Tuesday, February 26, 2019

A point in the right direction, or a stab in the dark?

In 2015, motor vehicle accidents claimed the lives of more than 35,000 Americans. Sadly, the toll exacted by motor vehicle accidents has now been eclipsed. Data from the American Society of Addiction Medicine show that more than 52,000 of we Americans lost our lives to opioid overdose in 2015. Here in the Commonwealth, the story is even more grim; even accounting for differences in average age from community to community — younger people are still more likely to be affected than older people — the opioid overdose death rate has climbed to 23 per 100,000 residents as compared to 9 per 100,000 for the nation as a whole. The causes are numerous and a subject for another day. Similarly, approaches to solve the crisis are numerous and no one solution works for everyone who decides he or she has developed an opioid problem.
Medication Assisted Treatment (MAT)

One approach to treat people who are addicted to opioids is Medication Assisted Treatment (MAT) that combines medications to treat addiction with more traditional counseling approaches. One medication often used in MAT programs is buprenorphine-naloxone (trade name Suboxone, among others). This preparation — hereafter BN — combines buprenorphine, an opioid medication with partial activity that blunts cravings, and naloxone, an opioid overdose reversal medication that discourages abuse of the medication. When we compare groups of people addicted to opioids who are treated with and without BN, we see that those who receive the medication have a significantly higher rate of remaining free of other opioids. But how long should one continue the medication? A month? A year? A lifetime? And is it safe to continue the medication? We do not have the full answers yet, but early signals from the research indicate that not only is it safe but that longer treatment is better than shorter treatment.
Long-term treatment for a chronic condition

Many in the medical community have come to view addiction as a chronic disease. And, like many chronic diseases, it is one that can be managed but not yet cured. The thinking goes that just as those of us with high blood pressure take high blood pressure fighting medication each day for years, those of us with addiction would take addiction-fighting medication every day over years. The evidence shows that long-term proper treatment for high blood pressure lowers the risk for heart attack; evidence is now beginning to grow that long-term MAT can similarly decrease risk for relapse in those with addiction. As reported in a 2008 study in the American Journal on Addictions, patients who were successfully stabilized with a short course of BN could then be switched to long-term treatment with the medication. Forty percent of patients remained in treatment at two years and 20% at five years. When we remember that nearly half of people prescribed medication for blood pressure do not take their pills, we see that people on BN are not more likely to skip their medication than are people with better-studied chronic diseases. More importantly, though, greater than 90% of urine samples from those in the study remained free of opioids other than BN.

Long-term treatment with BN works.
How do people do without longer-term buprenorphine-naloxone treatment?

It is one thing to say that someone on a medication has a good outcome, but it is something else to prove that without the medication the person would not do well. Many advocate short-term treatment with BN. Help a person become stable and then taper off the medication. We now have evidence that this approach, however well intentioned, may be misguided. A 2014 study reported in the Journal of the American Medical Association demonstrates that over half of people who continued on BN maintenance remained free of opioids compared to just a third of those who were stabilized on BN and then tapered off. Further, far more of those treated with maintenance BN remained in the study compared to those who were tapered, suggesting that people remain committed to treatment while receiving BN.
Is long-term MAT safe?

Even if many people can be helped by extended BN treatment, it is important to consider possible side effects. Though we do not know the effects of being on BN for many decades, the 2008 American Journal on Addictions study looked for but did not find any serious adverse effects on the people treated. Earlier concerns that BN could cause liver damage also appeared to be unfounded as blood tests did not show signs of liver problems in any of the patients in the study.

More research is needed, of course, but the early evidence suggests that BN can safely help people remain off unwanted opioids over the long term just as blood pressure medication can protect people from the effects of high blood pressure. That is good news because each day off unwanted opioids is a day a person can focus on improving his or her life. Of course, buprenorphine-naloxone maintenance is not for everyone, but when it works it can work well and can give people room to breathe and rebuild their lives. Many people do focused brain exercises to help develop their thinking. Some of these exercises work, while others do not. Regardless, the focus network in the brain is not the only network that needs training. The “unfocus” network needs training too.
The “unfocus network” (or default mode network)

Called the default mode network (DMN), we used to think of the unfocus network as the Do Mostly Nothing network. And this network uses more energy than any other network in the brain, consuming 20% of the body’s energy while at rest. In fact, effort requires just 5% more energy. As you can imagine, this network is doing anything but “resting” even though it operates largely under the conscious radar. Instead, when you turn your “focus” brain off, it will retrieve memories, link ideas so that you become more creative, and also help you feel more self-connected too. Somewhat surprisingly, although the DMN is involved in representing and understanding your self, it also helps you read the minds of others. No wonder then, with all these functions on board, this network metaphorically converts your brain into a crystal ball, allowing you to predict things more accurately too. This is the kind of sharpness that you will develop if you train the DMN.

There are many ways to activate the DMN. Below are some that will give you a good start.
Surprising ways to train the default mode network

Some simple interventions could help you engage this network, depending on your goal.

Napping: If, for example, you are dog tired in the midafternoon, and just need your mind to be clear, a 10-minute nap might be all you need for sharper thinking. But if you have a major creative project ahead of you, whether it is an innovative idea at work, or redecorating your house, you will need at least 90-minutes of napping time. This gives your brain enough time to shuttle around ideas to make the associations that it needs to make.

Positive constructive daydreaming (PCD): It’s hard to imagine daydreaming as a type of training, but it is. It has to be the right type of daydreaming. According to Jerome Singer, who has studied this for decades, slipping into a daydream is not of much use; neither is guiltily rehashing everything that makes you feel bad — like the expense you incurred when you bought the shoes you liked, or the one-too-many drinks that you had at a party. But there is a type of daydreaming that will make you more creative and likely re-energize your brain. Called positive constructive daydreaming (PCD), it is best done while you are engaged in a low-key activity, not when you are fading. And as opposed to slipping into a daydream, which is more like falling off a cliff, you must parachute into the recesses of your mind with a playful and wishful image — perhaps one of you lying on a yacht or floating on your back in a pool on vacation. Then comes the swivel of attention — from looking outside, to wandering inside. With this move, you engage your unfocus brain and all the riches that it can bring.

Physical exercise and free-walking: In the brain, thinking supports movement, and movement supports thinking. In fact, exercise improves your DMN function. It normalizes it in obese people (who have too much of it) and increases connectivity in young healthy people. Even a single session can make a difference. Aerobic exercise can help prevent atrophy of key regions within the DMN, and also help the connectivity between different regions too.

Walking does boost creative thinking, but how you walk matters. One year of walking boosts the connections between the different parts of the DMN too. In 2012, psychology professor Angela K. Leung and her colleagues tested three groups of people. One group walked around in rectangles while completing a mental test; one group walked around freely; and the last group sat down while taking the test. The free-walking group outperformed the other two groups. Other studies have shown that free-walking results in improvements in fluency, flexibility, and originality of thinking. So if you want to boost your creativity, go on a meandering hike on a safe path less traveled. Furthermore, walking outdoors may be even more beneficial than puttering around the house (unless you’re using PCD, of course!) Acupuncture is a treatment that dates back to around 100 BC in China. It is based on traditional Chinese concepts such as qi (pronounced “chee” and considered life force energy) and meridians (paths through which qi flows). Multiple studies have failed to demonstrate any scientific evidence supporting such principles. Acupuncture involves the insertion of thin needles into the skin at multiple, varying locations based on the patient’s symptoms. Once inserted, some acupuncturists hand turn the needles for added therapeutic benefit. Although there are many uses for acupuncture in traditional Chinese medicine, in Western medicine it is primarily used for the treatment of pain.
Acupuncture (im)pales in comparison to Western medicine

At a time when people are increasingly concerned about drug side effects, some consider acupuncture an attractive non-medication option. Unfortunately, many studies show that the potential benefits of acupuncture are short-lived. In my experience, I put acupuncture, massage, and chiropractic interventions in the same bucket. You may feel better for a day or two, but there is limited lasting improvement.

In one study, 249 people with migraines occurring two to eight times per month received either acupuncture, sham (fake/placebo) acupuncture, or were put on an acupuncture waiting list. The two treatment groups received treatment five days per week for four weeks. Twelve weeks after treatment, the acupuncture group had on average 3.2 fewer attacks per month, the sham acupuncture group had 2.1 fewer attacks per month, and the wait-list group had 1.4 fewer attacks per month. These results are modest at best, and carry an approximate treatment cost of $2,000 per month (estimating $100/session x 20 sessions). This figure does not include lost income from time away from work to attend appointments, travel costs, pain from the procedure, and recovery time.

In general, the effectiveness of standard treatment (medication and injectable therapies) is supported by much stronger scientific evidence than acupuncture, including large clinical trials with thousands of subjects. For those averse to medications, physical therapy is a great alternative — one based on actual human anatomy and scientific principles. My patients often complain that they do not feel significantly better after the five to 10 sessions of physical therapy that insurance companies typically approve. I advise them that the true benefit of physical therapy comes when the stretching and strengthening routines taught by the therapist are continued at home on a long-term basis. Expecting an instant and permanent cure from physical therapy is like going to the gym for a week, and expecting to lose 20 pounds — without any chance of regaining the weight. (If any readers find a gym like that, please let me know….)
Stuck with needles, then stuck with a bill

At a cost of around $100 per treatment, and with sessions that can last over an hour, acupuncture treatments can be limited by both time and cost. Some patients may confidently argue that they do not mind the cost, because their insurance plan covers acupuncture. I would caution those same patients that money does not grow on trees, especially in the health insurance forest. If money is spent on one expense, it cannot be spent on something else. A plan that covers acupuncture may include fine print about excessive co-pays or limited coverage for basic medications. In some cases, covering acupuncture or massage may affect other patients in the same pool. Imagine if everybody received free massages, but in turn a cancer patient’s lifesaving chemotherapy becomes unaffordable. Although this is an exaggerated example, it does demonstrate the economics of health insurance.
Skewer side effects?

Side effects are not just limited to medications; procedures can also have negative effects. Acupuncture is relatively safe when the practitioner uses single-use, sterile needles with a clean technique. Side effects can include skin infections, bleeding, and pneumothorax (collapsed lung) if the needles are inserted too deep in the chest. Physicians sometimes perform acupuncture, but medical training is not required, and the qualifications to secure a license to practice acupuncture vary by state. It is probably worth the added expense to have a more experienced and/or highly credentialed acupuncturist.
Needle-less to say, the procedure went well

I fondly recall meeting an elderly lady who had a good experience with acupuncture for the treatment of her migraines, but the benefit only lasted one to two days after each session. After failing multiple treatments, she tried Botox injections with physicians not named Dr. Mathew, which she found effective. Due to scheduling issues, she ended up seeing me for injections. After I explained the risks and benefits of the procedure, she asked, “Dr. Mathew, are you experienced?” I replied, “Well, I trained the other two doctors who performed your previous injections.” She replied, “Well, I guess that makes you experienced. Are you gentle?” I paused and then replied in a stern tone, “Well, I am known as the Butcher of New England.” The woman was mortified, and she actually turned a little pale. I then advised her that I was just kidding, and that I am one of the gentler injectors in the practice. We then proceeded with her treatment. After we were done, she said, “That was the gentlest set of injections I ever received, and my pain is actually better.” I then said, “Please don’t say that… you will ruin my horrible reputation as the Butcher of New England.”

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