5) Set the stage: a dark, quiet room that's cool (65-72°), with a comfortable bed.
6) The quiet hum of a fan, the soothing sound of a "nature" tape, a "white noise" machine, or earplugs can do wonders to block out distracting sounds. Sound attenuating the bedroom walls & windows also may help.
7) If you’re feeling frustrated at night from not being able to fall asleep, try turning on the light and do something different.
8) Self-fulfilling prophecies can also play a role: find ways to distract your thoughts if you worry about sleeping poorly; the worrying itself can make it more difficult to fall asleep.
9) Anxiety, no matter what the cause, interferes with sleep; Speak with your healthcare provider about non-medication techniques or medication to reduce anxiety.
10) Avoid stimulant medications, nicotine, and caffeine, and alcohol.

Make the bedroom a quiet, peaceful sanctuary for rest, relaxation, and sexual activity. Don't have arguments or heated discussions in the bedroom. Make an agreement with your mate on a cutoff time (9pm or 10pm) after which you will not talk about anything that is not soothing, supportive, nurturing. Don't read, watch TV, eat, do paperwork, or hobbies unless they help you relax. Avoid stimulating TV programs and reading material.

You can also try a light carbohydrate snack 1 hour before bedtime (fruit juice, fruit, crackers, bread) with or without a source of protein (cheese, nuts, milk).

Use herbal interventions or non-addictive medications before those that might be habit-forming. "Anti-depressant" medication is often most effective in those who have chronic sleep disorders.

DIET, SUPPLEMENTS, HERBAL REMEDIES

What you eat definitely effects not only your sleep but how you feel and function throughout the day. To improve energy during the day and sleep at night, make sure you get a good source of protein in the morning: whole-grain breads, cereals, pastas, beans, and fresh fruits & vegetables-the so-called complex carbohydrates. Avoid refined sugars and carbohydrates (such as overly processed and pre-sweetened cereals), which will rapidly increase blood sugar (glucose), stimulate the over-production of insulin, and result in low blood sugar 1-2 hours later. Just as insulin is released when blood sugar levels are too high, adrenaline is released when blood sugar drops too low. Proteins contain "amino acids," the building blocks for important hormones such as norepinephrine and serotonin. The amino acid "Tryptophan" is the major precursor to serotonin, which is of major importance for healthy sleep.

Consuming carbohydrates (with or without high protein foods) about an hour before bedtime is effective for many people. Healthy carbohydrate alternatives include dates, bananas, apples, fruit juice, granola, carrot cake, or bread. Healthy protein alternatives include milk, cheese, yogurt, nuts, and rice pudding. Many people have found that 1-3 grams at bedtime helps them to fall asleep faster.

B Vitamins, Calcium, Magnesium, Copper, and Iron are also important. If your dietary intake is not optimal, consider a supplement that contains 100% of the U.S. RDA for these nutrients. L-Tryptophan, available in supplement form, seems to be effective for some people to improve their sleep. It may be wise to try 1 to 3 gm of L-Tryptophan for a few nights. Its side effects are probably more benign than those of most medications.

Valerian is a European plant (Valeriana Officinalis) which has been used by many for relief of milder forms of insomnia. According to Andrew Weil, MD, tincture of valerian is the strongest and most effective form of the herb. It is safe, effective and not addictive. One teaspoonful of tincture of valerian, taken in an ounce or two of warm water, should induce sleep within 30 minutes. (If you're using tablets or capsules, follow the dosages recommended on the product). Two important notes: Even though it is mild compared to pharmaceutical sedatives, valerian is a depressant and should be reserved use rather than taken every night. Be aware also that combing it with alcohol or other depressants may produce an additive effect.

Melatonin is a naturally occurring brain hormone that regulates our biological clocks, especially our daily cycle of sleeping and waking. A synthetic form of melatonin has recently begun to appear in health-food stores under brand name Chrono-Set. Many people have found it to be an excellent remedy for jet lag and insomnia. It induces what feels like normal sleep, with no drug effect whatsoever. It leaves no hangover and does not interfere with dreaming. Dr. Weil recommends 1 to 2 mg a half-hour before bedtime, but 1/2 mg might be enough for some.

The Food and Drug Administration says that synthetic melatonin products are insufficiently researched, and would like to see them regulated as drugs. Until more is known about melatonin's effects, I share some of the FDA's concerns when it comes to using it as a daily supplement. But I have no hesitation in recommending it for occasional use as a safe, effective, and natural remedy for insomnia. One caution however. Because melatonin increases the activity of some components of the immune system, it should not be used by anyone with an autoimmune disease, or by anyone taking prednisone or other immunosuppressive medications.

How We Measure Pain: The “Four A’s”

Because we don’t have a blood test or x-ray that measures pain, it can be difficult to explain, evaluate, and track. So, how can we “measure” in the doctor’s office?

One of the best methods that we have is to follow the “Four A’s:” Analgesia (pain relief), Activities of Daily Living (functioning at home & work), Adverse Effects (medication side effects), and “Aberrant Behaviors” (warning signs for addiction).

For “Analgesia” (pain relief), the standard method at this time is to use the “1-to-10” scale, where “10 is the worse pain you can imagine” and “1 is barely noticeable pain.” Variations on this scale include pictures of the scale with more detailed descriptions of each level of pain.

For many people, this is not an easy scale to use. But it is an important tool to help the healthcare provider to understand how much relief a person is getting from their current treatment. I often suggest “imagine that we stop all of your medication…let’s call that a ’10’…so, WITH the medication you are now taking, how far away from a ‘10’ does that get you? Is there a 50% reduction in your pain, or 20%, 80%...?”

This scale is a tool to help the healthcare provider understand if the pain is better or worse since the last change in medication dosage. It is also important to communicate about changes in how much medication was actually taken, any unauthorized dosage increases, or running out of medication early, and how changes in the amount of medication taken affected the pain.

“Activities of Daily Living” (ADL’s) refer to a person’s ability to perform usual activities in important areas of their life: as parent, spouse, friend, family member, work, leisure, and community activities. Sometimes, the level of pain does not change because the person will increase their activity until they get to a certain level of pain. So, if pain has stayed the same but the person is able to do twice as much activity as before, this would be considered a positive treatment outcome.

“Adverse Effects” refer to medication side effects. It is important for those taking medication to inform their healthcare provider of any symptoms that get worse with an increase in any medication dosage. Some Adverse Effects are not medically dangerous (such as dry mouth), what I think of as “nuisance” side effects. Others can be medically dangerous, such as heart rhythm abnormalities, or changes in liver or kidney functioning. Some medications have Adverse Effects can be detected early only with blood work, and can cause severe illness if the one waits until they feel sick before they investigate.

The most important thing here is the communication between healthcare provider and the patient regarding any worsening of any symptoms, and being informed about any “routine” tests which should be performed for medication(s) being taken on a regular basis.

“Aberrant Behaviors” is a term that healthcare providers use to refer to those behaviors that may be a “warning sign” for addiction, which can occur with narcotic pain medication (or other potentially habit-forming medication) in genetically susceptible individuals.

Examples of “Aberrant Behaviors” include taking pain medications for symptoms other than pain (such as anxiety or sleep); unauthorized dosage increases, adverse effects on mood, irritability, anxiety, or sleep; intoxication; or motor vehicle accidents. Each of these alone would not result in a diagnosis of addiction, but it is best for the healthcare provider, the person taking the medication, and the family should all “be on the lookout” for any adverse behavior changes that continue or worsen over time when taking any potentially habit-forming medication on a regular basis. It is also important to avoid drinking alcohol with narcotic pain medication.

Healthcare providers can provide safe and effective treatment for pain conditions, but only with good communication about “the Four A’s” can the best possible treatment outcomes be safely achieved.

Acetaminophen: Miracle Drug or Liver Toxin?

Acetaminophen: Miracle Drug or Liver Toxin?

Today we are reading reports that the Food and Drug Administration (FDA) “assembled 37 experts to recommend ways to reduce deadly overdoses with acetaminophen, which is the leading cause of liver failure in the US and sends 56,000 people to the emergency room annually.”

As a physician who specializes in Pain Medicine for the last 20 years, I routinely order blood work to measure liver function studies at least once/year in those who are taking acetaminophen on a regular basis.

In my experience, everyone I have seen who has liver damage due to taking too much acetaminophen has either intentionally overdosed on acetaminophen or taken large doses of acetaminophen with pre-existing liver disease from other causes, such as Hepatitis C or alcoholic liver disease.

For those with pre-existing liver disease due to Hepatitis C, long term alcohol abuse, or other causes, I would recommend that they avoid acetaminophen completely. In my experience, acetaminophen will certainly “pour gasoline on the fire” of any pre-existing liver disease.

As the news reports correctly point out, acetaminophen is contained in many non-prescription medications (such as cold remedies, pain medications) as well as prescription medications (such as Vicodin, Lortab, Lorcet, Percodan, & Percocet).

Some people with severe pain conditions take more than the recommended maximum dosage of acetaminophen (two 500mg tablets up to 4 times daily) in order to get relief from their pain without going to a doctor or having to take prescription medications. I would certainly recommend against this.

BOTTOM LINE

If you have liver disease from other causes, such as Hepatitis C, regular alcohol use, or other causes, avoid regular use of significant amounts of acetaminophen and get blood work to track changes in liver function studies.

If you do not have liver disease, occasional use of acetaminophen is safe as long as you’ve never had an allergic reaction.

If you take acetaminophen on a regular basis, either alone or as an ingredient contained in other medications, speak with your healthcare provider about getting blood work to measure you liver function studies.

If your liver function studies are normal, then there is no evidence that your current intake of acetaminophen is doing harm. If they are elevated, then discuss this with your healthcare provider. Consider stopping acetaminophen & alcohol, and ask your healthcare provider about further investigation into other possible causes of liver disease, including other medications that can cause liver enzyme elevations.

Pain Treatment Outcomes: The “4 A’s”

“Treatment outcomes” is the term used by healthcare providers that refers to benefits as well as side effects that result from a particular treatment, or combination of treatments, at a particular point in time. For chronic pain conditions, one way to categorize these is known as the “4 A’s”:

Analgesia (pain relief), Activities of Daily Living (ability to do things that you want or need to do), Adverse Effects (side effects), and Aberrant Behaviors (behaviors that may be warning signs for a problem with addiction).

The first “A” stands for “Analgesia” which refers to the amount of pain relief from current treatments. The standard measurement for this is the “1 to 10 scale.” Some people find this difficult to use, but it is an important tool for communication between the person who suffers from the pain condition and their treating physician. “10/10” represents “the worst pain you can imagine.” I often suggest that the chronic pain sufferer “imagine that all medication has been stopped--THIS would be 10/10.”
So to assess analgesia, or the amount of pain relief, the question becomes:
“WITH THE MEDICATION YOU ARE NOW TAKING, HOW MUCH LESS THAN 10/10 IS YOUR PAIN LEVEL? HOW MUCH BENEFIT ARE YOU GETTING FROM YOUR MEDICATION?”

The second “A” stands for “Activities of Daily Living, which refers to your ability to do things that you want or need to do. This begins with basic issues of taking care of yourself, and extends to your ability to perform activities as parent, spouse, friend, family member, work, hobbies, & community member, including religious activities. The goal here is for treatment to increase your ability to function in these areas.

Very often there are physical problems with being able to do things that you want or need to do, because some of these activities make pain worse, and may even do physical damage to bones, discs, joints, or soft tissues (tendons, ligaments)

Managing Pain: Nursing Diagnosis & Decision Making presented at Baptist Memorial Hospital Nursing Staff

I enjoyed the opportunity to speak to a group of 40 nurses at Baptist Memorial Hospital in East Memphis regarding an important area of interest to them: how to administer enough narcotic pain medication to relieve suffering, while avoiding potential adverse medical & behavioral effects that these medications can have.


We discussed the nursing decision-making process, which involves not only assessment of the type & severity of the pain, but also the warning signs that additional dosages of narcotic pain might actually result in more side effects than benefits. They received a handout that included signs and symptoms of narcotic side effects, toxicity, & withdrawal.


As with any issue dealt with by healthcare professionals, understanding important aspects of the patient’s recent & past medical history is essential for achievement of best possible clinical outcomes. These include:

• Since your last dose of pain medication, in what way(s) are you feeling better, and in what way(s) are you feeling worse?


• Is this pain relatively recent in onset, or has this been present for months, or even years, prior to this hospitalization?


• Have you been taking pain medication on a regular basis, & for a long time? How much pain medication have you taken in the last week, or the last month?


• Which medication(s) have worked well in the past? Which have had adverse side effects?


• What about non-medication techniques?

Another concern was that some patients seem to request narcotic pain medications in order to feel better emotionally, as well as physically. This leads to the question of whether a particular patient may have a problem with addiction, with or without “real” physical pain. We discussed the warning signs of inappropriate use of these medications by patients, diagnostic criteria for addiction, and how nursing staff can intervene when concerned about this.

We also spoke about different routes of administering medication: IV vs oral, and the importance of making the transition to oral medications as discharge approaches.

One theme that consistently emerged during our discussion was communication. Communication with the patient, getting the point of view of concerned family member(s), keeping physicians informed about issues of concern, and keeping patients informed regarding their decisions about how & when to take or not take narcotic pain medications, including preparation for transition to home after discharge.

As always, the nursing staff enjoyed the opportunity to ask questions & learn about important clinical issues that concern their ability to provide the best possible care to their patients in the hospital, who face difficult & complex illnesses. Their highest concern was to improve their ability to provide the most effective possible treatment, while following the first rule of healthcare: “do no harm.”