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.