Health Tip: Opioid Addiction - Why you should be concerned

You may have heard that there is an opioid crisis in the United States with people becoming addicted to pain killers, overdosing, and dying. Even though the Trump administration has identified the opioid epidemic as a "public health emergency," a recent public opinion poll suggested that Americans aren't as concerned as they should be. The public sees opioid addiction as a second tier national problem, and few people (7%) worry that they themselves could become addicted to prescribed pain medication. That being said, opioid overdose is the number one cause of accidental deaths in the United States, outpacing gun-related deaths by more than four times.

What is an "opioid" drug?
Opioids are a class of drugs that interact with the same receptors on nerve cells in the body and brain. They influence pain perception and can produce feelings of both nausea and euphoria. Drugs in this class vary in strength and potency, from the illegally-produced heroin and opium, to synthetic (and semi-synthetic) prescription drugs including Fentanyl, Demerol, Dilaudid, methadone, oxycodone, hydrocodone, codeine, tramadol, and morphine.

Why are they addictive?
Because they can be effective pain relievers and also have the potential to produce euphoria, they may become addictive. It is estimated that 54 million Americans (more than 20 percent of those aged 12 and older) have used prescription opioids for nonmedical reasons at least once in their lifetime. An estimated 25 million Americans are living with chronic pain conditions (defined as pain every day for at least 3 months).

So we have a perfect storm: millions of Americans in pain, and pain medicines that have euphoric side effects.

The other challenge with opioid medications is that the body habituates to them fairly rapidly, requiring higher doses to produce the same effect (known as drug "tolerance"), and causing unpleasant withdrawal symptoms (such as sweating, agitation, anxiety, muscle aches, insomnia, diarrhea, and vomiting) if they are discontinued too rapidly.

When ceasing an opioid medication produces withdrawal symptoms, the body is considered to be "dependent" on the drug to maintain its homeostasis (i.e. feeling "normal"). Dependency is not addiction, but it can occur as quickly as a day or two after starting a pain medication. So if you take opioid pain medicine, you may well encounter withdrawal symptoms when you taper down to discontinue it. It's important to recognize this, and resist the urge to treat the symptoms with more opioid. Studies show that the longer you take pain medicine, the more likely you are to become addicted to it.

Among people given enough pain pills for eight days or more, 13.5 percent are still using them a year later. Among those given a month-long prescription, that rate climbs to 30 percent.

What can you do to avoid opioid dependence or abuse?
If you are having surgery or are in severe, acute pain from an accident, opioid medicines may be the most effective way to control the pain. In these cases, it may be difficult to avoid using these medicines to get you through the acute phase of your recovery. Ask your doctor to prescribe these medicines "as needed" instead of scheduled (where the nurse brings you the meds without asking for them), and try to opt out of taking them as much as you can. Use alternative non-opioid medicines if appropriate, including acetaminophen, ibuprofen, and naproxen. Sometimes an ice pack, topical numbing agents, or nerve pain medications can take the edge off your pain without resorting to opioids. Remember that it is unrealistic to expect your pain to be reduced to zero after trauma. Work towards a tolerable pain level instead.

If you have chronic pain, it's important to do everything you can to avoid reliance on opioids for your pain. Seek out a physiatrist or pain management specialist and review alternative pain management strategies, including physical therapy, massage, meditation, hot and cold treatments, non-steroidal anti-inflammatory drugs, nerve pain medicines, anti-anxiety medications, anti-depressants, and topical numbing agents. If you have been on opioid medications for a long time, it may take time to taper off them to avoid severe withdrawal symptoms. Be patient, but be committed to discontinuing them. There are medicines that can help to treat withdrawal symptoms if they occur, and medications are also available to assist with long taper plans (such as methadone, buprenorphine, and naltrexone).
What makes opioids lethal?
No one dies of withdrawal symptoms, no matter how unpleasant they may be. People die of opioid overdose because at high levels, these drugs have a sedating effect, which suppresses the brain activity that controls breathing rate. It also dampens signals to the diaphragm, which moves to expand or contract the lungs. Opioids also suppress the brain's ability to monitor and respond to carbon dioxide when it builds up to dangerous levels in the bloodstream. Usually, people pass out and suffocate to death during an opioid overdose.

The most potent opioids are the riskiest for overdose. This is why extremely strong opioids such as Fentanyl are highly regulated, but also abused on the illegal market. Tiny amounts of this opioid can kill.

Conclusion
Opioid medications have a role in acute pain management, but they must be handled with extreme care. Most of us will become tolerant to opioid medications after a few days of use, and many of us will experience withdrawal symptoms when we taper off the medications. Knowing what to expect may be empowering for patients - so that they can avoid the cycle of withdrawal and increasing doses that can spin into dependency, lead to addiction, and put people at risk for overdose and death. When it comes to opioid pain meds, my advice is to use the lowest effective dose, don't chase withdrawal symptoms with more pain medication, and get off them as quickly as you can. When possible, plan your taper strategy with your doctor before your first dose of opioid.

References
http://www.nejm.org/doi/full/10.1056/NEJMp1714529?query=TOC
https://www.drugabuse.gov/drugs-abuse/opioids
https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
http://www.newsweek.com/cdc-opiate-addiction-572498
https://www.scientificamerican.com/article/how-opioids-kill/

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Health Tip: What is the best way to work out?

I was recently asked this question - what is the best way to work out? I find that people mean many different things when they ask this. Some mean, "What is the minimal amount of exercise that I can do and be healthy?" while others mean: "What is the best exercise for fat loss?" and still others mean: "What is the simplest way to fit exercise into my busy schedule?"

As you may have guessed, the answer to this question varies based on its true intent. First of all, let me tell you what research suggests about the minimum amount of exercise for "optimal" health.

The first official physical activity guideline for Americans was developed by the American College of Sports Medicine in 1975. And you may be surprised to discover that all of their updates since then have focused on "toning down" their initial heart rate goals! In 1975 they recommended 3-5 days per week of 20-45 minutes per day, exercising such that the heart was kept at 70-90% of its maximum rate for all those consecutive minutes.

By 2000, the recommendations had dropped that goal to 7 days per week, at least 20 minutes per day where the heart is at 40-85% of its maximum rate. (By the way, your maximum heart rate is approximately 220 minus your age. So if you're 46, then your maximum heart rate is 220-46=174 beats per minute). Over time, research seemed to suggest that accumulating minutes of intense activity over the course of the day was acceptable - all those minutes didn't have to be continuous.

The Institute of Medicine, IOM, (one of the most prestigious, invitation-only, expert panels in the United States, founded in 1970 to advise the federal government on health issues) has researched the topic of optimal exercise for health benefits and has distilled it down to this (in 2005):

Adults should get 60 minutes of moderate intensity exercise 7 days a week to prevent chronic disease and maintain a healthy weight.

How they came to that conclusion is quite complicated and you can read about it here.*

Just to add to the confusion, the newest guidelines (which are now 10 years old actually) from the Centers for Disease Control and Prevention (CDC) allow you to accumulate activity on a weekly basis, and they make an additional clarification: aerobic activity that increases the heart rate is not enough. Exercise should consist of aerobic activity and strength training.

The latest minimum healthy exercise recommendation is:

150 minutes of moderate intensity activity (such as brisk walking) per week AND muscle strengthening activities that challenge all major muscle groups, at least twice a week.

In case you're feeling badly about your current exercise level, it is estimated that only 20% of American adults are meeting the minimum recommended physical activity requirements by the CDC.

So in this health tip we've actually only answered the "what is the minimal amount of exercise adults should do to be healthy?" That leaves us with the question of specific exercises that can help with fat loss goals, sports-specific performance, diabetes management, or physical appearance. Nevermind the recommendations for different age groups, or people with injuries or disabilities. I'll save those topics for another time.

Please feel free to ask your questions for Health Tips by emailing them to this address: weeklyhtblog@yahoo.com

References

https://www.nap.edu/read/11819/chapter/3#7
*https://academic.oup.com/ajcn/article/79/5/921S/4690229
https://www.cdc.gov/media/releases/2013/p0502-physical-activity.html
https://www.cdc.gov/physicalactivity/basics/adults/index.htm

If you have any questions about working out, please log into your account and send us your question. We are here to help.

Health Tip: Flu Update

This has been a particularly bad flu season, though it seems we may be at the peak and about to see a decrease in infections. The Centers for Disease Control and Prevention (CDC) reports that flu season usually peaks between December and February, and having this season's peak at the end of February means that it is still going strong. In fact, more than half of the country is still reporting high levels of activity. Experts predict that there are many more weeks of flu season to go, and it could last until mid-April.

Why are children especially vulnerable to the flu?
So far, 97 children have died of the flu this season, most of them unvaccinated. Children are more vulnerable to flu viruses because they have inexperienced immune systems that have not been exposed to many infections. Once the body has fought off a viral infection, it can recognize the virus more quickly when it is exposed the next time. Early, robust immune responses are the body's best form of defense against disease. Vaccines are critical in helping to teach our immune systems to recognize foreign invaders. Even though vaccines may not confer 100% immunity, even partial recognition (or matching) may shorten the time it takes to mount an immune response, preventing the invaders from multiplying and spreading more broadly across body tissues.

When the viral load is extremely high, it can trigger massive, microscopic chemical releases that swell the lungs and make air exchange difficult. In some cases, bacteria in the respiratory tract overgrow and penetrate deeper into the lung tissue that is damaged by the virus, creating a second source of infection. In severe cases, air cannot get through the inflamed lungs and into the bloodstream, resulting in decreased oxygen levels and possible death.

What can you do to prevent the flu?
First of all, it is worthwhile to get the flu vaccine, even at this later date. Although experts estimate that it is about 34% effective at preventing the flu this year, it may also reduce the severity of the illness if you get it. Remember that it takes 10-14 days for the flu shot to become effective, so be extra careful about exposure to sick individuals while your body's immune system is ramping up to recognize the viral invaders. You can get the flu in those first two weeks just as easily as if you hadn't been vaccinated. (Some people who get the flu just after the vaccine incorrectly assume that they got it from the vaccine.)

Our main weapons (besides the vaccine) are, according to the CDC:

1. Avoiding close contact. Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
2. Staying home when you are sick. If possible, stay home from work, school, and errands when you are sick. This will help prevent spreading your illness to others.
3. Covering your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
4. Washing your hands. Washing your hands often will help protect you from germs. If soap and water are not available, use an alcohol-based hand rub.
5. Avoiding touching your eyes, nose or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
6. Disinfecting contaminated surfaces. Clean and disinfect frequently touched surfaces at home, work or school, especially when someone is ill.
7. Keep your immune system strong. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

If you do get the flu, are there medicines to make it go away faster?
Yes, there are are three FDA-approved, anti-viral medications that can reduce the severity of the flu and reduce it's duration by a day or two.

• oseltamivir (available as a generic version or under the trade name Tamiflu®),
• zanamivir (trade name Relenza®), and
• peramivir (trade name Rapivab®).

If you are in a "high risk group" for flu complications, you should see your doctor about anti-viral medications (they are only available by prescription). But hurry, these medications only help if you take them within 48 hours of symptom onset.
Who is at high risk for flu complications?

• Children younger than 2 and adults over 65
• Pregnant women
• Nursing home residents
• Native Americans
• Those with medical conditions that put them at higher risk for flu complications (including heart disease, lung disease, asthma, and a long list of others.)

References
https://www.usatoday.com/story/news/politics/2018/02/23/cdc-flu-kills-13-more-children-bringing-toll-season-97-kids/354424002/
https://www.cdc.gov/flu/protect/habits.htm

If you have any questions about influenza (Flu), please log into your account and send us your question. We are here to help.