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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Opioids In​ ​Chronic​ ​Pain​ ​Management A​ ​Guide​ ​for​ ​Patients By J.​ ​Kimber​ ​Rotchford,​ ​M.D.,​ ​M.P.H. ISBN-13:​ ​978-1979806343 ISBN-10:​ ​1979806349

The​ ​book​ ​expresses​ ​the​ ​views​ ​of​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.,​ ​a​ ​specialist​ ​in treating​ ​patients​ ​suffering​ ​from​ ​chronic​ ​pain​ ​and​ ​substance​ ​use disorders.​ ​The​ ​book​ ​is​ ​published​ ​by​ ​Olympas​ ​Medical​ ​Services,​ ​Ltd.​ ​of Port​ ​Townsend,​ ​Washington. Olympas​ ​Medical​ ​Services J.​ ​Kimber​ ​Rotchford,​ ​M.D. 1136​ ​Water​ ​St.​ ​Suite​ ​107 Port​ ​Townsend,​ ​WA​ ​98368 Phone​ ​(360)​ ​385-4843 www.OPAS.us

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

©​ ​2017​ ​OMS​ ​Ltd.

Testimonials Dr.​ ​Rotchford's​ ​approaches​ ​are​ ​"cutting​ ​edge​ ​for​ ​addressing problematic​ ​opioid​ ​use​ ​in​ ​high-risk​ ​patients." Alex​ ​Cahana,​ ​M.D.,​ ​Professor​ ​and​ ​Chief, Division​ ​of​ ​Pain​ ​Medicine,​ ​University​ ​of​ ​Washington​ ​Medical Center ”Poster​ ​boy”​ ​for​ ​the​ ​cost​ ​effective,​ ​scientific,​ ​and​ ​successful treatment​ ​of​ ​pain​ ​and​ ​addiction​ ​patients." Samuel​ ​W.​ ​Shoen​ ​M.D. “I’ve​ ​met​ ​several​ ​people​ ​who​ ​were​ ​under​ ​Dr.​ ​Rotchford’s care,​ ​none​ ​of​ ​whom​ ​had​ ​a​ ​problem​ ​transitioning​ ​from narcotic​ ​treatment​ ​to​ ​being​ ​edication​ ​free." Audrey​ ​L.​ ​Fain,​ ​Ph.D.​ ​(retired)​ ​Registered​ ​Nurse​ ​CA-WA “Well​ ​regarded​ ​Pain​ ​Management​ ​consultant​ ​and​ ​has​ ​been recognized​ ​as​ ​a​ ​leader​ ​in​ ​the​ ​state." Alan​ ​G.​ ​Greenwald,​ ​M.D.,​ ​Jefferson​ ​Orthopedic​ ​Group “After​ ​surgery,​ ​the​ ​orthopedic​ ​surgeon​ ​prescribed​ ​heavy doses​ ​of​ ​oxycodone​ ​and​ ​oxycontin​ ​–​ ​believe​ ​me​ ​they​ ​were needed.​ ​Dr.​ ​Rotchford​ ​prescribed​ ​a​ ​non-narcotic​ ​pain​ ​drug and​ ​I​ ​was​ ​able​ ​to​ ​be​ ​off​ ​them​ ​in​ ​a​ ​month.​ ​I​ ​now​ ​take nothing,​ ​not​ ​even​ ​an​ ​aspirin." Marilyn​ ​Muller,​ ​patient “​Dr.​ ​Rotchford,​ ​thank​ ​you​ ​so​ ​much​ ​for​ ​helping​ ​the​ ​people who​ ​cry​ ​out​ ​for​ ​help​ ​and​ ​no​ ​one​ ​else​ ​will​ ​hear​ ​them​ ​but you​." Jean​ ​Tidwell “Dr.​ ​Rotchford​ ​does​ ​a​ ​job​ ​that​ ​no​ ​one​ ​else​ ​has​ ​the​ ​interest and​ ​skill​ ​to​ ​do​ ​in​ ​this​ ​community,​ ​which​ ​is​ ​to​ ​take​ ​care​ ​of the​ ​chronic​ ​narcotic​ ​dependent​ ​and​ ​chronic​ ​pain​ ​patient.” J.​ ​Szereny “Kim​ ​Rotchford,​ ​MD,​ ​works​ ​with​ ​the​ ​most​ ​difficult population​ ​in​ ​our​ ​community.” Gary​ ​Novak “I​ ​do​ ​not​ ​know​ ​what​ ​I​ ​would​ ​have​ ​done​ ​without​ ​him.” Anonymous

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Author J.​ ​Kimber​ ​Rotchford,​ ​M.D.,​ ​M.P.H​ ​has​ ​extensive​ ​clinical expertise​ ​in​ ​treating​ ​outpatients​ ​who​ ​suffer​ ​from​ ​chronic​ ​pain, addictions,​ ​and​ ​related​ ​disorders.​ ​Dr.​ ​Rotchford​ ​is​ ​among​ ​the oldest​ ​certified​ ​pain​ ​management​ ​specialists​ ​by​ ​the​ ​American Academy​ ​of​ ​Integrative​ ​Pain​ ​Management.​ ​Since​ ​1981​ ​he​ ​has emphasized​ ​integrative​ ​approaches​ ​to​ ​pain​ ​management. His​ ​longstanding​ ​interest​ ​and​ ​expertise​ ​in​ ​pain​ ​management​ ​led Dr.​ ​Rotchford​ ​to​ ​become​ ​a​ ​specialist​ ​in​ ​Addiction​ ​Medicine.​ ​He is​ ​one​ ​of​ ​the​ ​first​ ​physicians​ ​to​ ​be​ ​board​ ​certified​ ​in​ ​addiction medicine​ ​through​ ​the​ ​American​ ​Board​ ​of​ ​Addiction​ ​Medicine. He​ ​has​ ​written​ ​several​ ​publications​ ​related​ ​both​ ​to​ ​pain management​ ​and​ ​addiction​ ​medicine. Dr.​ ​Rotchford​ ​is​ ​passionate​ ​about​ ​finding​ ​effective​ ​and​ ​practical solutions​ ​for​ ​the​ ​opioid​ ​crisis.​ ​He​ ​has​ ​a​ ​strong​ ​background​ ​in Public​ ​Health​ ​and​ ​is​ ​a​ ​longstanding​ ​Fellow​ ​of​ ​the​ ​American College​ ​of​ ​Preventive​ ​Medicine.​ ​A​ ​native​ ​of​ ​Washington,​ ​he​ ​is​ ​a graduate​ ​of​ ​the​ ​University​ ​of​ ​Washington's​ ​School​ ​of​ ​Medicine and​ ​School​ ​of​ ​Public​ ​Health.​ ​The​ ​University​ ​of​ ​Washington​ ​has​ ​a noteworthy​ ​history​ ​of​ ​leadership​ ​and​ ​expertise​ ​in​ ​both​ ​chronic pain​ ​management​ ​and​ ​Public​ ​Health.​ ​He​ ​has​ ​studied,​ ​worked, and​ ​taught​ ​internationally. Recognized​ ​for​ ​his​ ​compassion​ ​and​ ​his​ ​expertise​ ​in​ ​the treatment​ ​of​ ​chronic​ ​pain​ ​and​ ​opioid​ ​use​ ​disorders,​ ​his​ ​entire clinical​ ​career​ ​has​ ​been​ ​in​ ​rural​ ​Washington,​ ​first​ ​on​ ​the​ ​coast​ ​of Washington​ ​and​ ​for​ ​the​ ​past​ ​25​ ​years​ ​in​ ​a​ ​specialty​ ​practice​ ​in Port​ ​Townsend,​ ​WA.

Editor Dan​ ​Youra​ ​is​ ​editor​ ​and​ ​publisher​ ​of​ ​books​ ​and​ ​online magazines.​ ​He​ ​is​ ​chairman​ ​of​ ​the​ ​board​ ​of​ ​directors​ ​for​ ​JC​ ​MASH free​ ​clinic​ ​in​ ​Port​ ​Townsend,​ ​Washington

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

TABLE​ ​OF​ ​CONTENTS Introduction

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Chapter​ ​One​ ​-​ ​New​ ​Patient​ ​Consultation​ ​for​ ​Opioids​ ​in​ ​Chronic Pain​ ​Management 6 1.​ ​Assess​ ​Current​ ​Pain​ ​Levels​ ​and​ ​Function 6 2.​ ​Chronic​ ​Pain​ ​vs​ ​Acute​ ​Pain

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3.​ ​Opioids​ ​are​ ​they​ ​part​ ​of​ ​the​ ​solution​ ​or​ ​the​ ​problem?

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4.​ ​What​ ​other​ ​interventions​ ​might​ ​best​ ​improve​ ​the​ ​function​ ​of the​ ​central​ ​nervous​ ​system​ ​and​ ​help​ ​with​ ​pain​ ​management? 13 5.​ ​Establish​ ​an​ ​initial​ ​plan​ ​for​ ​progress Chapter​ ​Two​ ​–​ ​Is​ ​the​ ​plan​ ​Working?

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Chapter​ ​Three​ ​–​ ​What​ ​are​ ​your​ ​options​ ​if​ ​the​ ​plan​ ​is​ ​not working​ ​or​ ​your​ ​physician/caregiver​ ​is​ ​not​ ​offering​ ​viable alternatives? 19 1.​ ​The​ ​first​ ​step​ ​is​ ​generally​ ​to​ ​make​ ​a​ ​visit​ ​with​ ​a​ ​primary​ ​care provider 21 2.​ ​How​ ​to​ ​help​ ​your​ ​doctor​ ​properly​ ​prescribe​ ​pain​ ​medications​ ​to you 24 3.​ ​10-Step​ ​“To​ ​Do”​ ​List​ ​to​ ​Help​ ​Your​ ​Doctor​ ​Help​ ​You 25 1.​ ​Make​ ​An​ ​Appointment. 2.​ ​Your​ ​First​ ​Visit. 4.​ ​Work​ ​With​ ​Your​ ​Doctor. 5.​ ​Ask​ ​Questions 6.​ ​Be​ ​Willing 7.​ ​Educate​ ​Yourself 8.​ ​Be​ ​Knowledgeable 9.​ ​Ask​ ​for​ ​Referral 10.​ ​One​ ​last​ ​clinical​ ​reminder:​ ​Minimize​ ​Stress

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25 26 27 28 28 29 29 30 31


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. Table​ ​of​ ​Contents​ ​(continued) References​ ​/​ ​Resources

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Appendix​ ​1 Rapid​ ​Opioid​ ​Dependence​ ​Screen​ ​(RODS)

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Appendix​ ​2 Global​ ​Pain​ ​Scale Basic​ ​OPAS​ ​Follow-Up​ ​Office​ ​Questionnaire: For​ ​patients​ ​with​ ​pain​ ​issues,​ ​substance​ ​use​ ​disorders,​ ​or​ ​any diagnoses​ ​or​ ​medications​ ​related​ ​to​ ​brain​ ​health.

35 35 36

Appendix​ ​3 OPAS​ ​Behavioral​ ​Plan​ ​Discussion Making​ ​a​ ​Plan

38 38 39

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Introduction This​ ​guide​ ​is​ ​primarily​ ​for​ ​patients​ ​with​ ​chronic​ ​pain​ ​who​ ​are asking​ ​whether​ ​the​ ​use​ ​of​ ​opioids​ ​is​ ​helpful​ ​or​ ​not.​ ​ ​The​ ​Greeks recognized​ ​a​ ​long​ ​time​ ​ago​ ​that​ ​“one​ ​person’s​ ​food​ ​is​ ​another’s poison.”​ ​Evidence-based​ ​modern​ ​medicine​ ​is​ ​built​ ​upon​ ​the​ ​study​ ​of populations​ ​or​ ​groups​ ​of​ ​patients.​ ​The​ ​clinical​ ​evidence​ ​in conjunction​ ​with​ ​basic​ ​scientific​ ​understandings​ ​guides​ ​the​ ​clinician to​ ​better​ ​care​ ​for​ ​a​ ​patient.​ ​While​ ​population​ ​studies​ ​are​ ​most​ ​useful, the​ ​best​ ​medical​ ​care​ ​is​ ​always​ ​individualized. As​ ​is​ ​the​ ​case​ ​with​ ​any​ ​potent​ ​prescription,​ ​it​ ​is​ ​wise​ ​to​ ​seek professional​ ​advice​ ​before​ ​a​ ​pharmaceutical​ ​(medication)​ ​is​ ​used. Physicians​ ​are​ ​historically​ ​the​ ​experts​ ​in​ ​prescribing​ ​opioids.​ T ​ ​heir prescribing​ ​authority​ ​as​ ​it​ ​pertains​ ​to​ ​opioids​ ​has​ ​been​ ​significantly compromised​ ​within​ ​the​ ​United​ ​States​.​ ​The​ ​explanations​ ​for​ ​this​ ​are multifactorial​ ​and​​ ​likely​ ​are​ ​to​ ​be​ ​longly​ ​debated. Government​ ​regulators​ ​and​ ​third-party​ ​payers​ ​(insurance​ ​companies, Medicare,​ ​Medicaid)​ ​have​ ​become​ ​the​ ​default​ ​authorities​ ​regarding​ ​the proper​ ​use​ ​of​ ​opioids.​ ​Regulators​ ​determine​ ​appropriate​ ​diagnoses​ ​and sometimes​ ​limit​ ​certain​ ​opioids​ ​to​ ​specific​ ​settings​ ​or​ ​prescribers.​ ​They determine​ ​the​ ​nature​ ​of​ ​care,​ ​oversight,​ ​doses,​ ​access,​ ​etc.​ ​Third-party payers​ ​regularly​ ​determine​ ​which​ ​opioid​ ​and​ ​how​ ​much​ ​of​ ​an​ ​opioid​ ​are appropriate.​ ​ ​Their​ ​authority​ ​is​ ​established​ ​by​ ​what​ ​they​ ​are​ ​willing​ ​to​ ​pay

for.​ ​ ​Third​ ​parties,​ ​despite​ ​concerns​ ​about​ ​financial​ ​conflicts​ ​of​ ​interest, even​ ​have​ ​been​ ​emboldened​ ​to​ ​judge​ ​what​ ​constitutes​ ​safe​ ​prescribing.

Rules​ ​and​ ​regulations​ ​regarding​ ​potentially​ ​life-threatening substances​ ​are​ ​useful.​ ​ ​As​ ​with​ ​opioids​ ​themselves,​ ​too​ ​much​ ​or​ ​too 6


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. little​ ​regulation,​ ​is​ ​nonetheless​ ​ ​a​ ​challenge​ ​to​ ​judge.​ ​ ​Rules​ ​and regulations​ ​in​ ​the​ ​context​ ​of​ ​opioids​ ​and​ ​other​ ​“controlled substances”​ ​are​ ​excessive​ ​and​ ​they​ ​likely​ ​contribute​ ​to​ ​opioid misuse.​ ​ ​Potential​ ​explanations​ ​are​ ​provided​ ​in​ ​another​ ​publication regarding​ ​the​ ​current​ ​opioid​ ​misuse​ ​crisis.​ ​ ​Visit: www.opidemic.help​. Physicians​ ​have​ ​understandably​ ​become​ ​fearful​ ​when​ ​it​ ​comes to​ ​prescribing​ ​opioids.​ ​The​ ​United​ ​States​ ​Attorney​ ​General​ ​has overtly​ ​threatened​ ​prescribers​ ​with​ ​serious​ ​legal​ ​consequences​ ​for alleged​ ​inappropriate​ ​prescribing​ ​of​ ​opioids.​ ​The​ ​underlying assumption​ ​by​ ​the​ ​regulators​ ​and​ ​others​ ​is​ ​that​ ​they​ ​know​ ​what constitutes​ ​appropriate​ ​prescribing.​ ​Physicians’​ ​fears​ ​are​ ​justified.​ ​ ​Is it​ ​safe​ ​for​ ​them​ ​to​ ​prescribe?​ ​Rather​ ​than​ ​determining​ ​proper medical​ ​care,​ ​ ​the​ ​ ​prescribing​ ​of​ ​opioids​ ​has​ ​become​ ​more​ ​a​ ​matter of​ ​law​ ​and​ ​politics. Even​ ​well-trained​ ​and​ ​well-intentioned​ ​experts​ ​in​ ​pain management​ ​and​ ​addiction​ ​medicine​ ​can​ ​come​ ​under​ ​serious attack.​ ​Regulatory​ ​investigations​ ​and​ ​criminal​ ​charges​ ​have​ ​serious repercussions​ ​to​ ​careers​ ​and​ ​to​ ​patient​ ​care.​ ​Physicians​ ​can​ ​be investigated,​ ​harassed,​ ​and​ ​even​ ​lose​ ​their​ ​licenses​ ​in​ ​cases​ ​where patient-outcomes​ ​are​ ​far​ ​better​ ​than​ ​average. Perhaps​ ​it​ ​is​ ​no​ ​longer​ ​prudent​ ​or​ ​reasonable​ ​for​ ​a​ ​physician outside​ ​the​ ​protection​ ​of​ ​a​ ​large​ ​institution​ ​to​ ​prescribe​ ​long​ ​term opioids?​ ​Given​ ​the​ ​regulatory​ ​and​ ​third​ ​party​ ​pressures,​ ​it​ ​is understandable​ ​many​ ​physicians​ ​choose​ ​not​ ​to​ ​prescribe​ ​opioids​ ​for chronic​ ​conditions,​ ​even​ ​when​ ​patients​ ​would​ ​likely​ ​or​ ​even​ ​surely benefit.

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. Most​ ​physicians​ ​are​ ​well​ ​trained​ ​to​ ​prescribe​ ​opioids​ ​in​ ​the context​ ​of​ ​acute​ ​pain,​ ​defined​ ​as​ ​pain​ ​which​ ​lasts​ ​less​ ​than​ ​a​ ​month or​ ​so.​ ​When​ ​it​ ​comes​ ​to​ ​managing​ ​chronic​ ​pain​ ​and​ ​opioid​ ​use disorders​ ​there​ ​is​ ​widespread​ ​ignorance​ ​even​ ​with​ ​seasoned​ ​and otherwise​ ​capable​ ​physicians.​ ​The​ ​majority​ ​of​ ​physicians uncommonly​ ​diagnose​ ​opioid​ ​use​ ​disorders​ ​and​ ​even​ ​fewer​ ​are familiar​ ​with​ ​the​ ​formal​ ​criteria.​ ​ ​ ​This​ ​remains​ ​true​ ​despite​ ​evidence that​ ​20-25%​ ​of​ ​patients​ ​on​ ​chronic​ ​opioid​ ​agonist​ ​therapy​ ​(COAT) for​ ​pain​ ​have​ ​a​ ​significant​ ​opioid​ ​use​ ​disorder​ ​(addiction).​ ​Agonist therapy​ ​refers​ ​to​ ​pain​ ​pills​ ​and​ ​substances​ ​that​ ​stimulate​ ​the​ ​opioid (mu)​ ​receptors​ ​in​ ​the​ ​brain. Many​ ​physicians​ ​continue​ ​to​ ​commonly​ ​explain​ ​chronic​ ​pain based​ ​on​ ​diagnoses​ ​that​ ​imply​ ​peripheral​ ​tissue​ ​damage​ ​is​ ​the primary​ ​cause​ ​of​ ​the​ ​pain.​ ​While​ ​this​ ​explanation​ ​may​ ​be​ ​typically true​ ​with​ ​acute​ ​pain,​ ​it​ ​becomes​ ​the​ ​exception​ ​with​ ​chronic​ ​pain. Western​ ​science​ ​has​ ​confirmed​ ​that​ ​the​ ​central​ ​nervous​ ​system (CNS)​ ​is​ ​primarily​ ​involved​ ​in​ ​understanding​ ​chronic​ ​pain.​ ​ ​CNS dysfunction​ ​is​ ​the​ ​rule​ ​in​ ​most​ ​cases​ ​of​ ​chronic​ ​pain.​ ​ ​Support​ ​for​ ​the central​ ​nervous​ ​system​ ​is​ ​inevitably​ ​helpful​ ​in​ ​chronic​ ​pain management.​ ​ ​While​ ​nociception​ ​(tissue​ ​damage)​ ​is​ ​stressful​ ​and interferes​ ​with​ ​the​ ​healthy​ ​functioning​ ​of​ ​the​ ​central​ ​nervous​ ​system, limiting​ ​nociception​ ​is​ ​not​ ​enough,​ ​particularly​ ​in​ ​cases​ ​of​ ​chronic pain.​ ​In​ ​treating​ ​chronic​ ​pain,​ ​procedures​ ​and​ ​surgical​ ​interventions can​ ​and​ ​often​ ​do​ ​make​ ​matters​ ​worse.​ ​In​ ​chronic​ ​pain,​ ​the​ ​central nervous​ ​system​ ​adapts​ ​to​ ​the​ ​painful​ ​input​ ​and​ ​there​ ​are corresponding​ ​neuroadaptations​ ​(changes​ ​in​ ​neural​ ​circuits).​ ​Rather than​ ​being​ ​part​ ​of​ ​a​ ​solution,​ ​procedures​ ​and​ ​surgical​ ​interventions can​ ​become​ ​part​ ​of​ ​the​ ​problem,​ ​if​ ​not​ ​the​ ​entire​ ​problem.​ ​Sleep 8


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. deprivation,​ ​mood​ ​disorders,​ ​and​ ​other​ ​stressors​ ​to​ ​brain​ ​health, even​ ​when​ ​there​ ​is​ ​no​ ​apparent​ ​source​ ​of​ ​peripheral​ ​nociception (tissue​ ​damage),​ ​are​ ​commonly​ ​associated​ ​with​ ​serious​ ​and sometimes​ ​widespread​ ​pain. Opioids​ ​as​ ​medicines​ ​are​ ​designed​ ​to​ ​help​ ​the​ ​body​ ​and​ ​central nervous​ ​system​ ​work​ ​better.​ ​ ​All​ ​the​ ​ways​ ​by​ ​which​ ​opioids​ ​help some​ ​brains​ ​function​ ​better​ ​and​ ​limit​ ​pain​ ​are​ ​complex​ ​and​ ​not entirely​ ​understood.​ ​ ​In​ ​simple​ ​metaphorical​ ​terms,​ ​opioids​ ​turn down​ ​the​ ​volume​ ​on​ ​pain​ ​“noise”.​ ​ ​In​ ​addition,​ ​opioids​ ​are​ ​potent anti-anxiety​ ​medications.​ ​Throughout​ ​modern​ ​times​ ​they​ ​have​ ​also been​ ​used​ ​as​ ​mood​ ​enhancers​ ​and​ ​to​ ​a​ ​lesser​ ​degree​ ​mood stabilizers. Bottom​ ​line,​ ​opioids​ ​prescribed​ ​appropriately​ ​are​ ​quite therapeutic​ ​and​ ​can​ ​be​ ​life​ ​saving.​ ​They​ ​also​ ​can​ ​be​ ​misused​ ​and can​ ​be​ ​lethal.​ ​It​ ​makes​ ​sense​ ​to​ ​have​ ​opioids​ ​prescribed​ ​by​ ​a knowledgeable​ ​clinician,​ ​and​ ​for​ ​them​ ​to​ ​be​ ​used​ ​only​ ​as​ ​prescribed. This​ ​guide​ ​intends​ ​to​ ​empower​ ​patients​ ​and​ ​their​ ​advocates​ ​to obtain​ ​proper​ ​pain​ ​management​ ​whether​ ​with​ ​opioids​ ​or​ ​not. Opioids​ ​can​ ​be​ ​an​ ​essential​ ​part​ ​of​ ​a​ ​solution​ ​or​ ​they​ ​can​ ​contribute to​ ​poor​ ​pain​ ​management​ ​and​ ​early​ ​demise. This​ ​guide​ ​starts​ ​with​ ​a​ ​brief​ ​review​ ​of​ ​considerations​ ​and discussions​ ​commonly​ ​provided​ ​to​ ​a​ ​new​ ​patient​ ​during​ ​an​ ​initial pain​ ​management​ ​consultation.​ ​New​ ​patient​ ​consultations​ ​in​ ​a specialized​ ​pain​ ​management​ ​and​ ​addiction​ ​medicine​ ​practice commonly​ ​hinge​ ​upon​ ​whether​ ​opioids​ ​are​ ​part​ ​of​ ​the​ ​problem​ ​or part​ ​of​ ​the​ ​solution.

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Chapter​ ​One​ ​-​ ​New​ ​Patient​ ​Consultation​ ​for Opioids​ ​in​ ​Chronic​ ​Pain​ ​Management There​ ​are​ ​five​ ​typical​ ​components​ ​to​ ​our​ ​new​ ​patient consultations​ ​regarding​ ​pain​ ​management.​ ​ ​Care​ ​is​ ​best,​ ​however, provided​ ​over​ ​time.​ ​Follow​ ​up​ ​visits​ ​are​ ​essential.​ ​Follow-up​ ​ensures adequate​ ​evaluations​ ​have​ ​been​ ​made​ ​and​ ​progress​ ​in​ ​pain management​ ​happens.​ ​ ​The​ ​five​ ​components​ ​of​ ​the​ ​initial consultation​ ​are: 1. Assess​ ​current​ ​pain​ ​levels​ ​and​ ​function 2. Introduce​ ​patients​ ​to​ ​the​ ​notion​ ​that​ ​chronic​ ​pain​ ​is​ ​different than​ ​acute​ ​pain.​ ​It​ ​feels​ ​the​ ​same​ ​and​ ​may​ ​or​ ​may​ ​not​ ​limit function​ ​in​ ​similar​ ​ways. 3. Assess​ ​whether​ ​opioids​ ​are​ ​part​ ​of​ ​the​ ​solution​ ​or​ ​the problem 4. Assess​ ​other​ ​interventions​ ​or​ ​support,​ ​in​ ​addition​ ​to​ ​or besides​ ​opioids,​ ​which​ ​might​ ​better​ ​help​ ​manage​ ​pain. 5. Establish​ ​an​ ​initial​ ​plan​ ​for​ ​clinical​ ​progress​ ​in​ ​pain management.

1. Assess​ ​Current​ ​Pain​ ​Levels​ ​and​ ​Function Questionnaires​ ​and​ ​other​ ​clinical​ ​tools​ ​assess​ ​the​ ​need​ ​for​ ​and success​ ​of​ ​pain​ ​management.​ ​Some​ ​questionnaires​ ​are​ ​designed​ ​to assess​ ​pain​ ​and​ ​disability​ ​related​ ​to​ ​specific​ ​types​ ​of​ ​pain​ ​such​ ​as low​ ​back​ ​pain.​ ​Most​ ​physicians​ ​have​ ​access​ ​to​ ​these​ ​instruments

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. and​ ​they​ ​are​ ​often​ ​quite​ ​helpful.​ ​Not​ ​only​ ​do​ ​the​ ​questionnaires quickly​ ​assess​ ​a​ ​patient’s​ ​current​ ​pain​ ​and​ ​function​ ​but​ ​are​ ​can​ ​be useful​ ​in​ ​monitoring​ ​progress.​ ​In​ ​our​ ​specialized​ ​clinic​ ​we​ ​use​ ​a customized​ ​version​ ​of​ ​the​ ​Wisconsin​ ​Brief​ ​Pain​ ​Inventory.​ ​The​ ​score associated​ ​with​ ​the​ ​maximum​ ​amount​ ​of​ ​possible​ ​pain​ ​and dysfunction​ ​during​ ​the​ ​past​ ​week​ ​is​ ​100.​ ​The​ ​responses​ ​to​ ​the different​ ​questions​ ​are​ ​subjective.​ ​ ​One​ ​patient’s​ ​five​ ​might​ ​be another’s​ ​seven​ ​or​ ​eight,​ ​or​ ​vice​ ​versa.​ ​ ​Nonetheless,​ ​these questionnaires​ ​not​ ​only​ ​allow​ ​a​ ​comparison​ ​of​ ​scores​ ​between patients,​ ​but​ ​most​ ​importantly​ ​they​ ​allow​ ​us​ ​to​ ​observe​ ​and​ ​validate individualized​ ​progress​ ​over​ ​time.​ ​ ​Pain,​ ​like​ ​blood​ ​pressure​ ​and other​ ​physiological​ ​processes,​ ​varies​ ​over​ ​time.​ ​One​ ​specific​ ​score has​ ​limited​ ​value.​ ​Changes​ ​in​ ​pain​ ​scores​ ​observed​ ​over​ ​time​ ​is what​ ​matters​ ​most. The​ ​following​ ​is​ ​a​ ​link​ ​to​ ​both​ ​a​ ​Global​ ​Pain​ ​Questionnaire​ ​& Brief​ ​Follow​ ​Up​ ​Inventory.​ ​The​ ​Brief​ ​Follow​ ​Up​ ​Inventory​ ​assesses overall​ ​brain​ ​health​ ​and​ ​recovery.​ ​Poorly​ ​managed​ ​chronic​ ​pain implies​ ​a​ ​brain​ ​is​ ​not​ ​working​ ​as​ ​well​ ​as​ ​possible.​ ​While​ ​the​ ​BFU inventory​ ​has​ ​not​ ​been​ ​formally​ ​validated,​ ​it​ ​has​ ​been​ ​found​ ​to​ ​be clinically​ ​helpful​ ​to​ ​better​ ​assess​ ​progress.​ ​At​ ​the​ ​very​ ​least,​ ​the BFU​ ​Inventory​ ​gives​ ​patients​ ​another​ ​opportunity​ ​to​ ​assess​ ​their progress​ ​or​ ​lack​ ​thereof.​ ​ ​See​ ​Appendix​ ​2.

2.​ ​Chronic​ ​Pain​ ​vs​ ​Acute​ ​Pain Chronic​ ​pain​ ​and​ ​acute​ ​pain​ ​are​ ​concepts​ ​introduced​ ​earlier​ ​in this​ ​guide.​ ​The​ ​difference​ ​between​ ​the​ ​two​ ​types​ ​of​ ​pain​ ​is​ ​important to​ ​appreciate.​ ​This​ ​may​ ​be​ ​challenging​ ​because​ ​their​ ​similarities​ ​are so​ ​obvious. 11


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. Acute​ ​pain​ ​is​ ​relatively​ ​new​ ​pain​ ​and​ ​it​ ​is​ ​most​ ​often​ ​associated with​ ​some​ ​tissue​ ​damage.​ ​While​ ​growing​ ​up,​ ​children commonlyexperience​ ​forms​ ​of​ ​acute​ ​pain.​ ​Knees​ ​are​ ​scraped​ ​and noggins​ ​are​ ​bruised.​ ​Cuts​ ​and​ ​insect​ ​bites​ ​cause​ ​pain.​ ​Hence,​ ​as one​ ​gets​ ​older,​ ​one​ ​may​ ​assume​ ​that​ ​all​ ​pain​ ​is​ ​related​ ​to​ ​“tissue damage.”​ ​Furthermore,​ ​it​ ​is​ ​often​ ​assumed​ ​that​ ​all​ ​pain​ ​is​ ​best managed​ ​like​ ​acute​ ​pain.​ ​ ​A​ ​hug​ ​from​ ​mom,​ ​a​ ​dressing,​ ​a​ ​suture,​ ​or at​ ​least​ ​a​ ​bandaid​ ​is​ ​what​ ​one​ ​expects​ ​to​ ​help​ ​acute​ ​pain.​ ​Perhaps the​ ​child​ ​or​ ​young​ ​adult​ ​was​ ​given​ ​an​ ​aspirin​ ​or​ ​even​ ​a​ ​Tylenol​ ​for the​ ​pain?​ ​Our​ ​early​ ​experiences​ ​condition​ ​us​ ​to​ ​believe​ ​that​ ​a​ ​pain pill​ ​is​ ​often​ ​an​ ​effective​ ​way​ ​to​ ​address​ ​all​ ​forms​ ​of​ ​pain,​ ​whether acute​ ​or​ ​chronic. For​ ​more​ ​severe​ ​forms​ ​of​ ​pain,​ ​whether​ ​from​ ​serious​ ​injuries​ ​or a​ ​surgical​ ​procedures,​ ​one​ ​may​ ​have​ ​been​ ​exposed​ ​to​ ​opioids.​ ​ ​As previously​ ​noted,​ ​it​ ​is​ ​understandable​ ​that​ ​when​ ​we​ ​experience​ ​pain as​ ​adults​ ​we​ ​look​ ​for​ ​similar​ ​explanations​ ​and​ ​remedies​ ​which worked​ ​in​ ​the​ ​past. The​ ​severity​ ​of​ ​chronic​ ​pain​ ​a​ ​patient​ ​feels​ ​does​ ​not​ ​correlate well​ ​with​ ​tissue​ ​damage​ ​and​ ​chronic​ ​pain​ ​often​ ​does​ ​not​ ​respond well​ ​to​ ​acute​ ​pain​ ​remedies.​ ​ ​As​ ​with​ ​assessing​ ​pain​ ​in​ ​general,​ ​it​ ​is impossible​ ​to​ ​be​ ​objective​ ​as​ ​to​ ​the​ ​amount​ ​of​ ​pain​ ​a​ ​patient​ ​is experiencing.​ ​This​ ​is​ ​so​ ​even​ ​with​ ​the​ ​best​ ​diagnostic​ ​x-rays​ ​or​ ​even more​ ​refined​ ​imaging​ ​techniques.​ ​For​ ​example,​ ​take​ ​the​ ​case​ ​of chronic​ ​pain​ ​associated​ ​with​ ​degenerative​ ​arthritis​ ​(osteoarthritis​ ​or “bad​ ​joints”).​ ​Some​ ​patients​ ​have​ ​minor​ ​or​ ​no​ ​pain​ ​even​ ​when​ ​there are​ ​serious​ ​x-ray​ ​findings​ ​of​ ​degenerative​ ​arthritis.​ ​Conversely, horrible​ ​pain​ ​may​ ​be​ ​associated​ ​with​ ​only​ ​limited​ ​changes​ ​in​ ​the​ ​joint or​ ​other​ ​structures. 12


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. Levels​ ​of​ ​inflammation​ ​and​ ​other​ ​local​ ​factors,​ ​not​ ​readily appreciated​ ​by​ ​standard​ ​imaging​ ​techniques,​ ​can​ ​play​ ​a​ ​role​ ​in contributing​ ​to​ ​the​ ​pain​ ​associated​ ​with​ ​chronic​ ​complex​ ​pain. Inevitably​ ​though,​ ​in​ ​addition​ ​to​ ​local​ ​factors,​ ​one​ ​is​ ​dealing​ ​with​ ​one degree​ ​or​ ​another​ ​of​ ​ ​neural​ ​dysfunction​ ​whether​ ​peripherally​ ​or​ ​in the​ ​central​ ​nervous​ ​system. References​ ​online​ ​and​ ​elsewhere​ ​review​ ​the​ ​nature​ ​of​ ​chronic pain​ ​and​ ​how​ ​it​ ​is​ ​different​ ​than​ ​acute​ ​pain​ ​(1-4).​ ​The​ ​referenced syllabus​ ​(5)​ ​was​ ​written​ ​over​ ​a​ ​decade​ ​ago​ ​and​ ​was​ ​part​ ​of​ ​a​ ​college course.​ ​It​ ​remains​ ​a​ ​fairly​ ​comprehensive​ ​source​ ​of​ ​basic information​ ​on​ ​pain.​ ​Most​ ​of​ ​the​ ​material​ ​is​ ​relevant​ ​but​ ​some​ ​is​ ​now outdated.​ ​For​ ​example,​ ​we​ ​now​ ​consider​ ​chronic​ ​pain​ ​as​ ​a​ ​disease, in​ ​and​ ​of​ ​itself,​ ​with​ ​significant​ ​and​ ​objective​ ​findings​ ​of​ ​inflammation and​ ​dysfunction​ ​in​ ​the​ ​brain,​ ​spinal​ ​cord,​ ​and​ ​occasionally​ ​the autonomic​ ​nervous​ ​system.​ ​Neuropathy​ ​related​ ​pain​ ​is​ ​a​ ​relatively unique​ ​form​ ​of​ ​chronic​ ​pain​ ​and​ ​often​ ​benefits​ ​from​ ​specific remedies​ ​(6)

3.​ ​Opioids​ ​are​ ​they​ ​part​ ​of​ ​the​ ​solution​ ​or​ ​the​ ​problem? This​ ​is​ ​perhaps​ ​the​ ​most​ ​“charged”​ ​part​ ​of​ ​a​ ​new​ ​patient consultation.​ ​Most​ ​patients​ ​either​ ​referred​ ​by​ ​a​ ​colleague​ ​or​ ​who independently​ ​seek​ ​out​ ​specialized​ ​care​ ​are​ ​concerned​ ​about needing​ ​opioids​ ​to​ ​manage​ ​their​ ​painful​ ​conditions. It​ ​surprises​ ​many​ ​of​ ​my​ ​colleagues​ ​that​ ​the​ ​opioids​ ​are​ ​part​ ​of​ ​a solution​ ​and​ ​are​ ​often​ ​essential.​ ​The​ ​most​ ​common​ ​reason​ ​for​ ​this​ ​is that​ ​patients​ ​have​ ​an​ ​opioid​ ​use​ ​disorder​ ​because​ ​of​ ​exposure​ ​to prescribed​ ​opioids.​ ​ ​In​ ​a​ ​small​ ​minority​ ​of​ ​cases​ ​the​ ​opioid​ ​use 13


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. disorder​ ​developed​ ​independently​ ​by​ ​means​ ​of​ ​illicit​ ​opioid​ ​abuse, such​ ​as​ ​with​ ​heroin,​ ​or​ ​street​ ​pain​ ​pills. In​ ​simple​ ​terms,​ ​an​ ​opioid​ ​use​ ​disorder​ ​implies​ ​the​ ​brain​ ​has been​ ​changed,​ ​most​ ​often​ ​permanently,​ ​as​ ​a​ ​result​ ​of​ ​being exposed​ ​to​ ​opioids.​ ​In​ ​a​ ​formal​ ​published​ ​paper​ ​on​ ​“Chronic​ ​Opioid Agonist​ ​Therapy”​ ​(COAT)​ ​(15)​ ​the​ ​author​ ​estimates​ ​that​ ​about​ ​20% of​ ​patients​ ​develop​ ​a​ ​significant​ ​opioid​ ​use​ ​disorder​ ​who​ ​receive opioids​ ​chronically​ ​for​ ​pain.​ ​Recently,​ ​estimates​ ​from​ ​the​ ​Centers​ ​for Disease​ ​Control​ ​(CDC)​ ​are​ ​as​ ​high​ ​as​ ​25%​ ​of​ ​patients​ ​on​ ​COAT develop​ ​an​ ​opioid​ ​use​ ​disorder.​ ​ ​In​ ​several​ ​references​ ​(14,15)​ ​the criteria​ ​for​ ​an​ ​opioid​ ​use​ ​disorder,​ ​or​ ​opiate​ ​dependence,​ ​as​ ​it​ ​was formerly​ ​called,​ ​can​ ​be​ ​found.​ ​The​ ​criteria​ ​represent​ ​what​ ​experts and​ ​the​ ​best​ ​research​ ​conclude​ ​as​ ​to​ ​the​ ​criteria​ ​regarding​ ​who​ ​has an​ ​opioid​ ​use​ ​disorder.​ ​Note​ ​that​ ​none​ ​of​ ​the​ ​criteria​ ​have​ ​anything to​ ​do​ ​with​ ​moral​ ​or​ ​even​ ​legal​ ​concerns.​ ​The​ ​criteria​ ​are​ ​such​ ​that​ ​it becomes​ ​relatively​ ​easy​ ​to​ ​establish​ ​or​ ​exclude​ ​the​ ​diagnosis. Unfortunately,​ ​there​ ​are​ ​yet​ ​no​ ​established​ ​biomarkers​ ​as​ ​in diabetes​ ​or​ ​other​ ​chronic​ ​relapsing​ ​diseases.​ ​While​ ​there​ ​is​ ​quite​ ​a bit​ ​of​ ​ignorance​ ​as​ ​to​ ​the​ ​criteria,​ ​even​ ​amongst​ ​physicians,​ ​they​ ​are the​ ​best​ ​we​ ​have.​ ​ ​ ​They​ ​remain​ ​primarily​ ​dependent​ ​on​ ​an​ ​accurate and​ ​thorough​ ​patient​ ​history.​ ​ ​Occasionally​ ​physical​ ​exam​ ​helps alert​ ​an​ ​astute​ ​clinician​ ​to​ ​the​ ​possibility​ ​or​ ​likelihood​ ​of​ ​a​ ​patient having​ ​the​ ​disease.​ ​ ​ ​Appendix​ ​I​ ​is​ ​a​ ​brief​ ​questionnaire​ ​that​ ​allows one​ ​to​ ​simply​ ​predict​ ​whether​ ​a​ ​patient​ ​has​ ​an​ ​opioid​ ​use​ ​disorder (OUD). It​ ​is​ ​important​ ​to​ ​appreciate​ ​that​ ​the​ ​20-25%​ ​of​ ​patients​ ​who develop​ ​an​ ​opioid​ ​use​ ​disorder​ ​(addiction)​ ​have​ ​risk​ ​factors. Genetics​ ​play​ ​a​ ​large​ ​role.​ ​Another​ ​important​ ​factor​ ​is​ ​the​ ​age​ ​when

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. one​ ​is​ ​first​ ​exposed​ ​to​ ​significant​ ​amounts​ ​of​ ​opioids.​ ​The​ ​earlier​ ​the age,​ ​the​ ​greater​ ​the​ ​risk.​ ​Exposure​ ​prior​ ​to​ ​brain​ ​maturity​ ​is particularly​ ​risky.​ ​We​ ​also​ ​know​ ​that​ ​significant​ ​trauma​ ​in​ ​the​ ​past, whether​ ​physical,​ ​sexual,​ ​psychological,​ ​or​ ​even​ ​spiritual,​ ​greatly increases​ ​risks.​ ​Comorbid​ ​substance​ ​use​ ​disorders,​ ​whether​ ​legal​ ​or not,​ ​such​ ​as​ ​to​ ​alcohol​ ​and​ ​tobacco,​ ​are​ ​major​ ​risk​ ​factors.​ ​Other co-morbid​ ​mental​ ​health​ ​problems​ ​increase​ ​the​ ​risks​ ​as​ ​well. Based​ ​on​ ​the​ ​patient’s​ ​history,​ ​familiarity​ ​with​ ​the​ ​formal​ ​criteria, as​ ​well​ ​as​ ​the​ ​risk​ ​factors,​ ​a​ ​diagnosis​ ​of​ ​an​ ​opioid​ ​use​ ​disorder​ ​is made.​ ​In​ ​cases​ ​less​ ​clear,​ ​it​ ​is​ ​best​ ​to​ ​be​ ​conservative​ ​and​ ​to​ ​treat patients​ ​as​ ​though​ ​they​ ​have​ ​an​ ​opioid​ ​use​ ​disorder,​ ​until​ ​proven otherwise.​ ​This​ ​is​ ​particularly​ ​true​ ​when​ ​the​ ​risk​ ​factors​ ​are significant. Bottomline,​ ​if​ ​a​ ​patient​ ​has​ ​an​ ​opioid​ ​use​ ​disorder,​ ​particularly​ ​if it​ ​is​ ​moderate​ ​or​ ​severe,​ ​their​ ​prognosis​ ​is​ ​poor​ ​without​ ​ongoing agonist​ ​(opioid)​ ​therapy.​ ​The​ ​literature​ ​and​ ​expert​ ​consensus confirming​ ​this​ ​are​ ​significant​ ​compared​ ​to​ ​most​ ​indications​ ​for medical​ ​care.​ ​The​ ​prognosis​ ​is​ ​particularly​ ​poor,​ ​and​ ​reasonably​ ​so, if​ ​a​ ​patient​ ​has​ ​comorbid,​ ​serious​ ​pain​ ​or​ ​other​ ​mental​ ​health disorders. Are​ ​Opioids​ ​Part​ ​of​ ​the​ ​problem? There​ ​are​ ​about​ ​30%​ ​of​ ​patients​ ​on​ ​COAT,​ ​who​ ​will​ ​likely​ ​do better​ ​if​ ​tapered​ ​off​ ​of​ ​opioids.​ ​These​ ​patients​ ​have​ ​been​ ​“neuro sensitized”​ ​to​ ​opioids​ ​and​ ​as​ ​a​ ​result​ ​of​ ​long​ ​term​ ​use​ ​of​ ​opioids their​ ​pain​ ​thresholds​ ​become​ ​quite​ ​low.​ ​While​ ​their​ ​pain​ ​might​ ​seem to​ ​be​ ​better​ ​as​ ​the​ ​result​ ​of​ ​taking​ ​a​ ​pill,​ ​the​ ​fact​ ​is​ ​that​ ​the​ ​continued use​ ​of​ ​opioids​ ​is​ ​making​ ​the​ ​pain​ ​worse!​ ​The​ ​problem​ ​is​ ​trying​ ​to sort​ ​out​ ​which​ ​patients​ ​fit​ ​into​ ​this​ ​category.​ ​There​ ​are​ ​some 15


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. possible​ ​clinical​ ​indicators​ ​based​ ​on​ ​history​ ​and​ ​findings​ ​but generally​ ​the​ ​only​ ​way​ ​to​ ​know​ ​is​ ​a​ ​trial​ ​where​ ​the​ ​patient​ ​is​ ​slowly tapered​ ​off​ ​opioids​ ​and​ ​one​ ​follows​ ​them​ ​over​ ​time​ ​to​ ​assure​ ​their pain​ ​improves​ ​or​ ​at​ ​least​ ​doesn’t​ ​get​ ​worse. How​ ​about​ ​the​ ​other​ ​50%​ ​or​ ​so​ ​of​ ​patients​ ​who​ ​are​ ​on​ ​COAT? Are​ ​the​ ​opioids​ ​part​ ​of​ ​the​ ​solution​ ​or​ ​the​ ​problem?​ ​Sometimes​ ​the clinical​ ​history​ ​tells​ ​the​ ​story.​ ​If​ ​a​ ​patient​ ​has​ ​taken​ ​opioids​ ​for​ ​years, perhaps​ ​is​ ​elderly,​ ​and​ ​has​ ​done​ ​well​ ​with​ ​opioids​ ​with​ ​little​ ​or​ ​no side​ ​effects,​ ​and​ ​is​ ​apparently​ ​otherwise​ ​healthy​ ​and​ ​doing​ ​well,​ ​this sort​ ​of​ ​history​ ​supports​ ​ongoing​ ​judicious​ ​use​ ​of​ ​opioids.​ ​It​ ​is​ ​risky​ ​to put​ ​an​ ​elderly​ ​patient​ ​through​ ​unnecessary​ ​withdrawal​ ​or unmitigated​ ​pain.​ ​In​ ​other​ ​words,​ ​clinical​ ​context​ ​needs​ ​to​ ​be judiciously​ ​reviewed​ ​to​ ​best​ ​assess​ ​who​ ​is​ ​to​ ​be​ ​tapered,​ ​and​ ​if​ ​so, how​ ​quickly.​ ​Some​ ​patients​ ​in​ ​the​ ​“gray”​ ​area​ ​of​ ​having​ ​an​ ​OUD come​ ​in​ ​and​ ​want​ ​to​ ​be​ ​tapered​ ​off​ ​opioids.​ ​Understandably​ ​so,​ ​for who​ ​wants​ ​to​ ​have​ ​to​ ​take​ ​a​ ​medication​ ​to​ ​remain​ ​functional, especially​ ​a​ ​medication​ ​with​ ​all​ ​of​ ​the​ ​social​ ​concerns​ ​and​ ​taboos associated​ ​with​ ​its​ ​use.​ ​When​ ​unable​ ​to​ ​make​ ​the​ ​diagnosis​ ​of​ ​a significant​ ​opioid​ ​use​ ​disorder,​ ​and/or​ ​there​ ​is​ ​a​ ​lack​ ​of​ ​serious​ ​or multiple​ ​risk​ ​factors,​ ​of​ ​course​ ​one​ ​can​ ​help​ ​taper​ ​a​ ​patient​ ​off opioids.​ ​Meanwhile,​ ​a​ ​physician​ ​must​ ​help​ ​the​ ​patient​ ​to​ ​better assure​ ​their​ ​pain​ ​is​ ​well​ ​managed.​ ​As​ ​already​ ​stated,​ ​routine​ ​and regular​ ​follow​ ​up​ ​is​ ​indicated​ ​to​ ​assure​ ​progress​ ​with​ ​pain​ ​and overall​ ​health. There​ ​is​ ​much​ ​to​ ​be​ ​written​ ​on​ ​the​ ​subject​ ​of​ ​whether​ ​the opioids​ ​are​ ​part​ ​of​ ​the​ ​problem​ ​or​ ​the​ ​solution.​ ​In​ ​this​ ​brief discussion,​ ​I​ ​have​ ​not​ ​entertained​ ​the​ ​social​ ​and​ ​community​ ​risks associated​ ​with​ ​prescribing​ ​opioids.​ ​The​ ​focus​ ​here​ ​remains​ ​on

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. patient​ ​well-being.​ ​ ​That​ ​being​ ​said​ ​healthy​ ​patients​ ​make​ ​for healthy​ ​communities. Lastly,​ ​for​ ​those​ ​patients​ ​who​ ​likely​ ​benefit​ ​from​ ​COAT​ ​I routinely​ ​suggest​ ​the​ ​use​ ​of​ ​long-acting​ ​forms​ ​of​ ​opioids.​ ​The​ ​brain is​ ​designed​ ​to​ ​benefit​ ​from​ ​staying​ ​in​ ​a​ ​state​ ​of​ ​homeostasis.​ ​This simply​ ​means​ ​that​ ​the​ ​brain​ ​doesn’t​ ​like​ ​its​ ​internal​ ​environment​ ​to change​ ​very​ ​much.​ ​Short​ ​acting​ ​opiates,​ ​as​ ​appropriate​ ​as​ ​they​ ​are for​ ​acute​ ​pain,​ ​have​ ​little​ ​or​ ​no​ ​role​ ​in​ ​managing​ ​chronic​ ​complex pain.​ ​There​ ​may​ ​be​ ​a​ ​role​ ​for​ ​shorter​ ​acting​ ​opiates​ ​in​ ​acute​ ​flares​ ​of an​ ​underlying​ ​disease​ ​such​ ​as​ ​rheumatoid​ ​arthritis​ ​or​ ​gout.​ ​Long acting​ ​stabilizing​ ​opioids​ ​are​ ​most​ ​often​ ​the​ ​best​ ​option​ ​for​ ​long-term pain​ ​management​ ​with​ ​opioids.​ ​The​ ​intention​ ​with​ ​chronic​ ​pain management​ ​is​ ​to​ ​first​ ​and​ ​foremost​ ​help​ ​the​ ​brain​ ​and​ ​the​ ​rest​ ​of the​ ​CNS​ ​ ​function​ ​better.

4.​ ​What​ ​other​ ​interventions​ ​might​ ​best​ ​improve​ ​CNS​ ​function and​ ​help​ ​with​ ​pain​ ​management? In​ ​addition​ ​to​ ​opioids,​ ​many​ ​other​ ​interventions​ ​are​ ​available​ ​to help​ ​better​ ​manage​ ​pain.​ ​The​ ​problems​ ​are​ ​associated​ ​with​ ​access and​ ​effectiveness​ ​for​ ​a​ ​given​ ​patient.​ ​When​ ​it​ ​comes​ ​to​ ​helping​ ​the brain​ ​function​ ​better,​ ​there​ ​are​ ​a​ ​myriad​ ​of​ ​approaches​ ​and​ ​issues​ ​to explore.​ ​The​ ​OPAS​ ​handout​ ​Brain​ ​Health​ ​101​​ ​can​ ​be​ ​helpful​ ​to review​ ​in​ ​view​ ​of​ ​pain​ ​management,​ ​let​ ​alone​ ​memory,​ ​and​ ​brain fog. One​ ​of​ ​the​ ​biggest​ ​barriers​ ​to​ ​effective​ ​pain​ ​management​ ​is​ ​our relative​ ​inability​ ​to​ ​accurately​ ​predict​ ​who​ ​will​ ​respond​ ​best​ ​to​ ​which intervention.​ ​ ​As​ ​the​ ​Greeks​ ​said​ ​long​ ​ago​ ​“one​ ​man’s​ ​food​ ​is another’s​ ​poison.”​ ​As​ ​a​ ​certified​ ​and​ ​longstanding​ ​member​ ​in​ ​the 17


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. American​ ​Academy​ ​of​ ​Integrative​ ​Pain​ ​Management,​ ​I​ ​am​ ​aware​ ​of the​ ​many​ ​modalities​ ​which​ ​help​ ​patients​ ​to​ ​safely​ ​and​ ​effectively manage​ ​their​ ​pain.​ ​The​ ​issue​ ​becomes:​ ​“Where​ ​does​ ​one​ ​start?” This​ ​question​ ​is​ ​problematic​ ​for​ ​patients​ ​as​ ​well​ ​as​ ​for​ ​providers. We​ ​sometimes​ ​inappropriately​ ​expect​ ​patients​ ​to​ ​know​ ​what’s​ ​best for​ ​them​ ​even​ ​when​ ​we​ ​know​ ​that​ ​their​ ​brains​ ​are​ ​not​ ​working properly.​ ​ ​Nonetheless,​ ​when​ ​appropriate,​ ​it​ ​is​ ​helpful​ ​to​ ​provide choices.​ ​It​ ​is​ ​also​ ​generally​ ​wise​ ​to​ ​start​ ​with​ ​the​ ​safest​ ​options​ ​and proceed​ ​from​ ​there. The​ ​old​ ​adage​ ​“First​ ​things​ ​first”​ ​works​ ​well.​ ​Let’s​ ​make​ ​sure​ ​we are​ ​getting​ ​proper​ ​nutrition,​ ​exercise,​ ​and​ ​socialization​ ​to​ ​help​ ​us feel​ ​safer​ ​and​ ​less​ ​threatened.​ ​The​ ​precepts​ ​for​ ​good​ ​health​ ​are nothing​ ​new.​ ​Entire​ ​religions​ ​are​ ​built​ ​upon​ ​them. In​ ​patients​ ​on​ ​opioids​ ​or​ ​with​ ​pain​ ​management​ ​needs,​ ​good sleep​ ​is​ ​especially​ ​important.​ ​Sleep​ ​apnea​ ​needs​ ​to​ ​be​ ​ruled​ ​out. Opioids​ ​commonly​ ​can​ ​cause​ ​or​ ​aggravate​ ​sleep​ ​apnea. We​ ​want​ ​to​ ​make​ ​sure​ ​the​ ​body​ ​has​ ​what​ ​it​ ​needs​ ​to​ ​work properly​ ​at​ ​its​ ​best.​ ​Hormone​ ​levels​ ​are​ ​to​ ​be​ ​adequate.​ ​Vitamin​ ​D and​ ​other​ ​basic​ ​nutrients​ ​are​ ​to​ ​be​ ​optimized.​ ​Then​ ​let​ ​us​ ​assure there​ ​are​ ​no​ ​other​ ​major​ ​medical​ ​problems​ ​or​ ​substances​ ​being used​ ​that​ ​could​ ​interfere​ ​with​ ​healthy​ ​brains.​ ​The​ ​referenced​ ​paper: “Interaction​ ​of​ ​pain,​ ​anxiety,​ ​mood​ ​disorders,​ ​sleep,​ ​and​ ​all​ ​the​ ​other variables​ ​that​ ​contribute​ ​to​ ​feelings”​ ​(2)​ ​reviews​ ​in​ ​more​ ​depth​ ​how some​ ​of​ ​these​ ​other​ ​factors​ ​contribute​ ​to​ ​pain​ ​and​ ​vice​ ​versa. As​ ​already​ ​indicated,​ ​health​ ​is​ ​often​ ​associated​ ​with​ ​a​ ​sense​ ​of safety​ ​and​ ​well-being.​ ​ ​Indeed,​ ​brains​ ​work​ ​best​ ​when​ ​they​ ​are feeling​ ​safe​ ​and​ ​in​ ​a​ ​state​ ​of​ ​homeostasis.​ ​ ​So​ ​it​ ​is​ ​imperative​ ​we 18


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. promote​ ​same.​ ​ ​ ​Situational,​ ​as​ ​well​ ​as​ ​internal​ ​stresses,​ ​interfere with​ ​proper​ ​brain​ ​functioning.​ ​Over​ ​time​ ​we​ ​must​ ​do​ ​our​ ​best​ ​to eliminate​ ​internal​ ​stressors​ ​as​ ​well​ ​as​ ​external​ ​ones​ ​if​ ​we​ ​are​ ​to​ ​be as​ ​healthy​ ​as​ ​possible. We​ ​are​ ​made​ ​to​ ​move.​ ​Movement​ ​and​ ​exercise​ ​help​ ​brains, hearts,​ ​and​ ​other​ ​organs​ ​to​ ​work​ ​better.​ ​Of​ ​course​ ​for​ ​a​ ​number​ ​of reasons​ ​patients​ ​with​ ​chronic​ ​pain​ ​often​ ​are​ ​limited​ ​in​ ​their movements​ ​and​ ​ability​ ​to​ ​exercise.​ ​A​ ​concerted​ ​effort​ ​must​ ​be made.​ ​Often​ ​it​ ​takes​ ​professional​ ​help​ ​with​ ​physical​ ​and occupational​ ​therapists​ ​as​ ​well​ ​as​ ​professional​ ​behavioral​ ​and​ ​social support​ ​to​ ​see​ ​progress​ ​with​ ​movement​ ​and​ ​exercise. Co-occurring​ ​mental​ ​health​ ​conditions​ ​are​ ​common.​ ​Depression is​ ​well​ ​known​ ​to​ ​contribute​ ​to​ ​pain​ ​and​ ​can​ ​even​ ​be​ ​a​ ​primary​ ​cause. Since​ ​anxiety​ ​and​ ​Post​ ​Traumatic​ ​Stress​ ​Disorders​ ​are​ ​quite common,​ ​patients​ ​may​ ​benefit​ ​from​ ​care​ ​for​ ​same.​ ​(See References/Resources​ ​below) At​ ​OPAS.us​ ​patients​ ​can​ ​access​ ​a​ ​myriad​ ​of​ ​ways​ ​to​ ​better manage​ ​chronic​ ​pain.​ ​ ​One​ ​of​ ​the​ ​biggest​ ​clinical​ ​challenges​ ​in​ ​this work​ ​is​ ​tailoring​ ​an​ ​effective​ ​program​ ​to​ ​a​ ​unique​ ​patient.​ ​ ​Generally, it​ ​is​ ​not​ ​one​ ​simple​ ​intervention​ ​or​ ​change.​ ​It​ ​is​ ​commonly​ ​a combination​ ​of​ ​factors​ ​that​ ​work​ ​over​ ​time. One​ ​does​ ​not​ ​need​ ​to​ ​be​ ​free​ ​of​ ​pain​ ​in​ ​order​ ​to​ ​have​ ​a​ ​healthy and​ ​vibrant​ ​life.​ ​Indeed,​ ​an​ ​expectation​ ​in​ ​patients,​ ​who​ ​have​ ​chronic complex​ ​pain,​ ​to​ ​be​ ​pain-free​ ​paradoxically​ ​can​ ​compromise​ ​pain management.​ ​Some​ ​patients​ ​are​ ​inclined​ ​to​ ​catastrophize​ ​when​ ​it comes​ ​to​ ​their​ ​pain.​ ​While​ ​the​ ​term​ ​“catastrophize”​ ​can​ ​be​ ​overly dramatic,​ ​it​ ​does​ ​remind​ ​us​ ​to​ ​look​ ​closely​ ​at​ ​our​ ​expectations​ ​and perceptions​ ​about​ ​what​ ​we​ ​experience.​ ​Our​ ​brains​ ​clearly​ ​can​ ​play 19


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. tricks​ ​on​ ​us​ ​based​ ​on​ ​prior​ ​conditioning.​ ​We​ ​all​ ​are​ ​susceptible​ ​to same.​ ​It​ ​is​ ​simply​ ​human​ ​nature.​ ​The​ ​good​ ​news​ ​is​ ​that​ ​there​ ​is overwhelming​ ​evidence​ ​that​ ​brain​ ​can​ ​change​ ​and​ ​has​ ​what​ ​is called​ ​“neuroplasticity.”​ ​This​ ​simply​ ​means​ ​we​ ​are​ ​designed​ ​to​ ​learn. Perhaps​ ​it​ ​is​ ​no​ ​coincidence​ ​that​ ​the​ ​word​ ​“physician”​ ​is​ ​derived from​ ​roots​ ​which​ ​mean​ ​“teacher.”​ ​A​ ​good​ ​physician​ ​promotes healing​ ​by​ ​helping​ ​bodies​ ​and​ ​brains​ ​learn​ ​healthier​ ​patterns.​ ​When one​ ​must​ ​resort​ ​to​ ​outside​ ​support​ ​or​ ​interventions​ ​rather​ ​than depend​ ​on​ ​natural​ ​processes​ ​or​ ​learning,​ ​ ​this​ ​is​ ​more​ ​challenging and​ ​problematic,​ ​albeit​ ​often​ ​required​ ​for​ ​the​ ​best​ ​outcomes.

5.​ ​Establish​ ​an​ ​initial​ ​plan​ ​for​ ​progress Patients​ ​should​ ​always​ ​have​ ​a​ ​plan​ ​after​ ​each​ ​office​ ​visit.​ ​Using some​ ​of​ ​the​ ​basic​ ​principles​ ​already​ ​mentioned​ ​it​ ​is​ ​hopefully​ ​rather easy​ ​to​ ​establish​ ​an​ ​initial​ ​plan.​ ​ ​I​ ​often​ ​refer​ ​patients​ ​to​ ​our​ ​Plan Handout.​ ​(See​ ​Appendix​ ​3)​ ​The​ ​most​ ​important​ ​part​ ​of​ ​the​ ​plan​ ​is​ ​a return​ ​visit​ ​to​ ​assure​ ​there​ ​is​ ​progress​ ​in​ ​meeting​ ​one’s​ ​goals. Another​ ​important​ ​part​ ​of​ ​the​ ​initial​ ​plan​ ​is​ ​to​ ​better​ ​ensure​ ​that a​ ​patient​ ​has​ ​an​ ​adequate​ ​health​ ​care​ ​team.​ ​No​ ​one​ ​physician​ ​can do​ ​it​ ​all​ ​particularly​ ​in​ ​caring​ ​for​ ​many​ ​of​ ​the​ ​more​ ​complex​ ​pain patients.​ ​Often​ ​other​ ​specialists,​ ​as​ ​well​ ​a​ ​primary​ ​care​ ​provider,​ ​are needed​ ​as​ ​effective​ ​members​ ​of​ ​the​ ​team.​ ​Unfortunately,​ ​putting together​ ​this​ ​“care​ ​team”​ ​can​ ​be​ ​one​ ​of​ ​the​ ​biggest​ ​challenges.

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Chapter​ ​Two​ ​–​ ​Is​ ​the​ ​plan​ ​Working? To​ ​assess​ ​whether​ ​plans​ ​are​ ​working,​ ​follow​ ​up​ ​visits​ ​are initially​ ​at​ ​least​ ​monthly​ ​and​ ​commonly​ ​more​ ​frequent​ ​than​ ​that.​ ​The brain​ ​often​ ​takes​ ​three​ ​to​ ​six​ ​months​ ​in​ ​order​ ​to​ ​heal​ ​and​ ​make​ ​long term​ ​changes.​ ​Generally,​ ​progress​ ​or​ ​lack​ ​thereof,​ ​occur​ ​within​ ​the initial​ ​weeks,​ ​therefore​ ​more​ ​frequent​ ​office​ ​visits​ ​are​ ​helpful.​ ​A physician​ ​or​ ​patient​ ​can​ ​never​ ​be​ ​entirely​ ​sure​ ​what​ ​is​ ​going​ ​to​ ​work when​ ​it​ ​comes​ ​to​ ​managing​ ​chronic​ ​pain.​ ​The​ ​variables​ ​involved​ ​are often​ ​complex.​ ​Progress​ ​commonly​ ​becomes​ ​a​ ​product​ ​of​ ​trial​ ​and error.​ ​In​ ​complex​ ​cases,​ ​patients​ ​can​ ​take​ ​six​ ​months​ ​or​ ​even​ ​longer to​ ​establish​ ​a​ ​plan​ ​that​ ​is​ ​working,​ ​relatively​ ​safe,​ ​and​ ​is​ ​sustainable. In​ ​any​ ​event,​ ​when​ ​the​ ​plan​ ​is​ ​not​ ​working,​ ​it​ ​needs​ ​to​ ​be​ ​changed. Patients​ ​with​ ​pain​ ​issues​ ​are​ ​commonly​ ​told​ ​that​ ​there​ ​is​ ​nothing more​ ​that​ ​can​ ​be​ ​done​ ​for​ ​their​ ​pain.​ ​This​ ​is​ ​not​ ​true.​ ​I​ ​have​ ​found​ ​it possible​ ​to​ ​help​ ​patients​ ​safely​ ​and​ ​dramatically​ ​without​ ​even​ ​being sure​ ​of​ ​the​ ​“why”​ ​for​ ​their​ ​pain. Some​ ​patients​ ​do​ ​not​ ​respond​ ​to​ ​standard​ ​measures.​ ​A physician,​ ​despite​ ​his​ ​or​ ​her​ ​expertise,​ ​may​ ​reasonably​ ​and professionally​ ​conclude​ ​that​ ​these​ ​patients​ ​cannot​ ​be​ ​helped.​ ​This​ ​is different​ ​than​ ​concluding​ ​there​ ​is​ ​nothing​ ​more​ ​that​ ​can​ ​be​ ​done​ ​to better​ ​manage​ ​a​ ​patient’s​ ​pain.​ ​The​ ​brain​ ​and​ ​central​ ​nervous system​ ​are​ ​very​ ​adaptable.​ ​The​ ​brain​ ​is​ ​capable​ ​of​ ​change​ ​and learning​ ​until​ ​it​ ​has​ ​deteriorated​ ​irreversibly.​ ​Some​ ​patients​ ​benefit from​ ​more​ ​intense​ ​therapy​ ​and​ ​might​ ​benefit​ ​from​ ​prolonged inpatient​ ​care.​ ​Even​ ​when​ ​this​ ​care​ ​may​ ​be​ ​indicated​ ​and​ ​helpful, patients​ ​and​ ​third​ ​party​ ​payers​ ​commonly​ ​balk.​ ​Indeed,​ ​financial constraints​ ​commonly​ ​limit​ ​access. 21


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. Family​ ​and​ ​psychological​ ​pressures​ ​can​ ​and​ ​do​ ​also​ ​impede progress.​ ​Based​ ​on​ ​a​ ​patient’s​ ​past​ ​experiences​ ​with​ ​prescribers and​ ​authority​ ​figures,​ ​a​ ​physician,​ ​particularly​ ​one​ ​who​ ​is​ ​a prescriber,​ ​may​ ​be​ ​unable​ ​to​ ​establish​ ​a​ ​therapeutic​ ​relationship. This​ ​is​ ​not​ ​a​ ​good​ ​prognostic​ ​sign.​ ​When​ ​patients​ ​do​ ​not​ ​like​ ​their physician​ ​or​ ​continue​ ​to​ ​feel​ ​worse​ ​as​ ​a​ ​result​ ​of​ ​ongoing​ ​office visits,​ ​common​ ​sense​ ​says​ ​something​ ​is​ ​wrong. We​ ​have​ ​already​ ​spoken​ ​to​ ​appropriate​ ​expectations​ ​in​ ​pain management,​ ​however,​ ​it​ ​bears​ ​repeating.​ ​Using​ ​our​ ​pain​ ​scale,​ ​if​ ​a patient’s​ ​pain​ ​levels​ ​are​ ​in​ ​the​ ​twenties​ ​or​ ​below​ ​out​ ​of​ ​100,​ ​this reflects​ ​successful​ ​pain​ ​management.​ ​Higher​ ​scores​ ​are​ ​quite acceptable​ ​for​ ​some​ ​and​ ​one​ ​day​ ​a​ ​patient’s​ ​pain​ ​score​ ​could​ ​be zero.​ ​Being​ ​pain​ ​free​ ​is​ ​not​ ​a​ ​reasonable​ ​expectation​ ​for​ ​most complex​ ​pain​ ​patients,​ ​albeit​ ​it​ ​does​ ​happen​ ​on​ ​occasion.​ ​Treating chronic​ ​pain​ ​is​ ​similar​ ​to​ ​treating​ ​most​ ​chronic​ ​and​ ​relapsing diseases.​ ​If​ ​one​ ​seeks​ ​perfection​ ​in​ ​treating​ ​diabetics​ ​one​ ​is​ ​likely​ ​to fail,​ ​become​ ​disappointed,​ ​or​ ​even​ ​cause​ ​harm.​ ​On​ ​the​ ​other​ ​hand, if​ ​one​ ​sees​ ​progress​ ​and​ ​ongoing​ ​reasonable​ ​blood​ ​sugar​ ​levels,​ ​the outcomes​ ​are​ ​generally​ ​favorable.​ ​It​ ​is​ ​similar​ ​in​ ​chronic​ ​pain management​ ​where​ ​progress​ ​and​ ​reasonable​ ​pain​ ​scores​ ​become indicators​ ​of​ ​good​ ​outcomes. The​ ​need​ ​to​ ​continue​ ​to​ ​evaluate​ ​our​ ​plans​ ​ ​is​ ​so​ ​important. Things​ ​change.​ ​ ​If​ ​a​ ​plan​ ​does​ ​not​ ​seem​ ​to​ ​be​ ​working​ ​as​ ​expected adjustments​ ​are​ ​in​ ​order.​ ​ ​Sometimes​ ​when​ ​the​ ​plan​ ​is​ ​working​ ​well, some​ ​of​ ​the​ ​components​ ​can​ ​be​ ​dropped​ ​and​ ​patients​ ​continue​ ​to do​ ​well.​ ​No​ ​single​ ​recipe​ ​works​ ​for​ ​everyone.​ ​That​ ​is​ ​why​ ​it​ ​is​ ​helpful to​ ​provide​ ​options​ ​for​ ​patients,​ ​whenever​ ​possible.​ ​Handouts​ ​and links​ ​related​ ​to​ ​pain​ ​management​ ​options​ ​are​ ​quite​ ​helpful. 22


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. The​ ​options​ ​are​ ​similar​ ​to​ ​a​ ​menu​ ​at​ ​a​ ​restaurant.​ ​We​ ​choose from​ ​the​ ​myriad​ ​of​ ​options​ ​and​ ​see​ ​what​ ​works​ ​and​ ​helps​ ​patients function​ ​better​ ​and​ ​feel​ ​better.​ ​If​ ​a​ ​patient​ ​wants​ ​help​ ​or​ ​suggestions in​ ​prioritizing​ ​what​ ​to​ ​try​ ​next,​ ​professional​ ​guidance​ ​is​ ​helpful. Sometimes,​ ​over​ ​time​ ​and​ ​in​ ​getting​ ​to​ ​know​ ​a​ ​patient,​ ​an​ ​astute clinician​ ​can​ ​become​ ​confident​ ​that​ ​one​ ​option​ ​will​ ​likely​ ​work​ ​better than​ ​another.​ ​It​ ​is​ ​often​ ​a​ ​humbling​ ​process​ ​for​ ​both​ ​patients​ ​and clinicians.​ ​Both​ ​may​ ​be​ ​commonly​ ​mistaken​ ​about​ ​what​ ​will​ ​work. ​ ​ ​ ​ ​ ​ ​ ​Given​ ​the​ ​uncertainties​ ​in​ ​initial​ ​plans,​ ​it​ ​makes​ ​sense​ ​to start​ ​with​ ​the​ ​safest​ ​remedies​ ​and​ ​proceed​ ​from​ ​there.​ ​During​ ​the process​ ​of​ ​coming​ ​up​ ​with​ ​an​ ​effective​ ​plan,​ ​some​ ​of​ ​the​ ​slogans found​ ​in​ ​12-step​ ​recovery​ ​programs​ ​can​ ​be​ ​helpful.​ ​ ​For​ ​example:​ ​it takes​ ​time,​ ​progress​ ​not​ ​perfection,​ ​easy​ ​does​ ​it,​ ​keep​ ​coming​ ​back, it​ ​works​ ​if​ ​you​ ​work​ ​it,​ ​it’s​ ​a​ ​“we”​ ​thing,​ ​take​ ​what’s​ ​of​ ​use​ ​and​ ​leave the​ ​rest,​ ​these​ ​are​ ​but​ ​suggestions.​ ​As​ ​with​ ​addictive​ ​disorders, family​ ​therapy​ ​can​ ​also​ ​be​ ​helpful​ ​adjunct.​ ​ ​In​ ​there​ ​wanting​ ​to​ ​help​ ​it is​ ​not​ ​uncommon​ ​for​ ​family​ ​members​ ​to​ ​be​ ​part​ ​of​ ​a​ ​problem.

Chapter​ ​Three​ ​–​ ​What​ ​are​ ​your​ ​options​ ​if​ ​the plan​ ​is​ ​not​ ​working​ ​or​ ​your​ ​physician/caregiver is​ ​not​ ​offering​ ​viable​ ​alternatives? 1. The​ ​first​ ​step​ ​is​ ​often​ ​to​ ​make​ ​a​ ​visit​ ​with​ ​a​ ​primary​ ​care provider. 2. How​ ​to​ ​help​ ​your​ ​doctor​ ​properly​ ​prescribe​ ​pain​ ​medications to​ ​you.

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. 3. 10-Step​ ​“To​ ​Do”​ ​List​ ​to​ ​Help​ ​Your​ ​Doctor​ ​Help​ ​You. Despite​ ​adequate​ ​medical​ ​coverage,​ ​patients​ ​and​ ​caregivers are​ ​regrettably​ ​needing​ ​to​ ​spend​ ​valuable​ ​time​ ​and​ ​effort​ ​to​ ​obtain the​ ​services​ ​that​ ​are​ ​medically​ ​indicated​ ​for​ ​their​ ​patients.​ ​Well​ ​over 50%​ ​of​ ​clinical​ ​time​ ​may​ ​be​ ​spent​ ​in​ ​debriefing​ ​and​ ​helping​ ​patients regarding​ ​third​ ​party​ ​and​ ​regulatory​ ​issues.​ ​Another​ ​common concern​ ​is​ ​the​ ​lack​ ​of​ ​ready​ ​access​ ​to​ ​indicated​ ​medical​ ​care. Former​ ​pain​ ​clinics,​ ​which​ ​helped​ ​many​ ​patients,​ ​are​ ​simply​ ​no longer​ ​around.​ ​Third​ ​parties​ ​will​ ​no​ ​longer​ ​pay​ ​for​ ​them.​ ​This​ ​latter concern​ ​is​ ​particularly​ ​pertinent​ ​for​ ​patients​ ​who​ ​benefit​ ​from​ ​COAT for​ ​their​ ​chronic​ ​complex​ ​pain​ ​concerns. No​ ​quick​ ​resolution​ ​is​ ​forthcoming​ ​to​ ​offset​ ​the​ ​waste​ ​of​ ​time and​ ​resources​ ​related​ ​to​ ​regulatory​ ​and​ ​third​ ​party​ ​involvement. These​ ​have​ ​become​ ​more​ ​of​ ​a​ ​problem​ ​than​ ​a​ ​help​ ​when​ ​it​ ​comes to​ ​cost-effective​ ​medical​ ​care.​ ​The​ ​waste​ ​increases​ ​costs​ ​and further​ ​limits​ ​access​ ​to​ ​services.​ ​Access​ ​to​ ​COAT​ ​in​ ​small​ ​towns​ ​and rural​ ​areas​ ​in​ ​the​ ​State​ ​of​ ​Washington​ ​has​ ​been​ ​limited​ ​further​ ​by recent​ ​legislation​ ​that​ ​has​ ​specified​ ​rules​ ​and​ ​regulations​ ​regarding the​ ​prescribing​ ​of​ ​opioids.​ ​Often​ ​physicians​ ​poorly​ ​understand​ ​the rules.​ ​Fear​ ​abounds​ ​because​ ​there​ ​is​ ​little​ ​in​ ​the​ ​way​ ​of​ ​legal precedent​ ​as​ ​to​ ​how​ ​the​ ​rules​ ​will​ ​be​ ​interpreted​ ​and​ ​reinforced. These​ ​liabilities​ ​have​ ​prompted​ ​even​ ​large​ ​practices​ ​to announce​ ​they​ ​will​ ​not​ ​provide​ ​opioids​ ​for​ ​chronic,​ ​non-cancerous pain.​ ​The​ ​liabilities​ ​are​ ​coupled​ ​with​ ​other​ ​factors​ ​that​ ​explain​ ​limited access​ ​to​ ​care:​ ​chronic​ ​pain​ ​management​ ​is​ ​relatively​ ​poorly reimbursed;​ ​many​ ​physicians​ ​are​ ​not​ ​prepared​ ​to​ ​safely​ ​and effectively​ ​manage​ ​chronic​ ​complex​ ​pain​ ​with​ ​or​ ​without​ ​opioids; complex​ ​pain​ ​is​ ​often​ ​complicated​ ​by​ ​other​ ​medical​ ​concerns, 24


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. substance​ ​use​ ​disorders,​ ​and​ ​other​ ​significant​ ​medical​ ​and​ ​mental health​ ​conditions;​ ​a​ ​team​ ​and​ ​collaborative​ ​approach​ ​to​ ​care​ ​is indicated.​ ​Given​ ​all​ ​these​ ​barriers​ ​to​ ​proper​ ​care​ ​what​ ​might​ ​one​ ​do? When​ ​confronting​ ​significant​ ​“system”​ ​problems​ ​over​ ​which​ ​we have​ ​little​ ​control,​ ​it​ ​is​ ​best​ ​to​ ​focus​ ​on​ ​solutions​ ​and​ ​come​ ​back​ ​to what​ ​we​ ​can​ ​do​ ​to​ ​receive​ ​the​ ​medical​ ​services​ ​indicated.​ ​The following​ ​is​ ​a​ ​list​ ​of​ ​some​ ​of​ ​the​ ​suggestions​ ​and​ ​steps​ ​which​ ​we have​ ​provided​ ​to​ ​patients​ ​at​ ​Olympas​ ​Pain​ ​and​ ​Addiction​ ​Services.

1.​ ​The​ ​first​ ​step​ ​is​ ​generally​ ​to​ ​make​ ​a​ ​visit​ ​with​ ​a primary​ ​care​ ​provider See​ ​what​ ​a​ ​primary​ ​care​ ​provider​ ​is​ ​able​ ​to​ ​do​ ​for​ ​you.​ ​Your primary​ ​care​ ​provider​ ​may​ ​be​ ​a​ ​physician​ ​or​ ​some​ ​other​ ​medical professional.​ ​They​ ​are​ ​the​ ​medical​ ​practitioners​ ​who​ ​help​ ​patients receive​ ​indicated​ ​specialized​ ​care.​ ​The​ ​following​ ​are​ ​some suggestions​ ​regarding​ ​your​ ​dialogue​ ​with​ ​a​ ​primary​ ​care​ ​provider: a. When​ ​a​ ​medical​ ​professional​ ​suggests​ ​a​ ​change​ ​in​ ​your medical​ ​regimen,​ ​ask​ ​on​ ​what​ ​basis​ ​the​ ​change​ ​will​ ​be judged.​ ​What​ ​is​ ​the​ ​time​ ​frame?​ ​How​ ​frequently​ ​will​ ​you​ ​be seen​ ​to​ ​assure​ ​progress?​ ​What​ ​assurance​ ​do​ ​they​ ​give​ ​if other​ ​therapies​ ​are​ ​not​ ​working​ ​or​ ​there​ ​are​ ​complications? What​ ​can​ ​or​ ​will​ ​be​ ​tried​ ​to​ ​at​ ​least​ ​provide​ ​you​ ​with​ ​similar relief​ ​to​ ​your​ ​current​ ​regimen.​ ​Formally​ ​documenting​ ​the content​ ​of​ ​the​ ​conversation​ ​helps​ ​to​ ​assure​ ​accountability. Even​ ​physicians​ ​can​ ​forget​ ​what​ ​they​ ​said​ ​or​ ​agreed​ ​to.​ ​Was the​ ​conversation​ ​part​ ​of​ ​the​ ​medical​ ​record?​ ​You​ ​have​ ​the right​ ​always​ ​to​ ​look​ ​at​ ​your​ ​medical​ ​record​ ​and​ ​correct​ ​it, when​ ​it​ ​is​ ​incomplete. 25


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. b. If​ ​one​ ​has​ ​an​ ​Opioid​ ​Use​ ​Disorder,​ ​be​ ​sure​ ​to​ ​discuss​ ​that even​ ​the​ ​Washington​ ​State​ ​pain​ ​rules​ ​confirm​ ​the​ ​importance of​ ​agonist​ ​therapy.​ ​To​ ​not​ ​have​ ​access​ ​to​ ​proper​ ​agonist therapy​ ​provides​ ​a​ ​patient​ ​redress​ ​under​ ​the​ ​pain​ ​rules​ ​and formal​ ​professional​ ​standards. c. When​ ​harm​ ​or​ ​financial​ ​loss​ ​ ​is​ ​present​ ​by​ ​either​ ​a​ ​failure​ ​to make​ ​an​ ​appropriate​ ​diagnosis​ ​or​ ​not​ ​assure​ ​appropriate care,​ ​malpractice​ ​laws​ ​may​ ​apply.​ ​This​ ​is​ ​the​ ​last​ ​resort because​ ​ultimately​ ​the​ ​process​ ​of​ ​malpractice​ ​litigation​ ​does not​ ​prevent​ ​patients​ ​from​ ​suffering,​ ​experiencing​ ​undue disability,​ ​or​ ​even​ ​dying.​ ​ ​The​ ​process​ ​of​ ​a​ ​malpractice​ ​suit​ ​is very​ ​stressful.​ ​This​ ​is​ ​not​ ​a​ ​prescription​ ​for​ ​well-being​ ​for anyone,​ ​let​ ​alone​ ​a​ ​patient​ ​with​ ​complex​ ​chronic​ ​pain. d. Any​ ​physician​ ​at​ ​times​ ​must​ ​make​ ​recommendations​ ​that​ ​a patient​ ​doesn’t​ ​like​ ​to​ ​hear,​ ​or​ ​is​ ​reticent​ ​about,​ ​whether​ ​it concerns​ ​prognosis,​ ​medications,​ ​surgery,​ ​hospitalization, behavioral​ ​therapy,​ ​diagnostic​ ​testing,​ ​stopping​ ​smoking,​ ​etc. It​ ​is​ ​a​ ​physician’s​ ​responsibility,​ ​however,​ ​to​ ​assure​ ​that​ ​long term​ ​health​ ​improves​ ​as​ ​a​ ​result​ ​of​ ​referrals​ ​and​ ​other recommendations.​ ​ ​These​ ​recommendations​ ​are​ ​best​ ​when based​ ​on​ ​individual​ ​needs​ ​in​ ​addition​ ​to​ ​the​ ​available population​ ​and​ ​group​ ​based​ ​studies​ ​(evidence​ ​based medicine). e. It​ ​is​ ​not​ ​enough​ ​for​ ​a​ ​primary​ ​care​ ​provider​ ​or​ ​other physicians​ ​to​ ​say​ ​they​ ​can’t​ ​help​ ​you.​ ​It​ ​is​ ​the​ ​responsibility​ ​of all​ ​licensed​ ​practitioners​ ​to​ ​advocate​ ​for​ ​and​ ​help​ ​a​ ​patient obtain​ ​the​ ​best​ ​medical​ ​care.​ ​There​ ​are​ ​limits​ ​as​ ​already discussed​ ​as​ ​to​ ​what​ ​any​ ​medical​ ​professional​ ​is​ ​able​ ​to 26


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. provide.​ ​Let​ ​us​ ​limit​ ​energy​ ​spent​ ​in​ ​being​ ​critical​ ​or​ ​blaming. Focus​ ​on​ ​possible​ ​solutions​ ​first​ ​for​ ​you,​ ​then​ ​loved​ ​ones,​ ​and then​ ​for​ ​the​ ​greater​ ​community. f. The​ ​Washington​ ​State’s​ ​Medical​ ​Quality​ ​Assurance Commission​ ​is​ ​the​ ​governmental​ ​authority​ ​that​ ​oversees whether​ ​patients​ ​receive​ ​professional​ ​care​ ​from​ ​licensed practitioners.​ ​The​ ​commission​ ​can​ ​be​ ​contacted​ ​online​ ​and the​ ​office​ ​has​ ​a​ ​handout​ ​(16)​ ​on​ ​seeking advocacy/accountability​ ​through​ ​the​ ​commission. Once​ ​we​ ​have​ ​assured​ ​care​ ​for​ ​ourselves​ ​or​ ​loved​ ​one,​ ​we​ ​all must​ ​wonder​ ​what​ ​we​ ​can​ ​do​ ​politically​ ​and​ ​socially​ ​to​ ​address​ ​the social​ ​concerns​ ​about​ ​access​ ​to​ ​necessary​ ​pain​ ​management​ ​care and​ ​the​ ​proper​ ​use​ ​of​ ​opioids.​ ​The​ ​over​ ​reliance​ ​on​ ​opioids​ ​for​ ​pain management​ ​has​ ​contributed​ ​to​ ​the​ ​current​ ​opioid​ ​abuse​ ​epidemic. The​ ​causes​ ​are​ ​much​ ​more​ ​complex​ ​and​ ​the​ ​reader​ ​can​ ​review​ ​the author’s​ ​thoughts​ ​and​ ​opinions​ ​on​ ​this​ ​subject​ ​in​ ​a​ ​small compendium​ ​on​ ​the​ ​subject​ ​(17).​ ​In​ ​addition,​ ​refer​ ​to​ ​the​ ​online publication​ ​on​ ​the​ ​cultural​ ​influences​ ​regarding​ ​how​ ​we​ ​address substance​ ​abuse​ ​issues.(18) The​ ​following​ ​suggestions​ ​were​ ​provided​ ​to​ ​patients​ ​in​ ​a​ ​memo provided​ ​many​ ​years​ ​ago.​ ​Some​ ​of​ ​the​ ​suggestions​ ​are​ ​most pertinent​ ​for​ ​patients​ ​residing​ ​in​ ​the​ ​State​ ​of​ ​Washington.​ ​Some​ ​of the​ ​suggestions​ ​duplicate​ ​what​ ​has​ ​already​ ​been​ ​said​ ​above.​ ​Often nothing​ ​seems​ ​to​ ​work​ ​and​ ​unfortunately​ ​patients​ ​suffer​ ​and​ ​die​ ​as the​ ​result​ ​of​ ​lack​ ​of​ ​access​ ​to​ ​proper​ ​medical​ ​care.​ ​Facts,​ ​reason, and​ ​even​ ​disciplinary​ ​consequences​ ​may​ ​not​ ​sway​ ​an​ ​individual​ ​or culture​ ​with​ ​a​ ​rigid​ ​belief​ ​system.​ ​This​ ​seems​ ​to​ ​be​ ​particularly​ ​true

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. when​ ​beliefs​ ​are​ ​reinforced​ ​by​ ​those​ ​in​ ​authority​ ​and​ ​relate​ ​to established​ ​laws​ ​and​ ​regulations.

2.​ ​How​ ​to​ ​help​ ​your​ ​doctor​ ​properly​ ​prescribe​ ​pain medications​ ​to​ ​you Audience:​ ​This​ ​is​ ​for​ ​patients​ ​in​ ​Washington​ ​State’s​ ​North Olympic​ ​Peninsula​ ​area,​ ​who​ ​struggle​ ​to​ ​find​ ​a​ ​physician​ ​who​ ​will prescribe​ ​them​ ​pain​ ​medications​ ​or​ ​agonist​ ​therapy​ ​for​ ​opiate addiction.​ ​It​ ​may​ ​be​ ​used​ ​in​ ​conjunction​ ​with​ ​our​ ​List​ ​of​ ​Providers and​ ​our​ ​Letter​ ​to​ ​Colleagues.​ ​Other​ ​pertinent​ ​handouts​ ​are​ ​available online​ ​at​ ​www.opas.us. Note:​ ​No​ ​single​ ​recommendation​ ​would​ ​help​ ​every​ ​patient​ ​with every​ ​doctor.​ ​As​ ​with​ ​the​ ​best​ ​of​ ​medical​ ​care,​ ​these​ ​matters​ ​need to​ ​be​ ​individualized.​ ​Certain​ ​principles​ ​and​ ​suggestions​ ​are​ ​more likely​ ​to​ ​help.​ ​For​ ​a​ ​host​ ​of​ ​reasons,​ ​physicians​ ​may​ ​not​ ​feel comfortable​ ​prescribing​ ​controlled​ ​substances​ ​to​ ​patients.​ ​Your​ ​job is​ ​not​ ​to​ ​convince​ ​your​ ​physician​ ​to​ ​feel​ ​differently​ ​or​ ​to​ ​convince him​ ​or​ ​her​ ​of​ ​anything.​ ​ ​Rather,​ ​I​ ​suggest​ ​you​ ​do​ ​your​ ​best​ ​to​ ​listen and​ ​understand​ ​the​ ​reasons​ ​they​ ​have​ ​for​ ​making​ ​their recommendations. In​ ​medicine​ ​there​ ​have​ ​always​ ​been​ ​different​ ​opinions​ ​about what​ ​constitutes​ ​the​ ​best​ ​care​ ​for​ ​a​ ​given​ ​patient.​ ​Decisions​ ​are sometimes​ ​based​ ​on​ ​“cultural”​ ​factors​ ​more​ ​than​ ​scientific​ ​evidence or​ ​knowledge.​ ​Nonetheless,​ ​as​ ​best​ ​one​ ​can,​ ​attempt​ ​to​ ​understand the​ ​medical​ ​reasons​ ​for​ ​the​ ​recommendations.​ ​Try​ ​not​ ​to​ ​focus​ ​just on​ ​what​ ​you​ ​think​ ​is​ ​indicated.​ ​Nonetheless,​ ​it​ ​is​ ​advisable​ ​to express​ ​one’s​ ​desire​ ​to​ ​receive​ ​the​ ​best​ ​of​ ​medical​ ​care.​ ​Also attempt​ ​to​ ​be​ ​understanding,​ ​for​ ​even​ ​the​ ​experts,​ ​such​ ​as​ ​those 28


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. who​ ​promoted​ ​guidelines​ ​at​ ​the​ ​CDC,​ ​made​ ​guidelines​ ​not​ ​so​ ​much on​ ​the​ ​facts​ ​or​ ​how​ ​we​ ​generally​ ​manage​ ​medication​ ​related problems,​ ​but​ ​on​ ​political​ ​and​ ​cultural​ ​factors.​ ​An​ ​example​ ​of​ ​this​ ​is the​ ​CDC’s​ ​attachment​ ​to​ ​the​ ​lack​ ​of​ ​evidence​ ​of​ ​efficacy​ ​for​ ​opioids for​ ​pain​ ​at​ ​52​ ​weeks.​ ​A​ ​recent​ ​review​ ​of​ ​the​ ​literature​ ​revealed​ ​no medication​ ​is​ ​prescribed​ ​for​ ​a​ ​chronic,​ ​painful​ ​condition​ ​which​ ​has demonstrated​ ​evidence​ ​for​ ​long​ ​term​ ​efficacy.​ ​Likewise,​ ​the​ ​benefits of​ ​opioids​ ​are​ ​similar​ ​to​ ​other​ ​medications​ ​used​ ​for​ ​chronic​ ​painful conditions.​ ​That​ ​is​ ​about​ ​20-30%​ ​improvement.

3.​ ​10-Step​ ​“To​ ​Do”​ ​List​ ​to​ ​Help​ ​Your​ ​Doctor​ ​Help​ ​You 1.​ ​Make​ ​An​ ​Appointment 2.​ ​Your​ ​First​ ​Visit 3.​ ​What​ ​You​ ​Want 4.​ ​Work​ ​With​ ​Your​ ​Doctor 5.​ ​Ask​ ​Questions 6.​ ​Be​ ​Willing​ ​to​ ​make​ ​regular​ ​visits,​ ​etc. 7.​ ​Educate​ ​Yourself 8.​ ​Be​ ​Knowledgeable 9.​ ​Ask​ ​for​ ​Referral 10.​ ​Minimize​ ​Stress

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

1.​ ​Make​ ​An​ ​Appointment. In​ ​general,​ ​it​ ​is​ ​best​ ​to​ ​make​ ​an​ ​appointment​ ​at​ ​a​ ​primary​ ​care office,​ ​where​ ​you​ ​have​ ​been​ ​seen​ ​sometime​ ​during​ ​the​ ​previous three​ ​years.​ ​You​ ​are​ ​then​ ​by​ ​definition​ ​“an​ ​established​ ​patient.” Make​ ​an​ ​initial​ ​appointment​ ​for​ ​a​ ​general​ ​checkup.​ ​Your appointment​ ​should​ ​be​ ​with​ ​a​ ​primary​ ​care​ ​provider,​ ​who​ ​is generally​ ​most​ ​interested​ ​in​ ​your​ ​general​ ​medical​ ​care​ ​rather​ ​than just​ ​addressing​ ​pain​ ​or​ ​addiction​ ​problems. 2.​ ​Your​ ​First​ ​Visit. ​ ​Once​ ​with​ ​the​ ​doctor​ ​or​ ​PCP,​ ​and​ ​after​ ​customary introductions,​ ​you​ ​may​ ​acknowledge​ ​that​ ​you​ ​are​ ​anxious.​ ​You might​ ​then​ ​ask​ ​the​ ​clinician​ ​if​ ​you​ ​may​ ​record​ ​the​ ​conversation​ ​to help​ ​better​ ​process​ ​what​ ​you​ ​are​ ​told.​ ​Another​ ​option​ ​is​ ​to​ ​bring​ ​a friend​ ​with​ ​you​ ​who​ ​will​ ​help​ ​you​ ​record​ ​what​ ​is​ ​said​ ​and​ ​likely​ ​allay some​ ​of​ ​your​ ​anxiety.​ ​People​ ​do​ ​not​ ​function​ ​at​ ​their​ ​best​ ​when overly​ ​anxious.​ ​It​ ​is​ ​advisable​ ​to​ ​review​ ​your​ ​medical​ ​record afterwards​ ​to​ ​make​ ​sure​ ​the​ ​discussions​ ​were​ ​properly​ ​and adequately​ ​recorded.​ ​One​ ​can​ ​always​ ​ask​ ​for​ ​corrections​ ​to​ ​the record​ ​when​ ​deemed​ ​appropriate. It​ ​is​ ​also​ ​helpful​ ​to​ ​bring​ ​in​ ​what​ ​old​ ​medical​ ​records​ ​you​ ​have which​ ​document​ ​who​ ​prescribed​ ​what​ ​and​ ​for​ ​what​ ​reasons.​ ​At​ ​the very​ ​least,​ ​bring​ ​in​ ​old​ ​prescription​ ​bottles.​ ​It​ ​is​ ​even​ ​better​ ​to​ ​bring in​ ​all​ ​the​ ​medications​ ​currently​ ​being​ ​prescribed.​ ​Most​ ​doctors​ ​now have​ ​access​ ​online​ ​to​ ​your​ ​list​ ​of​ ​currently​ ​prescribed,​ ​controlled substances,​ ​but​ ​nothing​ ​helps​ ​them​ ​more​ ​than​ ​seeing​ ​the​ ​actual prescription​ ​bottles.

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

3.​ ​What​ ​You​ ​Want ​ ​As​ ​much​ ​as​ ​possible​ ​be​ ​direct​ ​as​ ​you​ ​can​ ​in​ ​letting​ ​the​ ​doctor know​ ​what​ ​you​ ​want.​ ​“Doctor,​ ​whether​ ​you​ ​have​ ​additional​ ​or​ ​better suggestions​ ​for​ ​my​ ​pain​ ​management,​ ​I​ ​would​ ​feel​ ​less​ ​anxious,​ ​if​ ​I could​ ​have​ ​my​ ​prescriptions​ ​filled​ ​at​ ​their​ ​current​ ​level,​ ​at​ ​least​ ​until other​ ​options​ ​are​ ​on​ ​board​ ​and​ ​working.​ ​In​ ​my​ ​experience,​ ​it​ ​is​ ​my current​ ​regimen​ ​that​ ​works​ ​best.​ ​If​ ​we​ ​can​ ​find​ ​other​ ​safer,​ ​better options​ ​I​ ​will​ ​be​ ​thankful.​ ​Of​ ​course,​ ​I​ ​am​ ​not​ ​happy​ ​about​ ​being dependent​ ​on​ ​these​ ​medications.”​ ​An​ ​alternative​ ​dialogue​ ​might start​ ​with​ ​“Doctor,​ ​I​ ​am​ ​very​ ​anxious​ ​about​ ​going​ ​through​ ​withdrawal and​ ​having​ ​worse​ ​pain.​ ​What​ ​are​ ​you​ ​specifically​ ​recommending​ ​I do​ ​to​ ​help​ ​me​ ​avoid​ ​withdrawal​ ​symptoms​ ​and​ ​to​ ​more​ ​effectively manage​ ​my​ ​pain? If​ ​you​ ​haven’t​ ​been​ ​formally​ ​evaluated​ ​for​ ​being​ ​opiate​ ​addicted, and​ ​there​ ​is​ ​a​ ​question​ ​about​ ​that,​ ​ask​ ​for​ ​such​ ​an​ ​evaluation.​ ​The criteria​ ​for​ ​an​ ​opioid​ ​use​ ​disorder​ ​are​ ​listed​ ​in​ ​Reference​ ​1​.​ ​Also, please​ ​review​ ​Appendix​ ​One​.​ ​If​ ​you​ ​have​ ​an​ ​opioid​ ​use​ ​disorder (OUD)​ ​inform​ ​your​ ​primary​ ​care​ ​provider​ ​of​ ​such.​ ​Let​ ​him​ ​or​ ​her​ ​also know,​ ​that​ ​whenever​ ​possible,​ ​you​ ​intend​ ​to​ ​follow​ ​through​ ​as​ ​best you​ ​can​ ​with​ ​the​ ​recommendations. 4.​ ​Work​ ​With​ ​Your​ ​Doctor. If​ ​the​ ​doctor​ ​indicates​ ​a​ ​need​ ​for​ ​more​ ​records​ ​or​ ​more diagnostic​ ​tests​ ​before​ ​he​ ​or​ ​she​ ​would​ ​feel​ ​comfortable​ ​prescribing you​ ​opiates,​ ​acknowledge​ ​the​ ​request​ ​and​ ​your​ ​willingness​ ​to comply.​ ​Do​ ​not​ ​hesitate​ ​though​ ​to​ ​request​ ​further​ ​clarifications: “Doctor,​ ​my​ ​understanding​ ​is​ ​that​ ​complex,​ ​chronic​ ​pain​ ​can​ ​not​ ​be 32


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. readily​ ​measured​ ​by​ ​standard​ ​diagnostic​ ​tests​ ​but​ ​these​ ​tests generally​ ​only​ ​provide​ ​clues​ ​as​ ​to​ ​why​ ​I​ ​might​ ​be​ ​in​ ​pain.”​ ​“How​ ​are the​ ​diagnostic​ ​tests​ ​you​ ​are​ ​ordering​ ​going​ ​to​ ​determine​ ​how​ ​much pain​ ​I​ ​am​ ​in​ ​or​ ​how​ ​much​ ​pain​ ​medications​ ​I​ ​require?”​ ​Alternatively, try​ ​“Doctor,​ ​I​ ​am​ ​happy​ ​to​ ​complete​ ​any​ ​formal​ ​pain​ ​questionnaire for​ ​I​ ​understand​ ​they​ ​are​ ​helpful​ ​to​ ​you​ ​and​ ​for​ ​me​ ​to​ ​assess​ ​my progress.​ ​How​ ​do​ ​you​ ​suggest​ ​we​ ​are​ ​able​ ​to​ ​go​ ​forward​ ​with​ ​my pain​ ​management?​​ ​If​ ​you​ ​think​ ​it​ ​would​ ​be​ ​helpful,​ ​I​ ​am​ ​willing​ ​to see​ ​a​ ​pain​ ​specialist​ ​to​ ​validate​ ​my​ ​pain​ ​levels​ ​and​ ​plans​ ​for managing​ ​them.” Sometimes​ ​a​ ​doctor​ ​simply​ ​intends​ ​to​ ​confirm​ ​your​ ​prescriptions to​ ​assure​ ​you​ ​are​ ​not​ ​getting​ ​multiple​ ​prescriptions​ ​from​ ​multiple providers.​ ​This​ ​is​ ​reasonable.​ ​Fortunately,​ ​they​ ​can​ ​now​ ​check​ ​that out​ ​while​ ​you​ ​are​ ​in​ ​the​ ​office​ ​with​ ​the​ ​Washington​ ​State​ ​prescription monitoring​ ​program. When​ ​appropriate​ ​thank​ ​him​ ​or​ ​her​ ​for​ ​helping​ ​you​ ​find​ ​other options​ ​besides​ ​pain​ ​pills​ ​to​ ​get​ ​relief.​ ​Meanwhile,​ ​request​ ​that​ ​your pain​ ​be​ ​effectively​ ​addressed​ ​and​ ​remind​ ​them​ ​you​ ​want​ ​help​ ​to avoid​ ​any​ ​symptoms​ ​of​ ​withdrawal.​ ​Let​ ​them​ ​know​ ​that​ ​you​ ​are prepared​ ​to​ ​come​ ​back​ ​as​ ​often​ ​as​ ​they​ ​find​ ​necessary​ ​to​ ​help​ ​make sure​ ​that​ ​the​ ​medications​ ​are​ ​being​ ​used​ ​properly.​ ​You​ ​want​ ​them​ ​to be​ ​part​ ​of​ ​a​ ​solution​ ​rather​ ​than​ ​any​ ​problem. 5.​ ​Ask​ ​Questions If​ ​they​ ​recommend​ ​lowering​ ​your​ ​dosage​ ​ask​ ​them​ ​why.​ ​Ask them​ ​what​ ​they​ ​will​ ​do​ ​if​ ​the​ ​pain​ ​gets​ ​worse,​ ​or​ ​you​ ​develop​ ​classic symptoms​ ​of​ ​withdrawal,​ ​or​ ​you​ ​suffer​ ​from​ ​other​ ​stress​ ​related disorders.​ ​If​ ​they​ ​do​ ​not​ ​offer​ ​effective​ ​care​ ​for​ ​withdrawal,​ ​ask​ ​them why​ ​not? 33


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

6.​ ​Be​ ​Willing Remember​ ​that​ ​our​ ​current​ ​payment​ ​system​ ​does​ ​not​ ​reward physicians​ ​for​ ​spending​ ​much​ ​time​ ​with​ ​a​ ​patient.​ ​Be​ ​willing​ ​to​ ​come back​ ​frequently​ ​to​ ​have​ ​your​ ​questions​ ​answered​ ​or​ ​to​ ​express​ ​your concerns.​ ​Let​ ​them​ ​know​ ​you​ ​are​ ​willing​ ​to​ ​attempt​ ​behavioral​ ​and other​ ​interventions,​ ​if​ ​they​ ​are​ ​practically​ ​available,​ ​safe,​ ​and​ ​they are​ ​as​ ​likely​ ​to​ ​help​ ​with​ ​your​ ​pain​ ​management.​ ​Indeed,​ ​there​ ​is​ ​a subgroup​ ​of​ ​pain​ ​patients​ ​who​ ​will​ ​actually​ ​do​ ​much​ ​better, when​ ​they​ ​are​ ​off​ ​of​ ​all​ ​opioids​. 7.​ ​Educate​ ​Yourself ​ ​If​ ​they​ ​bring​ ​up​ ​the​ ​new​ ​Washington​ ​State​ ​law​ ​as​ ​the​ ​reason they​ ​cannot​ ​prescribe,​ ​inform​ ​them​ ​that​ ​you​ ​have​ ​read​ ​it​ ​(13).​ ​Share with​ ​the​ ​doctor​ ​that​ ​you​ ​do​ ​not​ ​see​ ​where​ ​the​ ​law​ ​prohibits​ ​them from​ ​maintaining​ ​patients​ ​on​ ​their​ ​current​ ​levels​ ​of​ ​opiates.​ ​If​ ​they request​ ​a​ ​formal​ ​pain​ ​management​ ​consultation​ ​agree​ ​to​ ​have​ ​one as​ ​soon​ ​as​ ​they​ ​can​ ​arrange​ ​it.​ ​Meanwhile,​ ​request​ ​that​ ​they prescribe​ ​adequate​ ​opioids​ ​for​ ​pain​ ​management​ ​to​ ​avoid​ ​any unnecessary​ ​withdrawal​ ​symptoms​ ​or​ ​pain. 8.​ ​Be​ ​Knowledgeable If​ ​they​ ​say​ ​that​ ​clinic​ ​or​ ​hospital​ ​policies​ ​do​ ​not​ ​allow​ ​them​ ​to prescribe​ ​you​ ​opioids​ ​or​ ​higher​ ​doses​ ​of​ ​opioids,​ ​then​ ​ask​ ​to​ ​see​ ​a copy​ ​of​ ​those​ ​policies.​ ​While​ ​confrontational,​ ​you​ ​might​ ​also​ ​ask whether​ ​those​ ​policies​ ​protect​ ​them​ ​from​ ​the​ ​legal​ ​and​ ​professional mandate​ ​to​ ​provide​ ​proper​ ​medical​ ​care.​ ​If​ ​they​ ​say​ ​you​ ​need treatment​ ​for​ ​addiction,​ ​ask​ ​them​ ​where​ ​you​ ​might​ ​get​ ​that​ ​help​ ​and ask​ ​for​ ​a​ ​formal​ ​referral.​ ​If​ ​they​ ​recommend​ ​a​ ​state​ ​licensed​ ​facility, other​ ​than​ ​a​ ​methadone​ ​clinic,​ ​remind​ ​them​ ​that​ ​agonist​ ​therapy​ ​is 34


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. not​ ​routinely​ ​available​ ​through​ ​state​ ​facilities​ ​and​ ​that​ ​our​ ​state licensed​ ​facilities​ ​rarely​ ​provide​ ​medical​ ​care.​ ​These​ ​facilities​ ​are also​ ​ill​ ​prepared​ ​to​ ​address​ ​chronic,​ ​complex​ ​pain.​ ​Agonist​ ​therapy is​ ​often​ ​required​ ​for​ ​proper​ ​brain​ ​function​ ​in​ ​patients​ ​who​ ​have​ ​an OUD.​ ​If​ ​this​ ​seems​ ​to​ ​be​ ​news​ ​to​ ​them,​ ​provide​ ​them​ ​with references​ ​from​ ​the​ ​“Agonist”​ ​paper​ ​(14). 9.​ ​Ask​ ​for​ ​Referral If​ ​the​ ​doctor​ ​acknowledges​ ​feeling​ ​unqualified​ ​to​ ​manage​ ​your pain​ ​or​ ​addiction​ ​needs,​ ​thank​ ​the​ ​doctor​ ​for​ ​being​ ​forthright.​ ​Then ask​ ​for​ ​a​ ​timely​ ​referral​ ​and​ ​if​ ​possible​ ​ask​ ​them,​ ​on​ ​account​ ​of​ ​your anxiety,​ ​to​ ​have​ ​the​ ​consultation​ ​set​ ​up​ ​before​ ​you​ ​leave.​ ​Another option​ ​is​ ​for​ ​you​ ​to​ ​ask​ ​them,​ ​as​ ​noted​ ​above,​ ​if​ ​they​ ​are​ ​willing​ ​to work​ ​with​ ​a​ ​specialist​ ​to​ ​assure​ ​you​ ​get​ ​the​ ​medical​ ​care​ ​required. Your​ ​primary​ ​care​ ​provider​ ​is​ ​arguably​ ​responsible​ ​to​ ​help​ ​you find​ ​the​ ​best​ ​medical​ ​care​ ​for​ ​you,​ ​especially​ ​when​ ​that​ ​care​ ​could be​ ​life-saving.​ ​If​ ​he​ ​or​ ​she​ ​does​ ​not​ ​know​ ​who​ ​to​ ​call​ ​for​ ​help​ ​or where​ ​to​ ​send​ ​you,​ ​acknowledge​ ​the​ ​lack​ ​of​ ​expertise​ ​or​ ​access​ ​to same​ ​in​ ​the​ ​area.​ ​Offer​ ​to​ ​go​ ​out​ ​of​ ​the​ ​area​ ​when​ ​needed.​ ​Even state​ ​Medicaid​ ​will​ ​transport​ ​patients​ ​out​ ​of​ ​an​ ​area​ ​to​ ​have​ ​access to​ ​needed​ ​specialized​ ​care. Lastly,​ ​you​ ​might​ ​ask​ ​whether​ ​they​ ​feel​ ​comfortable​ ​stabilizing you​ ​medically​ ​until​ ​more​ ​specialized​ ​care​ ​is​ ​available.​ ​If​ ​they​ ​do​ ​not think​ ​it​ ​is​ ​medically​ ​indicated​ ​to​ ​limit​ ​symptoms​ ​of​ ​withdrawal​ ​or​ ​to adequately​ ​treat​ ​pain,​ ​then​ ​I​ ​suggest​ ​you​ ​establish​ ​medical​ ​care elsewhere.​ ​This​ ​is​ ​also​ ​true​ ​if​ ​you​ ​feel​ ​they​ ​have​ ​qualified​ ​you​ ​simply as​ ​a​ ​“drug​ ​seeker.”​ ​There​ ​are​ ​significant​ ​prejudices​ ​toward​ ​patients on​ ​chronic​ ​opioids.​ ​ ​Be​ ​prepared​ ​to​ ​get​ ​second​ ​opinions​ ​and​ ​to complain​ ​to​ ​the​ ​Medical​ ​Quality​ ​Assurance​ ​Commission.​ ​When​ ​a 35


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. clinician​ ​simply​ ​writes​ ​off​ ​your​ ​symptoms​ ​as​ ​to​ ​“drug​ ​seeking behavior”​ ​without​ ​an​ ​appropriate​ ​evaluation,​ ​this​ ​constitutes unprofessional​ ​conduct.​ ​Patients​ ​have​ ​died​ ​or​ ​nearly​ ​died​ ​as​ ​a​ ​result of​ ​such​ ​questionable​ ​medical​ ​care. 10.​ ​One​ ​last​ ​clinical​ ​reminder:​ ​Minimize​ ​Stress Any​ ​change​ ​to​ ​care,​ ​particularly​ ​care​ ​perceived​ ​to​ ​be​ ​helping and​ ​part​ ​of​ ​a​ ​longterm​ ​approach,​ ​is​ ​stressful​ ​for​ ​a​ ​patient.​ ​I​ ​advise​ ​all patients,​ ​who​ ​are​ ​struggling​ ​to​ ​get​ ​proper​ ​medical​ ​care,​ ​to​ ​seek​ ​out professional​ ​and​ ​other​ ​support​ ​in​ ​dealing​ ​with​ ​anxiety.​ ​Anxiety​ ​does not​ ​help​ ​pain​ ​or​ ​the​ ​brain​ ​function​ ​better.​ ​Rather,​ ​anxiety​ ​is​ ​a​ ​strong trigger​ ​for​ ​pain​ ​to​ ​flare​ ​up​ ​or​ ​even​ ​to​ ​abuse​ ​substances,​ ​whether legal​ ​substances​ ​or​ ​not.

36


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

References​ ​/​ ​Resources 1. Opioid​ ​Use​ ​Disorder​ ​-​ ​Diagnostic​ ​Criteria 2. Overlap​ ​of​ ​chronic​ ​complex​ ​pain​ ​with​ ​other​ ​conditions​ ​by​ ​Dr. Rotchford​ ​2017 3.​ ​“Mystery​ ​of​ ​Chronic​ ​Pain"​ ​A​ ​Ted​ ​Talk​ ​by​ ​Dr.​ ​Krane​ ​reviews the​ ​evidence​ ​for​ ​considering​ ​chronic,​ ​non​ ​cancerous​ ​pain​ ​a​ ​disease unto​ ​itself. 4. “Pain​ ​and​ ​the​ ​brain:​ ​How​ ​love,​ ​fear,​ ​and​ ​much​ ​more​ ​affect​ ​the experience​ ​of​ ​pain”​ ​A​ ​Ted​ ​talk​ ​by​ ​Sean​ ​Mackey​ ​M.D.,​ ​PhD​ ​from Stanford​ ​University. 5. “Syllabus​ ​Regarding​ ​the​ ​basics​ ​of​ ​Chronic​ ​Pain​ ​and​ ​its management”​ ​ ​Dr.​ ​Rotchford 6.​ ​“Neuropathy”​ ​by​ ​Dr.​ ​Rotchford​ ​–​ ​2016 6A.​ ​“The​ ​OPAS​ ​Experience”​ ​–​ ​an​ ​article​ ​in​ ​the​ ​Pain​ ​Practitioner 2007,​ ​Dr.​ ​Rotchford 7. “Calming​ ​Trauma​ ​–​ ​How​ ​Understanding​ ​the​ ​Brain​ ​Can​ ​Help” Dawn​ ​McClelland,​ ​PhD 8. “PTSD​ ​-​ ​A​ ​Primer​ ​for​ ​patients”​ ​by​ ​J.K.​ ​Rotchford,​ ​M.D.​ ​2016. 9. “Dealing​ ​with​ ​the​ ​Effects​ ​of​ ​Trauma”​ ​-​ ​This​ ​is​ ​a​ ​great​ ​resource for​ ​lists​ ​of​ ​behavioral​ ​ways​ ​to​ ​more​ ​effectively​ ​reduce​ ​anxiety​ ​and feel​ ​safer. 10.​ ​“Ketamine​ ​and​ ​Low​ ​Dose​ ​therapy​ ​for​ ​Pain,​ ​Depression​ ​and PTSD”​ ​by​ ​J.​ ​K.​ ​Rotchford,​ ​M.D.​ ​2015.

37


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. 11.​ ​“Anxiety​ ​-​ ​A​ ​discussio”n​ ​-​ ​By​ ​J.K.​ ​Rotchford,​ ​M.D.​ ​Using anxiety​ ​as​ ​an​ ​example,​ ​a​ ​very​ ​brief​ ​review​ ​of​ ​the​ ​role​ ​of​ ​diagnoses, scientific​ ​methodology,​ ​and​ ​cultural​ ​factors​ ​and​ ​how​ ​they​ ​influence our​ ​therapeutic​ ​options.​ ​2016 12.​ ​“Four​ ​Simple​ ​Things​ ​to​ ​do​ ​to​ ​Eliminate​ ​Anxiety”​ ​–​ ​Amen Clinic 13.​ ​“Washington​ ​State​ ​Guideline​ ​on​ ​Prescribing​ ​Opioids​ ​for Pain”​ ​(2015​ ​revised) 14.​ ​“Agonist​ ​Therapy​ ​for​ ​Opioid​ ​Use​ ​Disorders” 15.​ ​“Rotchford,​ ​J​ ​K,​ ​“An​ ​Informal​ ​Review​ ​of​ ​Opioid​ ​Dependence (Addiction)​ ​Associated​ ​with​ ​Chronic​ ​Opioid​ ​Analgesic​ ​Therapy (COAT)​ ​for​ ​Chronic​ ​Pain.”​ ​ ​(Title​ ​page​ ​only​ ​in​ ​Czech)​ ​ ​Journal ADIKTOLOGIE​ ​15(3)​ ​2015. 16.​ ​“Complaining​ ​to​ ​the​ ​Medical​ ​Commission” 17.​ ​Opidemic​ ​Reference

38


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Appendix​ ​1 Rapid​ ​Opioid​ ​Dependence​ ​Screen​ ​(RODS) Instructions:​ ​[Interviewer​ ​reads]​ ​The​ ​following​ ​questions​ ​are​ ​about​ ​your prior​ ​use​ ​of​ ​drugs.​ ​For​ ​each​ ​question,​ ​please​ ​indicate​ ​“yes”​ ​or​ ​“no”​ ​as it​ ​applies​ ​to​ ​drug​ ​use​ ​during​ ​the​ ​last​ ​12​ ​months​ ​or​ ​any​ ​12​ ​months.. 1. Have​ ​you​ ​ever​ ​taken​ ​any​ ​of​ ​the​ ​following​ ​drugs? a. Heroin

Yes​ ​☐ No​ ​☐

b. Methadone

Yes​ ​☐ No​ ​☐

c. Buprenorphine

Yes​ ​☐ No​ ​☐

d. Morphine

Yes​ ​☐ No​ ​☐

e. Other​ ​opioid​ ​analgesics

Yes​ ​☐ No​ ​☐

(Eg:​ ​Vicodin,​ ​Darvocet,​ ​fentanyl,​ ​tramadol,​ ​hydrocodone,​ ​codeine,​ ​etc.) If​ ​“Yes”​ ​answer​ ​questions​ ​2-8​. 2.​ ​Did​ ​you​ ​ever​ ​have​ ​to​ ​use​ ​more​ ​opioids​ ​to​ ​get​ ​the​ ​same​ ​high​ ​as​ ​when you​ ​started​ ​to​ ​use​ ​opioids? Yes​ ​☐ No​ ​☐ 3.​ ​Did​ ​the​ ​idea​ ​of​ ​missing​ ​a​ ​dose​ ​ever​ ​make​ ​you​ ​anxious? Yes​ ​☐ No​ ​☐ 4.​ ​ ​In​ ​the​ ​morning​ ​did​ ​you​ ​ever​ ​have​ ​to​ ​take​ ​a​ ​dose​ ​to​ ​avoid​ ​feeling​ ​dope sick​ ​or​ ​did​ ​you​ ​ever​ ​feel​ ​dope​ ​sick? Yes​ ​☐ No​ ​☐ 5.​ ​ ​Did​ ​you​ ​worry​ ​about​ ​your​ ​use​ ​of​ ​opioids?

Yes​ ​☐ No​ ​☐

6.​ ​ ​Did​ ​you​ ​ever​ ​find​ ​it​ ​difficult​ ​to​ ​stop​ ​or​ ​not​ ​use​ ​opioids?

Yes​ ​☐ No​ ​☐

7.​ ​ ​Did​ ​you​ ​ever​ ​have​ ​to​ ​spend​ ​a​ ​lot​ ​of​ ​time/energy​ ​obtaining​ ​opioids​ ​or recovering​ ​from​ ​feeling​ ​high​ ​or​ ​other​ ​effects? Yes​ ​☐ No​ ​☐ 8.​ ​ ​Did​ ​you​ ​ever​ ​miss​ ​important​ ​things​ ​like​ ​doctor’s​ ​appointment, family/friend​ ​activities,​ ​or​ ​other​ ​things​ ​because​ ​of​ ​opioids? Yes​ ​☐ No​ ​☐ Scoring​:​ ​ ​If​ ​3​ ​or​ ​more​ ​of​ ​questions​ ​2-8​ ​are​ ​“Yes,”​ ​this​ ​is​ ​consistent​ ​with opioid​ ​dependence.

39


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Appendix​ ​2 ​ ​ ​Global​ ​Pain​ ​Scale Instructions:​ ​For​ ​each​ ​question,​ ​please​ ​indicate​ ​your​ ​level​ ​of​ ​pain​ ​by circling​ ​a​ ​number​ ​from​ ​0​ ​to​ ​10. YOUR​ ​PAIN: 1.​ ​My​ ​current​ ​pain​ ​is:

No​ ​pain:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Extreme​ ​pain 2.​ ​During​ ​the​ ​past​ ​week,​ ​the​ ​best​ ​my​ ​pain​ ​has​ ​been:​ ​ No​ ​pain:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Extreme​ ​pain 3.​ ​During​ ​the​ ​past​ ​week,​ ​the​ ​worst​ ​my​ ​pain​ ​was: No​ ​pain:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Extreme​ ​pain 4.​ ​During​ ​the​ ​past​ ​week,​ ​my​ ​average​ ​pain​ ​was:​ ​ No​ ​pain:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Extreme​ ​pain 5.​ ​During​ ​the​ ​past​ ​3​ ​months,​ ​my​ ​average​ ​pain​ ​was No​ ​pain:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Extreme​ ​pain

YOUR​ ​ACTIVITIES​:​ ​During​ ​the​ ​past​ ​week​ ​I​ ​was​ ​NOT​ ​able​ ​to: 6.​ ​Go​ ​to​ ​the​ ​store​ ​................................. Strongly​ ​Disagree:​ ​ 0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​ :Strongly​ ​Agree 7.​ ​Do​ ​chores​ ​in​ ​my​ ​home​ ​..................... Strongly​ ​Disagree:​ ​ 0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​ :Strongly​ ​Agree 8.​ ​Enjoy​ ​my​ ​friends​ ​and​ ​family Strongly​ ​Disagree:​ ​ 0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​ :Strongly​ ​Agree 9.​ ​Exercise​ ​(including​ ​walking) Strongly​ ​Disagree:​ ​ 0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​ :Strongly​ ​Agree 10.​ ​Participate​ ​in​ ​my​ ​favorite​ ​hobbies or​ ​perform​ ​normal​ ​tasks: Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​ :Strongly​ ​Agree

YOUR​ ​FEELINGS:​​ ​During​ ​the​ ​past​ ​week​ ​I​ ​have​ ​felt: 11.​ ​Afraid

Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree

12.​ ​Depressed Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree 13.​ ​Tired

Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree

14.​ ​Anxious

Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree

15.​ ​Stressed

Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree

40


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

YOUR​ ​CLINICAL​ ​OUTCOMES​​ ​ ​ ​ ​During​ ​the​ ​past​ ​week: 16.​ ​I​ ​had​ ​trouble​ ​sleeping Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree 17.​ ​I​ ​had​ ​trouble​ ​feeling​ ​comfortable Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree 18.​ ​I​ ​was​ ​less​ ​independent Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree 19.​ ​Unable​ ​to​ ​work​ ​or​ ​take​ ​on​ ​normal​ ​responsibilities Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree 20.​ ​I​ ​needed​ ​to​ ​take​ ​more​ ​medicines Strongly​ ​Disagree:​ ​0​ ​1​ ​2​ ​3​ ​4​ ​5​ ​6​ ​7​ ​8​ ​9​ ​10​ ​:Strongly​ ​Agree

Total​ ​Score:​ ​_________​

Add​ ​up​ ​the​ ​total​ ​score​ ​and​ ​divide​ ​by​ ​2.​ ​Each​ ​subset​ ​is worth​ ​25​ ​points.​ ​The​ ​maximum​ ​total​ ​score​ ​is​ ​100.

Your​ ​score:

____

________________________________________ Basic​ ​OPAS​ ​Follow-Up​ ​Office​ ​Questionnaire: For​ ​patients​ ​with​ ​pain​ ​issues,​ ​substance​ ​use​ ​disorders,​ ​or​ ​any​ ​diagnoses or​ ​medications​ ​related​ ​to​ ​brain​ ​health.

Since​ ​your​ ​last​ ​visit,​​ ​please​ ​circle​ ​any​ ​of​ ​the​ ​following​ ​symptoms you​ ​have​ ​had​:​ ​ ​Constipation,​ ​diarrhea,​ ​nausea,​ ​anorexia,​ ​weight​ ​loss​ ​or​ ​gain, malaise/fatigue,​ ​problems​ ​with​ ​concentration,​ ​memory​ ​problems,​ ​irritability, hopelessness,​ ​anxiety,​ ​legal​ ​problems,​ ​loss​ ​of​ ​feeling​ ​or​ ​strength,​ ​thoughts​ ​of hurting​ ​yourself/suicide. Others​ ​possibly​ ​important:_______________________

​For​ ​each​ ​question​ ​the​ ​lower​​ ​the​ ​score​ ​the​ ​better​​ ​you​ ​think​ ​you​ ​are doing 1.​ ​ How​ ​have​ ​your​ ​relationships​ ​with​ ​significant​ ​others​ ​or​ ​immediate family​ ​members​ ​been​ ​during​ ​the​ ​past​ ​month? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ Delightful​ ​and​ ​wonderful​ ​relations​ ​–​ ​Nobody​ ​wants​ ​to​ ​be​ ​around​ ​me

41


​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. 2.​ ​ Please​ ​rate​ ​your​ ​fear​ ​of​ ​financial​ ​insecurity​ ​during​ ​this​ ​past​ ​month. 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ No​ ​fear​ ​of​ ​financial​ ​insecurity​ ​–​ ​Fear​ ​of​ ​starvation​ ​or​ ​dying​ ​from​ ​exposure 3.​ ​ How​ ​far​ ​along​ ​are​ ​you​ ​in​ ​meeting​ ​your​ ​goals​ ​of​ ​pain​ ​relief,​ ​recovery, or​ ​general​ ​well-being? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ I’ve​ ​met​ ​all​ ​my​ ​goals​ ​–​ ​It’s​ ​all​ ​hopeless 4.​ ​ How​ ​many​ ​legal​ ​worries​ ​have​ ​you​ ​had​ ​during​ ​the​ ​past​ ​three​ ​months? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ None​ ​–​ ​In​ ​jail​ ​the​ ​whole​ ​time 5.​ ​ How​ ​happy​ ​with​ ​your​ ​living​ ​situation​ ​have​ ​you​ ​been​ ​during​ ​the​ ​past month? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ Couldn’t​ ​be​ ​better​ ​–​ ​Couldn’t​ ​be​ ​worse 6.​ ​During​ ​last​ ​week how​ ​much​ ​time​ ​have​ ​you​ ​spent​ ​in​ ​thinking​ ​about​ ​or seeking​ ​pain​ ​relief,​ ​medications,​ ​alcohol,​ ​or​ ​drugs​ ​of​ ​abuse? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ None​ ​–​ ​Every​ ​awake​ ​minute 7.​ ​ How​ ​abstinent​ ​from​ ​non-prescribed​ ​mind​ ​altering​ ​substances​ ​have you​ ​been​ ​during​ ​the​ ​past​ ​month? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ Total​ ​Abstinence​ ​–​ ​Daily​ ​Relapse​ ​of​ ​all​ ​drugs/alcohol 8.​ ​ How​ ​would​ ​you​ ​rate​ ​your​ ​overall​ ​physical​ ​health? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ Superb ​ ​–​ ​Expect​ ​death​ ​in​ ​next​ ​week 9.​ ​ How​ ​would​ ​you​ ​rate​ ​your​ ​overall​ ​mental/emotional​ ​health? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ As​ ​well​ ​as​ ​can​ ​be​ ​imagined​ ​–​ ​As​ ​bad​ ​as​ ​can​ ​be​ ​imagined 10.​ ​ How​ ​would​ ​you​ ​rate​ ​your​ ​overall​ ​spiritual​ ​health? 0​ ​ ​ ​ ​1​ ​ ​ ​ ​2​ ​ ​ ​ ​3​ ​ ​ ​ ​4​ ​ ​ ​ ​5​ ​ ​ ​ ​ 6​ ​ ​ ​ ​7​ ​ ​ ​ ​8​ ​ ​ ​ ​9​ ​ ​ ​ ​10​ ​ ​____ Feel​ ​loving​ ​Higher​ ​Power​ ​is​ ​in​ ​charge​ ​–​ ​Feel​ ​totally​ ​alone​ ​and​ ​hopeless Total​ ​Score​ ​ ​ ​ ​ ​ ​ ​_____

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D.

Appendix​ ​3 OPAS​ ​Behavioral​ ​Plan​ ​Discussion Patients​ ​with​ ​chronic​ ​complex​ ​pain,​ ​substance​ ​use​ ​disorders,​ ​or​ ​other conditions​ ​which​ ​benefit​ ​from​ ​a​ ​healthy​ ​brain,​ ​ ​are​ ​often​ ​helped​ ​by “behavioral”​ ​changes.​ ​To​ ​help​ ​appreciate​ ​the​ ​interplay​ ​between​ ​standard medical/surgical​ ​interventions​ ​and​ ​“behavioral”​ ​interventions,​ ​the metaphor​ ​of​ ​the​ ​brain​ ​being​ ​like​ ​a​ ​computer​ ​is​ ​useful.​ ​The​ ​brain​ ​gets input,​ ​processes​ ​the​ ​input,​ ​and​ ​then​ ​produces​ ​an​ ​output​ ​similar​ ​to​ ​a computer.​ ​In​ ​computers​ ​the​ ​hardware​ ​and​ ​software,​ ​while​ ​integrated, they​ ​do​ ​not​ ​change​ ​one​ ​another.​ ​If​ ​a​ ​computer​ ​is​ ​malfunctioning​ ​one​ ​must wonder​ ​if​ ​it​ ​is​ ​a​ ​hardware​ ​ ​problem,​ ​software​ ​problem,​ ​or​ ​both.​ ​In​ ​the case​ ​of​ ​the​ ​brain,​ ​however,​ ​the​ ​brain’s​ ​software​ ​can​ ​transform​ ​brain hardware​ ​(structural​ ​and​ ​physiological​ ​findings).​ ​Likewise​ ​the​ ​brain’s hardware​ ​problems​ ​can​ ​change​ ​the​ ​software​ ​programming.​ ​Therefore,​ ​the brain’s​ ​software​ ​and​ ​hardware​ ​are​ ​not​ ​only​ ​integrated​ ​but​ ​they​ ​can change​ ​each​ ​other. Some​ ​examples​ ​might​ ​help.​ ​Patients​ ​who​ ​are​ ​prescribed anti-depressants​ ​after​ ​a​ ​time​ ​will​ ​start​ ​to​ ​behave​ ​differently​ ​and​ ​think differently​ ​about​ ​a​ ​whole​ ​host​ ​of​ ​things,​ ​even​ ​their​ ​belief​ ​in​ ​God​ ​can change.​ ​The​ ​opposite​ ​is​ ​also​ ​true!​ ​When​ ​one​ ​changes​ ​one’s​ ​thinking​ ​and behavior​ ​one​ ​may​ ​change​ ​the​ ​actual​ ​ ​structure​ ​of​ ​the​ ​brain!​ ​Even​ ​with​ ​a serious​ ​degenerative​ ​disease​ ​such​ ​as​ ​dementia​ ​“exercising”​ ​the​ ​brain, through​ ​certain​ ​“behavioral”​ ​efforts,​ ​potentially​ ​reverses​ ​some​ ​of​ ​the structural​ ​changes.​ ​Doing​ ​yoga​ ​regularly,​ ​for​ ​example,​ ​has​ ​been​ ​shown scientifically​ ​to​ ​increase​ ​“grey​ ​matter”​ ​the​ ​important​ ​responding, organizing,​ ​remembering,​ ​and​ ​executive​ ​components​ ​of​ ​the​ ​brain.​ ​Bottom

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. line,​ ​behavioral​ ​interventions​ ​can​ ​help​ ​the​ ​brain​ ​function​ ​better​ ​and​ ​over time​ ​may​ ​even​ ​change​ ​the​ ​structure​ ​as​ ​well​ ​as​ ​the​ ​chemistry​ ​of​ ​the​ ​brain. The​ ​potential​ ​for​ ​behavioral​ ​interventions​ ​to​ ​improve​ ​brain​ ​function are​ ​enormous.​ ​In​ ​turn,​ ​healthier​ ​brains​ ​promote​ ​better​ ​pain​ ​management, recovery​ ​from​ ​addictions,​ ​less​ ​anxiety,​ ​improved​ ​immune​ ​function,​ ​better relationships,​ ​and​ ​often​ ​promote​ ​progress​ ​with​ ​other​ ​medical​ ​issues​ ​such as​ ​heart​ ​or​ ​breathing​ ​problems. A​ ​challenge​ ​is​ ​to​ ​find​ ​the​ ​best​ ​ ​behavioral​ ​plan​ ​for​ ​each​ ​person.​ ​Given the​ ​variations​ ​in​ ​“software”​ ​let​ ​alone​ ​“hardware”​ ​in​ ​our​ ​different​ ​brains,​ ​it makes​ ​sense​ ​that​ ​plans​ ​are​ ​best​ ​individualized.​ ​Because​ ​there​ ​are​ ​often limited​ ​clinical​ ​trials​ ​to​ ​guide​ ​us,​ ​a​ ​trial​ ​and​ ​error​ ​approach​ ​is​ ​commonly used.​ ​As​ ​a​ ​physician​ ​my​ ​job​ ​is​ ​to​ ​help​ ​patients​ ​establish​ ​plans​ ​that​ ​make sense​ ​and​ ​are​ ​likely​ ​to​ ​help.​ ​Nonetheless,​ ​it​ ​often​ ​comes​ ​down​ ​to​ ​a​ ​trial and​ ​error​ ​effort.​ ​A​ ​team​ ​effort​ ​though​ ​is​ ​often​ ​essential!. While​ ​one’s​ ​plan​ ​is​ ​likely​ ​to​ ​change​ ​with​ ​time,​ ​it​ ​is​ ​important​ ​to​ ​have one.​ ​Formal​ ​plans​ ​help​ ​assess​ ​over​ ​time​ ​what​ ​might​ ​or​ ​might​ ​not​ ​be working.

Making​ ​a​ ​Plan A​ ​factor​ ​to​ ​remember​ ​when​ ​starting​ ​to​ ​establish​ ​a​ ​treatment​ ​plan​ ​is that​ ​multiple​ ​combined​ ​interventions​ ​often​ ​work​ ​best.​ ​Of​ ​course,​ ​it​ ​makes sense​ ​to​ ​start​ ​with​ ​the​ ​safe,​ ​easy,​ ​and​ ​readily​ ​available​ ​options.​ ​When there​ ​are​ ​proven​ ​effective​ ​interventions​ ​for​ ​your​ ​condition​ ​we​ ​plan​ ​to implement​ ​those​ ​first.​ ​If,​ ​however,​ ​one​ ​limits​ ​interventions​ ​to​ ​ones​ ​that are​ ​“proven​ ​efficacious”​ ​outcomes​ ​are​ ​often​ ​compromised. Another​ ​principle​ ​in​ ​establishing​ ​your​ ​plan​ ​for​ ​better​ ​brain​ ​health​ ​is​ ​to at​ ​the​ ​first​ ​emphasize​ ​changes​ ​that​ ​promote​ ​better​ ​homeostasis. Homeostasis​ ​is​ ​just​ ​a​ ​fancy​ ​way​ ​of​ ​helping​ ​to​ ​maintain​ ​stability​ ​and

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. balance.​ ​The​ ​brain​ ​doesn’t​ ​do​ ​well​ ​with​ ​“ups​ ​and​ ​downs”,​ ​ ​and​ ​we​ ​want​ ​to do​ ​what​ ​we​ ​can​ ​to​ ​promote​ ​more​ ​“regular”​ ​functioning​ ​of​ ​the​ ​brain. For​ ​example,​ ​when​ ​long​ ​acting​ ​medicines​ ​are​ ​prescribed​ ​to​ ​be​ ​taken routinely,​ ​at​ ​the​ ​same​ ​time​ ​every​ ​day,​ ​better​ ​brain​ ​homeostasis​ ​is promoted.​ ​When​ ​brains​ ​are​ ​in​ ​a​ ​better​ ​state​ ​of​ ​homeostasis,​ ​ ​we​ ​are​ ​safer, and​ ​we​ ​often​ ​feel​ ​safer.​ ​Any​ ​intervention​ ​which​ ​ ​promotes​ ​a​ ​greater​ ​state and​ ​sense​ ​of​ ​“safety”​ ​is​ ​likely​ ​to​ ​help​ ​brains​ ​work​ ​better.​ ​That​ ​being​ ​said, differences​ ​between​ ​people​ ​about​ ​what​ ​promotes​ ​safety​ ​is​ ​common​ ​and why​ ​plans​ ​are​ ​best​ ​individualized​ ​to​ ​see​ ​what​ ​works​ ​best. Lastly,​ ​any​ ​plan​ ​for​ ​change​ ​can​ ​by​ ​itself​ ​create​ ​anxiety.​ ​Change threatens​ ​the​ ​“status​ ​quo.”​ ​So​ ​all​ ​good​ ​plans​ ​for​ ​significant​ ​change​ ​must include​ ​support​ ​and​ ​structure,​ ​particularly​ ​early​ ​on​ ​in​ ​the​ ​process.​ ​ ​In many​ ​patients​ ​it​ ​helps​ ​when​ ​the​ ​changes​ ​occur​ ​slowly​ ​over​ ​time. Your​ ​Plan​ ​as​ ​of​ ​ ​ ​_____/______/______ Passive​ ​Elements​ ​of​ ​Your​ ​Plan:​​ ​(Things​ ​being​ ​done​ ​to​ ​you​ ​or​ ​for​ ​you,​ ​for example​ ​medications,​ ​procedures,​ ​testing,​ ​ ​doctor​ ​visits,​ ​ ​therapy,​ ​etc.) 1. 2. 3. 4. 5.

​ ​__________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________

Active​ ​Elements​ ​of​ ​your​ ​plan:​ ​Things​ ​you​ ​are​ ​doing​ ​differently;​ ​for example​ ​changes​ ​in​ ​diet,​ ​exercise,​ ​daily​ ​routines,​ ​relationships​ ​and​ ​living changes,​ ​work,​ ​pleasure,​ ​spiritual​ ​or​ ​religious​ ​practices,​ ​taking medications​ ​as​ ​directed,​ ​rather​ ​than​ ​as​ ​needed,​ ​studying​ ​about​ ​what works,​ ​etc. 1. 2. 3. 4.

__________________________________________ ___________________________________________ ___________________________________________ ___________________________________________

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​ ​Opioids​ ​–​ ​A​ ​Guide​ ​For​ ​Patients​ ​ ​ ​ ​by​ ​ ​ ​J.​ ​Kimber​ ​Rotchford,​ ​M.D. 5. ___________________________________________ 6. ___________________________________________ 7. ___________________________________________ Note:​​ ​ ​Attempt​ ​to​ ​have​ ​more​ ​active​ ​elements​ ​of​ ​your​ ​plan​ ​than​ ​passive ones.​ ​In​ ​the​ ​short​ ​run​ ​passive​ ​modalities​ ​are​ ​often​ ​effective​ ​but​ ​the​ ​active changes​ ​are​ ​associated​ ​with​ ​the​ ​best​ ​long​ ​term​ ​outcomes. To​ ​help​ ​your​ ​healthcare​ ​team​ ​better​ ​care​ ​for​ ​you​ ​we​ ​suggest​ ​you​ ​keep​ ​a folder​ ​of​ ​your​ ​current​ ​plans​ ​and​ ​keep​ ​a​ ​“diary”​ ​of​ ​what​ ​seems​ ​to​ ​work best​ ​for​ ​you.​ ​In​ ​my​ ​experience​ ​patients​ ​rarely​ ​do​ ​this​ ​but​ ​to​ ​update​ ​your plan​ ​after​ ​each​ ​visit​ ​makes​ ​sense.​ ​It​ ​all​ ​takes​ ​time​ ​for​ ​the​ ​brain​ ​most​ ​often heals​ ​slowly​ ​over​ ​months​ ​and​ ​years​ ​rather​ ​than​ ​over​ ​days​ ​or​ ​weeks. Finally:​​ ​ ​list​ ​some​ ​of​ ​what​ ​you​ ​expect​ ​to​ ​change​ ​for​ ​the​ ​better​ ​as​ ​a​ ​result of​ ​your​ ​above​ ​plan​ ​keep​ ​the​ ​focus​ ​on​ ​positive​ ​things​ ​rather​ ​than avoidance​ ​of​ ​negative​ ​ones: ____________________________________________________________ ____________________________________________________________ _____________________________

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Opioids In Chronic Pain Management – A Guide For Patients  

Opioids In Chronic Pain Management – A Guide For Patients is authored by J. Kimber Rotchford, M.D. specialist in pain and addiction.

Opioids In Chronic Pain Management – A Guide For Patients  

Opioids In Chronic Pain Management – A Guide For Patients is authored by J. Kimber Rotchford, M.D. specialist in pain and addiction.

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