Looking beyond opioids: Stanford pain psychologist briefs Congress

Photo by K-State Research and Extension

Reducing opioid use has become a national priority, but where does that leave the millions of Americans who suffer from underdiagnosed or undertreated chronic pain?

Do alternative treatments strategies like cognitive behavioral, physical and pharmacologic therapies alleviate chronic pain? And how should these alternatives be implemented for different populations with different needs?

These questions will be explored at an upcoming congressional briefing in Washington, D.C. on Oct. 2, which is organized by the Patient-Centered Outcomes Research Institute. Beth Darnall, PhD, a clinical professor of anesthesiology, perioperative and pain medicine at Stanford, is one of the speakers.

Congress is considering legislation — The Opioid Crisis Response Act of 2018 — that would affect the federal funding allocated to address the opioid crisis, including funding for non-opioid pain treatments. So it is critical that Congress understand evidence-based research on implementing safer chronic pain treatments in real-world clinical settings, Darnall told me.

Darnall was invited to speak about her EMPOWER study, a clinical trial in which participants partner with their clinicians to slowly reduce their opioid dose over a year. Patients are randomized to receive pain self-management classes, cognitive behavioral classes for chronic pain, or tapering only.

“The goal is not zero opioids. We’re aiming to help patients reduce to lower, safer doses without increasing their pain,” said Darnall. “We are testing whether the two types of classes help.”

Darnall argues that the best pain care is comprehensive and personalized to each patient’s needs. Although she recognizes that staving the flow of prescription opioids is important and can save lives, she says opioids can be part of a comprehensive care plan that works for some patients.

Darnall explained:

“Much of the overprescribing of opioids was born from a lack of opioid data, lack of clinician education about how best to treat pain and lack of accessible alternatives. Limiting opioids alone will not solve these three underlying problems. We need to better train physicians, psychologists, physical therapists, nurses and all healthcare clinicians on how to treat pain, so patients have access to evidence-based pain care.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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Bill for later school start times is defeated, but Stanford sleep specialist isn’t

 

Photo by Santiago Gomez

The medical evidence is clear — teens are suffering physical and mental health problems due to chronic sleep deprivation. That’s why the American Academy of Pediatrics and many other health organizations recommend starting classes at all middle and high schools at 8:30 am or later.

“We’ve known for decades that teenagers are not getting enough sleep,” says Rafael Pelayo, MD, a clinical professor in psychiatry and behavioral sciences with the Stanford Center for Sleep Sciences and Medicine. “Senate Bill 328 came out of presenting the strong evidence-based, peer-reviewed data to elected officials. Even the people opposed to the bill accept the science.”

So if everyone agrees that our teens need more sleep, why didn’t the bill pass? The main objection of teachers, school boards and ultimately Governor Jerry Brown centers on giving the local community control of individual school decisions.

“We’ve stepped into this ongoing battle between state control and local control of schools,” Pelayo says. “But I don’t consider this a political issue. This is a public health issue. Hundreds of schools have already changed and they see the same result — kids are healthier and perform better. This is a matter of honoring kid’s biology. It doesn’t work to just say they should go to bed earlier.”

Pelayo’s push for later school start times is also inspired by his professional experiences. “My career as a sleep doctor began through my knowledge of adolescent sleep. During medical school, my research found a link between suicidal thinking and sleep problems in teenagers. I’ve been learning about poor sleep and mental health issues in teens since the 1980s.”

Despite this recent setback, Pelayo plans to keep volunteering. For years, he’s been giving talks about sleep at many local high schools and middle schools. “Teenagers are interested in sleep apnea, their dreams and all aspects of sleep. I’ve given a bunch of talks on sleep for years,” Pelayo says.

He’s also recently become a director of a national organization called Start School Later. Overall, he hopes to promote more education, research and funding for this issue.

“About 300 school districts have already mandated a later school start time,” Pelayo says, adding that San Diego schools are planning to implement later start times by 2020. “If California had passed SB 328, it would have accelerated this process. Instead, we’ll have to do it piecemeal. And that’s too bad, since kids need sleep now.”

But, Pelayo says, “This issue is not going away, it is actually gaining momentum.”

This is a reposting of my Scop blog story, courtesy of Stanford School of Medicine.

Tai chi may help prevent older adults from falling, a study finds

Photo by Craig Nagy

As our parents age, we worry about them falling. Falls in older adults can lead to emergency department visits, hospital admissions and even death. At best, falls cause anxiety for patients and their loved ones.

Studies show that regular exercise can reduce the risk of falling, but it is unclear which kind of exercise is most effective for older adults. Now, a new multi-institutional clinical trial has assessed the effectiveness of two proven exercise interventions — tai chi and a multimodal exercise program — which were compared to a control intervention of stretching.

Tai chi is an ancient Chinese practice involving a series of movements performed in a slow, focused manner. Traditionally, people practicing tai chi flow between as many as 100 different postures. However, the study investigated a simplified form focused on eight core movements that were selected to improve balance for older adults.

The researchers also evaluated a more conventional, multimodal exercise program that incorporated aerobic, strength, balance and flexibility exercises.

The 670 participants were 70 years and older with a high risk of falling, based on impaired mobility or a history of falling in the previous year. They performed a 60-minute exercise session twice weekly for 24 weeks, which was randomly assigned as either tai chi balance training, multimodal exercise or stretching.

These interventions were primarily evaluated by the incidence of falls, which were self-reported monthly and then confirmed using follow-up appointments and medical records.

The study found tai chi balance training to be more effective than the conventional exercise approaches for reducing falls, as recently reported in JAMA Internal Medicine. During the 6 months, 152 falls occurred among 85 participants in the tai chi group, 218 falls among 112 participants in the multimodal exercise group and 363 falls among 127 participants in the stretching group.

TC Cowles, a nurse and program manager at Stanford Health Care’s Supportive Care Program, said he wasn’t surprised that tai chi reduced falls. These new findings agree with previous smaller studies, including a meta-analysis study. However, he was very excited to have it confirmed with so many participants.

“This is the largest study I’ve seen focused on tai chi as a fall prevention. It’s encouraging to see that it reduces falls by 58 percent compared to the stretching exercises and 31 percent compared to a multimodal exercise intervention,” Cowles said.

Cowles manages similar tai chi classes on Tuesdays through the Neuroscience Supportive Care Program and on Thursdays through the Cancer Supportive Care Program. These classes are very popular — almost 900 people have attended the tai chi classes in the last year, he said. Many of the participants are in their mid-60s or 70s.

“I like the practice because it is modifiable. You can start in a chair with arms to decrease the risk of falling during some of the movements. And if you strengthen, you can advance to a standing position,” said Cowles.

According to Cowles, however, attending consistently is key. “Patients that come regularly report that they feel less wobbly and can walk better on their own,” he said. “They also build core strength, so they can hold themselves upright for longer periods of time. And they build confidence, so they’re more apt to participate in other programs and activities.”

Stanford Supportive Care Programs also offer weekly classes on qigong, meditation and yoga, which can increase stability too. And all the classes are free and open to the community.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Space, the new surgical frontier? A Q&A

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Many medical treatments — in their current form — would be unfeasible on deep space missions, such as a journey to Mars.

How will we diagnose and treat the ailments of future space travelers? And what medical issues will they likely encounter? I posed these questions to Sandip Panesar, MD, a postdoctoral research fellow at Stanford who wrote a recent article about surgery in space in the British Journal of Surgery.

What inspired you to research surgery in space?

“From a young age, I’ve always been interested in space travel. I also have a background in surgery, trauma and emergency medicine. So it just clicked one day when I was reading about SpaceX. I realized they may actually send people to Mars, so we need to consider the medical implications of that. Specifically, how would you perform surgery?

The need for surgical care in space in the near future will likely revolve around emergency situations — such as crushes, impacts, falls and burns — since the possibility of trauma occurring during exploratory missions can never be ruled out. In cases of severe trauma, significant internal bleeding may necessitate invasive surgical procedures.”

What adverse conditions do space travelers face?

“People are exposed to a few key physical conditions in space — solar particle radiation, temperature extremes and a lack of gravity. Solar particle radiation is a lot different than the particles people are exposed to on Earth. It has a higher chance of causing DNA damage, leading to an increased risk of high-grade cancers prone to metastasize. However, a lack of gravity causes a whole host of even more critical changes in the human body.”

How does this extraterrestrial environment impact human physiology?

“One of the biggest changes is the redistribution of bodily fluids. On Earth, gravity and walking upright pulls most of our fluids down to our legs. In space, these fluids distribute evenly throughout the body. This affects heart rate and blood pressure, increases intracranial pressure and causes face swelling. And it decreases leg size, a phenomenon called ‘chicken legs.’

An absence of gravity also causes the bones and muscles to atrophy.

In addition, the makeup of white blood cells changes in space. Plus, the body produces more stress hormones, called glucocorticoids, which further weaken the immune system. This may negatively affect wound healing, which is critical to surgical recovery.

Microbes are also known to be more pathological in space, making the risk of a serious infection after surgery even higher.”

How can surgery be adapted for space?

“One idea is to include a trauma pod, an enclosed medical suite, in the space station or vessel — a concept that originated in military medicine.

We’ve also proposed minimally-invasive keyhole surgery, but it has limited use in trauma situations and a pretty large learning curve. So open surgery is likely but challenging in space. For instance, the bowel is free-floating within the abdominal cavity,  so it can float out when you open the stomach if there’s no gravity. This carries a risk of infection, contamination and perforation. One potential solution is to use a hermetically sealed enclosure — placing a clear plastic box over the wound and working essentially in a glove box with a pressure differential.”

Could surgical robots or other equipment help?

“Mars is 48 million miles away and the radio signal delay is 20 minutes, so using robots controlled by surgeons on Earth isn’t feasible. Instead, researchers are developing robots that can perform surgery by themselves or with really minimal human assistance. There have already been trials of robots that can suture together pig bowels with minimal assistance.

Finally, the size and weight of the payload is a huge barrier and surgical specialties all use different tools. A feasible solution is to bring a 3D printer that can print bandages, casts, surgical tools and even maybe pharmaceuticals. Also, you could diagnosis with an ultrasound scanner and a compact CT scanner like the ones used in ambulances in the UK.”

Would you want to be an on-board surgeon?

“Not just yet. I still have a lot of things I want to do on Earth.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.