Lactation and Breastfeeding Medicine (Spieler, Prieto 12/20/2023)

 A link to a recording of this presentation can be found HERE.

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A summary will follow.

An Integrative Approach to Substance Use Disorder (Adachi Serrano, 12/13/2023)

 A recording of this presentation is available HERE. 

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Many many thanks to Dr. Katya Adachi Serrano, SRFMR Alumna class of 2014 and Integrative Medicine Fellow (2015) on An Integrative Approach to Substance Use Disorders. Dr. Adachi Serrano blends her family medicine background with training in herbal and integrative medicine, plus a board certification in addiction medicine. In so doing, she spoke thoughtfully on topics from buprenorphine  induction to  herbal supplements for SUD to spiritual support. This is definitely a presentation worth watching! The link is above.

For those of you who prefer the written word, my notes below:

Dr. Adachi Serrano took us through the case of a young man suffering from alcohol use disorder (AUD) and repeated episodes of alcohol withdrawal syndrome (AWS). She started by grounding us in the concept of the tribal MAT Echo Clinic Wellness Wheel (see below): consideration of the mind, body, spirit, and community, as a means to think about the care of patients with SUD. 

Tribal MAT Echo Clinic "Wellness Wheel"

The Body

Medication assisted treatment -- or medication for addiction treatment (MAT)-- is the gold standard for treatment of patients with many SUD. SUD is just like any other chronic disease, Dr. Adachi Serrano argues: SUD has a gradual onset, affects all races/ethnicities/SES, it relapses and remits, is partially relieved by lifestyle changes. And so, we should approach SUD like any other chronic disease.

AWS; Typical treatment for acute alcohol withdrawal involve either long-acting benzodiazepines (chlordiazepoxide or diazepam), or gaba-ergic meds (e.g. gabapentin) tapered by either dosing interval or amount daily. See these patients daily, says Dr. Adachi Serrano.

AUD: The best medication option we have for chronic management of AUD is naltrexone, which decreases cravings and suppresses the pleasure people get from drinking ETOH. This can be dosed 25-50mg qhs, Precaution with: acute hepatitis, liver enzymes 3-5x normal, decompensated cirrhosis, active opioid use. Common adverse events include headache, nausea, drowsiness. Some people also experience anhedonia. 

Another option is long-acting naltrexone (aka vivitrol), which is an IM injection 380mg given q4 weeks (after a 4 day PO trial of naltrexone oral). An alternative maintenance medication is acamprosate, which is dosed 666mg TID (2 tabs of 333 TID). Side effects include diarrhea and adherence. A third option is Gabapentin 100-300mg daily to TID.

OUD: Standard treatment or opiate withdrawal syndrome (OWS) is supportive measures (e.g. clonidine, hydroxyzine, trazodone, ondansetron). Maintenance for OUD is either suboxone or methadone, usually dosed 2-4mg q2-4 hours, max 8mg on D#1. Sublocade, a long-acting injectable buprenorphine, may be available to better-insured patients, dosed at 300mg SQ x 1-2 doses, then 100mg q28 days. Finally, naltrexone is a third maintenance option, but you must be opioid free for minimum of 5 days (ideally 7-10 days). This is idea for patients who do not use opioids. Clonidine is often used as an adjunct during the withdrawal phase 0.1-0.3mg q1 hour. 

Dr. Adachi went on to talk about the value of herbal supplements for SUD, as an adjunct to the standard allopathic medications. Three main categories of herbs: adaptogens, nervine, and nutritive. 

1) Adaptogens help the body to adapt to stress, "normalizing influence on physiology". They tend to be derived from the roots of plants that grow in hardy environments and rugged terrain, and their effect is thought to be due to the hormones the plants themselves have generated in these rugged environments.

• Ashwagandha, dosed 400-500mg BID helps to normalize GABA activity in the body. This can be helpful in all forms of SUD. Precautions: nightshade allergy, hyperthyroid
• Rhodiola, derived from arctic regions, is very stimulating. Dosed 100-200mg. Caution: can sometimes be too stimulating, especially in stimulant use, w/d and recovery. Thought to "get the fire burning again"
• Eleutero aka Siberian Ginseng, increased dopamine, thereby increasing energy levels
• Licorice also can be helpful, sweet and easy to take

2) Nervines: have a direct effect on the nervous system. The following nervines are considered "calming nervines" which can be helpful in recovery:

• Skull cap, a GABA agonist, 850-1200mg daily in tincture (very concentrated)
• Valerian, another GABA agonist
• Lavender, 1-2 tsp in 8 oz of water

3) The last category are the Nutritives, which are nutrient rich and thought to support the body. One of Dr. Adachi's favorite is milky oats extract, which is nourishing to the nervous system and also increases dopamine. 

The Mind

Mental health treatment should be considered an essential part of MAT. All patients with SUD should be screened for underlying mood disorders (including anxiety, complex PTSD), learning disabilities, and ADHD. These underlying disorders should be treated with both medications and therapy.

Trauma: 90% of patients with OUD report a history of trauma, 80% have child sexual abuse, emotional abuse, or violent trauma. We should see SUD as a marker of trauma and work to normalize  in a therapeutic way. Here Dr. Adachi Serrano used the image of a record playing in our ear-- "our early experiences teach us messages, like a record playing in our mind" that we may not even know is playing. 

This is where mindfulness practice comes in, also CBT. Introduce the concept of brief CBT for a non-therapist (for those of working in primary care practices where mental health services can be hard to come by). Dr. Adachi Serrano took us through brief CBT (see image) and reminded us that the goal is to rewrite the core message, overwrite the music playing in our head: "I am valuable. I am loved. I matter. I am safe"

She encouraged us to teach residents to cultivate their own dopamine -- "give yourself a high five and do a little dance". But in order to prevent burnout in primary care, really important to use motivational interviewing techniques and meet patients where they are at-- know the stages of change and tailor your intervention to the patient's stage, not your desired outcome.

The Spirit

This leads us to spiritual and somatic treatments. Often in patients with SUD there is a temporal disconnect between what the body is experiencing and the present, i.e. the spirit is not living within themselves. This is categorized in different cultures with different words, including susto, soul wound, etc.

EMDR and somatic experiencing may be helpful treatment modalities.

In addition, there are many other spiritual treatments: sweat lodges, talking circles, spiritual counseling, limpiezas.

Meaning is important, and looking for ways to experience normal emotions  -- a safe space to feel both sadness and JOY. To look for one's core values, to recognize safety.

The Community

Healing community is necessary to support recovery. Patients need to ask if their community is supportive to recovery? Is their current community a barrier to recovery? Dr. Adachi Serrano described a person in recovery as being in a "bubble". When you are early in recovery, you are cleaning up your space, trying to keep your bubble strong. If your bubble doesn't have a thick shell, you don't want to be in an environment that is going to stress or test that bubble. You also need the community to provide support around that bubble, to protect the individual while they are vulnerable. This involves tending to the community, offering community -- in whatever healthy forms are available.

Group settings for SUD include: NA, AA, SMART Recovery groups, Talking circles, spiritual communities, etc. Creating connection to community, culture, family. Find space for new identity to grow. We may need to help patients guide them through a change of identity, friends/support circles to see the opportunities that are there.

Multidisciplinary Pain Management (Revelis 12/6/2023)

 A recording of this presentation is available HERE. 

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Thank you to Dr. Yulia Revelis, SMGR Pain Management physician, for an excellent Grand Rounds presentation this week on Multidisciplinary Pain Management. Dr. Revelis, who is fellowship trained in pain management, is a relatively new addition to SMGR. Dr. Revelis took us systematically through how she assesses and treats pain complaints in her clinic. I was most impressed with her pragmatic approach to pain and her simple advice to believe patients when they complain of pain.

Here are the rest of my notes:

• Acute pain: days to weeks (after acute injury, surgery, etc.)
• Subacute pain: <3 months
• Chronic pain: >3 months

Most common pain, no surprise, is low back pain, followed by neck pain, joint pain (knee, shoulder, hip), and TBD or "total body dolor", which is all-body pain.

Dr. Revelis encouraged us to always go back to the history and physical when assessing pain. Also consider imaging, medications/interventions/treatments, social components, and psychiatric components ("depression and anxiety go hand in hand with chronic pain, and it is a vicious cycle")

She covered a few key tools to help in your assessment of pain. These include the following (links are live when possible)

• Oswestry Low Back Pain Disability Questionnaire
• SF-36
• McGill Pain Assessment
• Fibromyalgia Questionnaire
• Pain in Advanced Dementia (PAINAD)

These are all tools to quantify pain, its impact on activities of daily living and quality of life, and can often be used to track benefit of interventions offered.

To evaluate pain, Dr. Revelis encouraged us to go back to the history: get detailed description of the pain, its location, associated factors, chronicity, family history and social history. Then do a focused exam including inspection, palpation and any indicated special testing. "You don't always have to get imaging," she cautioned, "only when it is clinically appropriate to do so." 

Pain management is multifactorial

• Physical therapy
• Medications 
• Interventional options
• Counseling/CBT

Physical therapy offers long-term solutions gives people autonomy and self-determination with regards to their pain. She is a big big fan.

Medication options are many:

• topical meds (including lidocaine patches, Voltaren gel, and compounded creams including ones that have TCA or topical gabapentin)
• NSAID (care with elders, contraindications)
• Acetaminophen is an excellent pain med and is often under-dosed!
• Anti-spasmodic (including cyclobenzaprine, baclofen, tizanidine) her first line is cyclobenzaprine (Flexeril) 5mg at bedtime x 2 weeks max, "start low, go slow". Only rx'd as needed and should almost always be rx'd in conjunction with PT
• Gabapentinoids (gabapentin and pregabalin), particularly for neuropathic or radicular pain
• TCA/SSRI/SNRI: duloxetine particularly helpful in fibromyalgia
• Opioids should be A LAST RESORT, really only indicated for cancer-pain and acute pain, not adequately treated with all of the above

Dr. Revelis is able to over her patients injections, when appropriate, using either ultrasound or x-ray guidance. These include injections of neck, epidural injections, knees, hips, etc. 

It is important to screen for addiction/addictive behaviors in patients with chronic pain and remember that chronic pain specialists are not the same as addiction specialists. Pts with chronic pain exhibiting addictive behaviors should be evaluated by addiction specialists.

When to refer to pain specialist?

• chronic non-cancer pain
• cancer pain
• acute on chronic pain
• most importantly, patients who WANT to be helped