Renewal Medicine

06/27/2024

PRACTICE CLOSING: The State Medical Board is requiring that I stop practicing addiction medicine and pain medicine. We anticipate closing at the end of August. Thanks to all our patients who have trusted me with their care.

12/22/2021

Highly recommended for any suboxone patients interested in the complex story of how op**te problems became so widespread in the early 2000s. Very well acted and produced, and sure to touch anyone who has lost a loved one.

A few quibbles: the stories are set in the era before fentanyl, which is now far and away the most dangerous op**te, legal or illegal, on the streets. The Purdue drug company and the Sackler family are easy targets; but I suspect there's an agenda to support litigation against other drug manufacturers. Cost of that legal action will only be passed on to the sick. Finally, the narrative ignores the legitimate needs of suffering humans with real pain. Cutting back on prescriptions has failed to reduce the overdose death rates, and has failed to meet the needs of people who struggle with debiltating injuries and illnesses.

From Executive Producer Danny Strong and starring and executive produced by Michael Keaton, “Dopesick” examines how one company triggered the worst drug epid...

07/27/2021

We are recommending the covid vaccine for most patients. New information says the vaccine is offers further protection, even for people who have had covid. Patients with complex immune diseases or prior significant allergic reactions to vaccines should probably still discuss it with their doctors first.

04/26/2020

Off topic; supplements that may prevent or help COVID infections.

As states relax the lockdown, people with pre-existing conditions may see their risk of COVID infection increasing. There is a plausible reason to think that some over-the-counter supplements may decrease that risk. One specialist who treats COVID patients recommends:

Zinc
Quercitin
Vitamin D
Vitamin C
N-acetyl cysteine

all available over-the-counter, although becoming scarce on shelves

For more information, go to You Tube and search for Dr. Roger Seheult Medcram episode 59.

03/22/2020

Telemedicine is here. We started remote visits for current patients on March 21. We are doing everything we can to be sure our patients are able to continue on their medicines while staying safe from Coronavirus. Please remember to store your medicine securely at all times, and to take your medicine exactly as directed.

12/08/2019

LOW T TIME
Men who are on methadone or substantial doses of op**tes should all be tested for low testosterone. This is a widely recognized effect of op**tes. Symptoms may be subtle, such as fatigue or mood disturbances. Typically, doctors will require two blood tests showing low testosterone before considering testosterone supplementation. There are some risks with testosterone, so it's important to make an informed decision.

Limited evidence suggests this is less of an issue for men on Suboxone or other buprenorphine medicines.

12/08/2019

TAKEAWAYS FROM A WEEKEND WITH THE PAIN SPECIALISTS
Thoughts after the Pain Society of the Carolinas meeting in Charleston, SC.

1. CBD oil and, where legal, therapeutic ma*****na use is spreading like a California wildfire, while the scientific evidence, while mostly positive, is accumulating at a much slower rate.

2. Buprenorphine for pain.Quite a bit of interest in low-dosage format products (Belbuca, Butrans patch) which is a good option for mild to moderate pain. Higher dose buprenorphine (in Suboxone dose ranges), and buprenorphine in combination with conventional op**tes sadly ignored as usual.

3. Review of major interventions: The really major interventional procedures are Spinal Cord Stimulators and Intrathecal "Pain pumps" which deliver high concentrations of pain medicine directly to the space around the spinal cord. You would think these might be the magic bullet for severe intractable back pain, but success rates range around 50%

Because these procedures are so expensive, insurers require:
a. pre-procedure formal psychological evaluation, and b. placement of a temporary stimulator or pump to document likely effectiveness. One concern about intrathecal pumps is growing evidence that chronic pain is a BRAIN process that may not respond to huge amounts of drug around the spinal cord.

4. Virtual Reality is more likely the real deal. Harvard Medtech smart VRT is a system specifically designed for pain patients. Grab those goggles and feel better.

5. For chronic pain patients who are considering tapering off opioids, MUSC in Charleston has a 3 week "pain rehab" program that has full days of group therapy, physical therapy, occupational therapy, and much more. It comes close to the "multidisciplinary pain management" that the founders of modern pain management envisioned, but that insurers have never been willing to pay for.

Many people may not know that Pain Medicine is considered a subspecialty of Anesthesiology, although specialists in Physical Medicine, Neurology, and Emergency Medicine are eligible to be certified after a 1 year fellowship (that's about 25 years in school after kindergarten.) There aren't nearly enough doctors with subspecialty training in Pain Medicine to care for the 20 million or so Americans with significant chronic pain.

10/07/2018

CHRONIC PAIN: ITS ALL IN YOUR HEAD (AND NOW WE'RE LEARNING WHY)

The tradiitional paradox has been the persistence of chronic pain, despite all sorts of treatment directed to the supposed offending body part: the low back, knee, belly, injury site, etc etc. The assumption has always been that the problem is from the affected body part.

It looks like that's often wrong. An accumulating body of research is now telling us that the real problem is in the brain and spinal cord, where a number of mechanisms operate to induce misprocessing of brain signals that are then perceived as pain, sometimes excruciating. The offenders appear to be microglial cells, supportive cells around nerves which became inflamed and contribute to activiation.

A couple of recent studies. more or less at random, show increased markers of microglial activation in fibromyalgia patients. Another study show inflammatory chemicals released from ruptured discs and the spine. Its a straight shot for nearby sections of the spinal cord to absorb these inflammatory chemical and lead to chronic pan THAT IS NO LONGER COMING FROM THE DISC.

Treatment of these conditions is in its infancy. Trial and error of several agents is the only option.

I would be remiss without ackowledging the help of a couple of my patients, whose situations could not be explained without resorting to intrinsic injury within the central nervous system and resultant pain syndromes.

06/18/2018

THERE ARE NO ADDICTS* AT MY CLINIC.

There is a lot of confusion about definitions in this business. Most authorities say something like: "addiction is where behavior or substance use is UNCONTROLLED and HARMFUL."

My take is that once patients come in through the door for treatment, they have courageously begun to exert control. At that point, it is incorrect, as well as insulting, to refer to people as addicts.

The definition of addiction is often confused by the presence or absence of strictly pharmacologic effects, such as tolerance and physical dependence, which is withdrawal symptoms when the substance is stopped. These effects have no bearing on whether or not addiction is present.

*NOTE 1 I believe that addiction, in one form or another, is part of the human condition, although there are a few souls out there with the self discipline to refrain from any addictive behavior.

*NOTE 2 Strictly speaking, people who come in for treatment are, like the rest of us, likely to have several addictions, such as smoking or buying lottery tickets. But the important point is people stop being addicted to op**tes the moment they enter treatment.

04/13/2018

GUIDE TO DAILY SUBOXONE-TYPE MEDICINES:

First of all, you don't need to know all this. You and your doctor can easily find a product that will work well. But keeping all the products straight is confusing, not only to patients but to doctors and pharmacists.

The original product is brand-name Suboxone, now marketed as a film that dissolves under the tongue.

Suboxone, as well as all the products below except generic buprenorphine, is a mix of the active ingredient, buprenorphine, as well as naloxone, an op**te antagonist which puts people into withdrawal if injected. The only reason the naloxone is there is to discourage the misuse of these products by injection. The naloxone is supposed to be inactive in normal use.

Zubsolv is a brand name tablet, that some people prefer over the film. The tablet tastes like a breath mint.

Bunavail is a sticky patch that is applied to the inside of the cheek

Generic "Suboxone" is a tablet containing the two ingredients, dissolved under the tongue.

Finally, there is generic buprenorphine, also a tablet that dissolves under the tongue. This is sometimes called "Subutex" after a comparable brand-name product that is no longer marketed. Sometimes it is called "monoproduct" to distinguish it from versions that contain naloxone.

Generic buprenorphine is preferred in pregnant patients. Because it is the least expensive product, it is used in clinics where it is administered on-site. It is sometimes used for patients who are paying out-of-pocket, and sometimes used for patients with well-established allergy or intolerance to the naloxone.

Don't worry, you won't have to pass a test on this information.😀😀

03/10/2018

INPATIENT "REHAB" FOR OP**TE ADDICTION: A Good Idea Except: (1) it's often ineffective, and (2) it bankrupts families

The Wall Street Journal today has a big front page article titled "After Addiction Comes Families' Second Blow: The Crushing Cost of Rehab" The article is behind a paywall but you get the idea. An accessible article saying the same thing is: https://www.thedailybeast/why-drug-rehab-is-outdated-expensive-and-deadly

The stories have a tragic sameness: an ordinary family spends all its resources on rehab stays for an addicted member, only to find that the individual continues to be addicted and at extreme risk for fatal overdose.

Numbers are notoriously difficult to find, though you may find glowing individual testimonials. One estimate is that rehab succeeds 30% of the time.

Here's my take:

Well-run inpatient programs can bring someone safely off drugs
and can teach some coping skills, but there's no magic bullet or secret sauce that these programs have that will take away the looming risk of relapse after discharge.

Insurers and families should apply some tough love: If patient and family agree, try rehab ONCE. Relapse after that, and all support should be applied towards medication assisted treatment that has overwhelming published proof of efficacy. Any inpatient stay should only be in a facility that will start a patient on methadone or buprenorphine, with a plan to transition to outpatient maintenance.

Addicted patients who claim "it'll be different this time. I'm really going to get clean" are fooling either themselves or their loved ones.

03/02/2018

PAIN MEDICINE UPDATE:
Little change in 5000 years

Considering the staggering advances in much of medicine in the last couple of decades, there is an astounding primitiveness in the care of the pain patient.

O***m was harvested along the Tigris and Euphrates, in present-day Iraq, about 5400 years ago. The Sumerians called the o***m poppy "Hul Gil" translated as "Joy Plant.". Today we still use o***m derivatives and knock-offs; there's no other medicine besides general anesthesia for severe pain.

Assessment of pain has not advanced much in five millennia either. "Rate your pain on a scale of 1-10" would have been the approach of the Sumerian doctors, just as it is now. But there now is, in theory, a way to objectively measure this most subjective phenomenon---if your doctor's office has a functional MRI scanner. Pain pathways in the brain have been visualized in research studies. But in everyday practice, it's still the 1-10 scale.